The hidden problems behind delayed discharges and their costs

In the past six months, there has been a rapid increase in the number of people experiencing delayed discharge from hospitals in England, with the number of patients remaining in hospital overnight who no longer meet the criteria to remain averaging 13,771 in February 2023. That’s up from 12,589 on average in April, an increase of 9.4 per cent.

Delays are also increasing at a time when the NHS is pushing harder than ever to find cost savings. There is no official estimate of the direct costs of these delays (staff time spent on additional NHS care and overheads from an overnight stay), but we have estimated one by uplifting the last estimate (from 2017/18) by inflation to produce an estimate of £395 per night. That means that the direct costs of delayed discharges alone (excluding additional costs from activities such as cancelled operations or staff time spent arranging care packages) in 2022/23 so far has been at least £1.7 billion. 

If the winter discharge fund does not reduce delayed discharges below the average number of people experiencing delayed discharge per day we’ve seen so far this year, by the end of March the NHS will have spent £1.89 billion on the direct costs of people unable to leave hospital because of delayed discharge in 2022/23. Not all this money is spending that wouldn’t exist otherwise – the beds occupied by people experiencing delayed discharge would otherwise be filled by other people with other care needs – but it does provide an indication of sub-optimal use of resources that should be deployed in other ways. This estimate also excludes the indirect cost of delays, such as the costs incurred through cancelled elective operations, so these figures are an underestimate of the true cost of delays (a recent leaked estimate from the Department of Health and Social Care put the potential savings of reductions in delayed discharges to the NHS at up to £7 billion). 

It's difficult to really diagnose the nature of the problems here, as the previous, more detailed, dataset on delayed discharges has been suspended since the Covid-19 pandemic started. That makes it difficult to tell if the problems are with arranging care packages for patients, or with arranging assessments of patient need at discharge, for example. 

The government has recognised the need for additional investment in social care: the announcement of an additional £2.8 billion in funding for social care at the Autumn Statement represents the third time that one-off funding has been allocated to social care in fiscal events in the past three years. This is in addition to the £500 million announced previously as part of the winter discharge fund and the £250 million announced by the Secretary of State in March 2023. However, improving social care’s capacity to assist with discharging people from hospital will require measures to tackle the workforce crisis currently faced by the sector and it is not clear how effective short-term pots of money will be in achieving this. 

Let’s not slip into a sole focus on social care though. As former NHS England Chief Executive David Nicholson pointed out recently, it’s possible to miss the things the NHS can do better among these figures. Discharge-planning practice is still variable across different areas of England and delays that aren’t related to social care don’t attract as much attention in policy debates, but with a new focus on inequalities and a need to find financial savings in the short-term, improving discharge practice represents an opportunity. Before the pandemic, for example, the fastest increase in delays was not coming from issues relating to social care, but rather from delays relating to housing issues. The number of bed days delayed due to housing issues (note that this is a different definition than the delays collected in the sit reps collection mentioned earlier) grew by more than one-third in one year, from 5,124 delays in February 2019 to 8,027 in February 2020.

The NHS normally thinks of issues related to housing and other wider determinants of health as problems for other partners, especially at times where performance is under extreme pressure. Can the NHS work with partners in local government, housing associations and voluntary and community sector organisations to make a significant difference to operational pressures and financial bottom lines? Short-term actions might offer a chance to forge connections with valuable partners that could pay off even more in the long-term. 

One last note, I’ve focused a lot on money and operational issues here, but behind these numbers are thousands of individuals who have experienced frustration, disruption and discomfort because they’ve been stuck in hospital when they’ve been ready to leave.