Analysis

Delayed discharges remain 'stubbornly high', says NHS Providers

Extra funding for emergency care system may not be enough to improve the care of frail, older patients.

Extra funding for emergency care system may not be enough to improve the care of frail, older patients.

winter_warning
The four-hour waiting time target in emergency care has not been met for over two years. Picture: Alamy

 

Ministers have made improving the way the urgent and emergency care system works for frail, older patients a priority.

This year, councils in England given an extra £1 billion for social care, with another £1 billion promised over the next two years.

In addition, a £100 million pot has been set aside to introduce front-door streaming in emergency departments (EDs) to allow staff to focus on more complex patients, who are usually those aged over 65.

But a report released at the end of the summer by NHS Providers, which represents the range of NHS public provider trusts, has cast doubt on whether these initiatives will succeed.

£1 billion

extra funding for social care in 2017-18

(Source: HM Treasury)

The report acknowledges that support – led by NHS Improvement and NHS England – was ‘considerably more developed’ than it was last year. But it highlights a lack of progress in tackling delayed discharges, bed occupancy rates and the proportion of patients being admitted or discharged in four hours.

NHS Providers chief executive Chris Hopson says feedback from its members and analysis of latest performance data suggest these failures could produce the worst winter for a generation.

‘Last winter was widely considered the worst in recent times. But everything indicates this could be even worse,’ he said.

He is calling for an emergency cash injection of between £200 million and £350 million to pay for extra beds and staff, which he says could be drawn from money earmarked for future developments.

The NHS Providers report says the money is needed because delayed discharges remain ‘stubbornly high’, with progress in only one third of areas.

So far, the government has not been forthcoming.

Viable services

The report highlights figures from the Association of Directors of Adult Social Services showing that, in other places, extra funding has been spent on ensuring services remain viable rather than on speeding up the discharge process.

British Geriatrics Society nurses and allied health professionals council chair Cliff Kilgore says this choice is understandable.

‘Both sectors face similar problems with staffing and money. It is difficult to make progress in this sort of situation.

‘My local authority colleagues often have problems finding suitable providers. The private market is more attractive to providers so even with the extra money it is difficult.’

£100 million

to help set up front-door streaming in hospitals

(Source: NHS England)

Mr Kilgore adds that this is not simply a hospital and social care issue, but that pressure is also falling on district nurses and community teams.

‘It is difficult in the community. The complexity of patients and workload mean services are stretched. In most areas staff are just about keeping their heads above water.’

Deborah Sturdy, who is a special adviser on nursing for Care England, which represents providers, believes a ‘lack of trust’ between councils and the care home sector has not helped.

She says that, as a result, too few have ‘taken the leap’ to commission rehabilitation and step-down beds that would make a big difference.

She believes that councils are likely to be afraid that the influx of new money could result in prices being pushed for all contracts.

Winter planning

Despite these difficulties, NHS bosses are confident that their plans will help the health service cope.

NHS national director for urgent and emergency care Pauline Philip says there will be challenges as there are every year, but adds: ‘Winter planning is more advanced than last year and special attention is being paid to areas where pressures are likely to be greatest.’

She says extra beds are already in the process of being opened, while the social care money still has the potential to free up another ‘2,000 to 3,000’ beds by the time winter hits.

Front-door streaming will also help, she adds. So far, 116 hospitals have had a share of the £100 million pot to help set up the physical infrastructure.

0.7 percentage points

is the deterioration in four-hour ED performance August 2017 v August 2016

(Source: NHS England)

The aim is that every ED will have some form of streaming in place by October.

But while this money has been welcomed, RCN emergency care association chair Janet Youd says it will have only a limited effect given staffing shortages and continuing pressure on the rest of the hospital system.

She says people highly dependent on nursing care, such as frail patients with sepsis or fractured hips, suffer when there is no appropriate inpatient bed for them.

‘Sadly, no amount of GP availability will reduce the harm these patients suffer or the distress the nurses feel as a result.’

 

How one hospital is reducing delayed discharges and readmissions

The Royal Free London NHS Foundation Trust has had great success in reducing length of stay and avoidable readmissions for patients with dementia.

In 2013 a new role – specialist dementia occupational therapist – was created with help from the Health Foundation. The post acted as a single point of contact for patients, carers and staff.

It guaranteed patient assessment within 24 hours, early development of a discharge plan, intensive daily therapy and a supported discharge process. Temporary social care was arranged if necessary.

The approach has achieved impressive outcomes. Length of stay has been reduced by 2.6 days and readmission through the emergency department by 26%. There are also signs it enabled patients to return home rather than be admitted to a care home.

Other staff are now being trained to provide the support, while the Royal Free, which is part of NHS England’s vanguard programme, is also helping other hospitals introduce similar arrangements.

Danielle Wilde, the therapist who led the scheme, says: ‘One of the things we challenged was the preconception that discharging patients with dementia to their home poses a safety risk.

‘If all Joyce needs to stay at home is to be able to get out of bed, sit in the chair, go to the toilet and make a cup of tea, does it matter if she can tell what day it is?’

 

Summer 2016 v Summer 2017

Attendances and admissions: There were 1.92 million emergency department (ED) attendances during August, 0.5% fewer than in 2016. But emergency admissions are up. There were 486,669, 3.4% more than the year before.

Delayed discharges: This has been a priority for ministers. There were nearly 181,692 days of delays in July, compared with 184,578 in the corresponding month the year before.

ED waiting: The four-hour target has not been hit for over two years. In August 90.3% of patients were treated or admitted in four hours, worse than the 91.0% in August 2016.

Bed occupancy: It is recommended that bed occupancy is kept below 85%, but in the quarter ending June it was 87.1%, marginally better than the corresponding quarter the year before when it was 88.3%.

(Source: NHS England)

 


About the author

Nick Evans is a freelance writer

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