Delayed
Discharge & Inappropriate Admissions - Select Committee on Health
In March, Prof Cameron Swift, accompanied by Dr David
Black, gave evidence to the House of Commons Select Committee on Health
The
report published by the Committee in July is summarised here.
The Committee urges the
Department of Health (DoH) to reject the use of the term “blocked beds”
to refer to patients ready for discharge, but who are occupying hospital beds.
The Committee calls for further clarification of the definition of “delayed
discharges”, and further guidance on its practical application.
The DoH needs to refine
its data gathering procedure to achieve a more comprehensive picture of the delayed
discharge patient population. There is a need to highlight specific problems in
the care and placement of those suffering from mental illness, head injury or
other conditions.
The
Committee welcomes the downward trend in delayed discharges, but it remains to
be seen how sustainable this will be. The wide regional and local variations in
delayed discharge trends continues.
The
Committee recognises the crucial role occupied by timely discharge in enabling
the attainment of other key NHS objectives, and wholly supports the key objective
of ensuring that the right care, in the right place, at the right time, is attained
for individual patients and their carers.
The
Committee is not able to assess the impact of the recently established Change
Agent Team. The team’s findings will need to be disseminated at the earliest
opportunity if the experience of working in depth with a small number of authorities
is to be of wider benefit.
The
Committee recommends that the DoH identify and publish examples of good practice
in promoting avoidance of inappropriate admission to hospital.
Management
of Discharge and Beyond
There
is merit in having a named person responsible for co-ordinating all stages of
the patient journey up to and beyond discharge.
Patients
should be partners in the discharge process. In circumstances where they lack
capacity, they should have access to advocacy services.
Arrangements
for management of discharge need radical overhaul in many hospitals. In the Committee’s
view, best practice involves a multi-agency team, with clear links to all key
points in the patient’s journey, actively managing all aspects of the discharge
process. The leader of this team should be jointly appointed by the NHS and councils
with social services responsibilities. The discharge management process should
be proactive rather than reactive.
Even
if good systems are instituted, there is a danger that they will stagnate. The
committee recommends that discharge procedures should be a focused element of
clinical governance, and of every CHI review in the NHS. It is also vital that
these matters be addressed in inspection pro-cedures, both through the proposed
new in-dependent healthcare regulator and through the equivalent body for social
services.
The
Hospital Discharge Workbook should be updated. The Committee recommends that new
statutory guidance on health and social care responsibilities for hospital discharge
should be issued as a matter of urgency.
The
Committee is concerned that the focus on tackling delayed discharges, entirely
laudable in itself, could lead to an intensification of pressures to discharge
patients too quickly, and with inadequate preparation.
Optimising
Resources
The Committee believes
that community hospitals are an important provision andu should be a resource
centre. This approach requires a new mind-set so that the community hospital is
used appropriately, and staff with the right skills provide the support required.
Building capacity,
whether in the acute sector, in community hospitals or in residential/nursing
homes, risks feeding the problem of delayed discharges. Breaking the cycle demands
the simultaneous development of alternative facilities in the community, to ensure
that inappropriate admissions can be avoided and timely discharges supported.
Current targets are structured to encourage a preoccupation with short-term objectives.
The Committee is
concerned that “re-badging” NHS services as intermediate care might
lead to a misuse of resources identified for the development of intermediate care,
and it represents a failure to utilise the skills and wider experience of statutory
and independent sector partners for maximum benefit.
The
Committee recognises the value of additional resources being invested in under-performing
health authorities, but worries that this appears to reward poor practice. It
recommends that, in line with the Government’s emphasis on ‘earned autonomy’,
there should be a corresponding development of support to authorities that are
performing well.
If
the Government is committed to using the independent sector, which provides the
majority of intermediate care, it must ensure that the sector is involved in developing
care and support services in which the care home is only one of a range of service
options, tailored to meet the diversity of need of individuals.
The
Committee is not convinced that the requirement for homes to clarify the breakdown
of their fees for residents will do anything to redress the situation of nursing
homes raising fees to absorb the value of NHS funded nursing care payments. The
Government is urged to ensure that the full value of the registered nursing care
contribution is passed on to residents as intended.
Innovative
care models
Hospitals