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Delayed discharge at the heart of the NHS crisis

How big a problem are delayed discharges and what can be done to reduce them? 
Discharge-tile©Getty.jpg

How big a problem are delayed discharges and what can be done to reduce them?

There are no winners when a patient's discharge from hospital is delayed. The frustration is felt by the patient, their family and the healthcare professionals caring for the patient. Ultimately, the entire health system is affected, as a badly-needed bed can't be used for other patients.

In December 2016, a total of 6,191 people experienced delayed discharge in acute and non-acute settings in the NHS in England, compared to 3,649 three years earlier. This represents a rise of 70%. Delayed discharges on this level are the equivalent of ten large hospitals being taken out of use. It is a massive problem.

Some commentators argue that the true burden of delay is even

...

How big a problem are delayed discharges and what can be done to reduce them?


NICE guidelines stress that discharge should be patient-focused,
with an emphasis on communication. Picture: Getty Images

There are no winners when a patient's discharge from hospital is delayed. The frustration is felt by the patient, their family and the healthcare professionals caring for the patient. Ultimately, the entire health system is affected, as a badly-needed bed can't be used for other patients.

In December 2016, a total of 6,191 people experienced delayed discharge in acute and non-acute settings in the NHS in England, compared to 3,649 three years earlier. This represents a rise of 70%. Delayed discharges on this level are the equivalent of ten large hospitals being taken out of use. It is a massive problem.  

Some commentators argue that the true burden of delay is even greater than the figures suggest. The National Audit Office has highlighted that many patients who may be in hospital unnecessarily won't be counted in delayed discharge figures, because a decision has not yet been made as to whether or not they are medically fit to leave.

Varied reasons 

However they are defined, delayed transfers of care are bad news for the NHS. Not being able to move medically fit patients out of hospital means that those who need to be admitted, either in an emergency or for an elective procedure, may not be able to get a bed. Where a hospital has a high number of delayed discharges, this can lead to long waits for admission for patients stuck in A&E, which in turn affects the ability of staff to deal with new patients coming into the emergency department.

The unprecedented pressures across health and social care in recent months have highlighted the inefficiency and human cost of delayed discharge, but the problem pre-dates the current crisis by many years. 'We seem to know what needs to be done but are in the same position we have been in for decades,' says Queen’s Nursing Institute project manager Candice Pellett. 'Everyone wants the same thing: discharge in a timely manner. So what is stopping this happening?'

The reasons for delayed transfers are varied. More than half of all delays are due to issues in the NHS itself, for example, a step-down bed not being available. But social care delays – especially delays in providing a package of care to patients in their own homes – have increased faster than NHS-related delays. In a small number of cases, patients or their families are unhappy with what is offered. For example, they might feel that the care home at which they have been offered a place is unsuitable, and want to wait for an alternative.

Not just numbers

Progress was expected through improved working between the NHS and local authorities, and the Better Care Fund (BCF), which was meant to promote more integrated services. But the anticipated benefits have been limited. The BCF was expected to reduce the number of days patients were delayed by 293,000 in 2015-16; instead, the number of delayed days actually increased by 185,000.

While social care cuts are often blamed for increases in delayed transfer of care, the relationship is far from clear. King's Fund senior fellow of policy Richard Humphries points out there are huge variations in the likelihood of delayed discharge across local authority areas, with 13% of councils accounting for a third of all council-related delays. Yet, surprisingly, the evidence does not suggest a correlation between delays and funding levels. NHS organisations also have enormous variation in relation to delays, adds Mr Humphries.

The increased number of delayed discharges is likely to reflect demographics: a rising number of over-75s with more complex problems and co-morbidity. 'It's not simply about the numbers. It's the complexity of packages required to support them,' says RCN professional lead for older people's care Dawne Garrett.

Planned around needs

The growth in the number of patients with dementia or other cognitive impairments as well as physical health problems is an added concern. It can also be difficult to find accommodation with the right support for patient's with challenging behaviour.

'These are the people who need a well-planned discharge home,' says Ms Pellett, who wrote a major report for the QNI in 2016, examining the barriers to effective discharge and presenting examples of best practice. In the report, she called on commissioners and provider organisations to ensure the processes they have in place for transfer of care between services is planned around the needs of patients, families and carers. She also called for improved partnership working between hospital and community nurses.

From a community nurse perspective, the reason why discharge is delayed is simply 'the lack of a care package to get a person home safely', she says. Sometimes it is difficult to put a home care package in place because agencies can't recruit staff, and putting a package in place over weekends and bank holidays is particularly problematic. Her research-based report found that community and hospital nurses often had different views on the level of support available to discharged patients, with community nurses more likely to see gaps. 

Starting in A&E

NICE guidelines stress that discharge should be patient-focused, with an emphasis on communication and information sharing. Nicky Hayes, a nurse consultant for older people at King's College Hospital, says nurses need to reflect on what they can do to meet people's needs and preferences. But with services at full capacity, what can be done to reduce delays and ensure appropriate discharge?

Discharge to assess has been adopted in many areas, which means the patient is assessed in familiar surroundings, with the focus on what they can do there rather than in the hospital environment. Anecdotally, patients assessed in this way need less support than expected. It has also proved helpful for some patients with dementia whose ability to cope is considerably enhanced when they are in their own home. However, there are issues around how to assess risk and the impact on families. 'We have to take on board the huge impact discharging someone home has on those caring for them,' says Ms Garrett.

She adds that effective discharge planning needs to start in the emergency department to avoid people becoming deskilled and institutionalised. A National Audit Office report in 2015 revealed that more than half of hospitals said discharge planning did not start early enough.

Cohorting approach

The pressure on general hospital wards can make it difficult for staff to encourage patients to become more active. 'It is easier to do things for people than let them do it for themselves. If you are time-pressured, rehabilitation is difficult to do well because it requires a lot of input,' says Ms Garrett. 

Some hospitals, such as Yeovil District Hospital, have adopted a cohorting approach to patients who are medically fit for discharge but need further rehabilitation and support to enable them to move safely into the community. The ward for these patients focuses on rehabilitation provided by a multidisciplinary team, including nurses, physios and occupational therapists, often with minimal input from medics. Associate director of nursing Maddie Groves says the 36-bed ward is usually full; although there are community hospital beds available, many of the patients would not meet the criteria for admission.  

One of the positives has been that staff on the ward have become experts at organising discharge, with the knowledge and skills to get people through the system as quickly as possible. Some patients regain their independence on the ward and are able to return home, rather than going into residential care.

Using step-down beds in intermediate care, community hospitals or nursing home beds can also help free up acute beds. Ironically, one of the themes of the new sustainability and transformation plans has been reducing community beds.

Ms Garrett says that when a discharge goes wrong, the patient often ends up being readmitted into an acute setting when a community or nursing home bed would have been more appropriate. Unfortunately, direct admission to these beds is not always available during out-of-hours periods. A well-planned discharge can make this scenario less likely.

Ms Pellett says: 'If we get people home in a timely manner with the equipment they need and their medication, and a care package in place, they are less likely to need readmission.' While much of what happens in delayed discharge is not under the control of nurses, this is an area, she says, where nurses can have an impact. 

Preventing delayed discharge: what works 

  • Effective local processes: commissioners and provider organisations ensuring that transfer of care between services is planned around the needs of patients, families and carers.
  • Communication, co-ordination and collaboration: partnership working between hospital and community nurses.
  • Early discharge planning from the point of admission.
  • A single person responsible for arranging discharge but able to call on other health and social care professionals.
  • Assessment in an appropriate setting, which is unlikely to be an acute hospital.
  • Sharing information, with consent between those involved in a patient's care.
  • Involving the patient, family and other carers.

Alison Moore is a freelance health writer

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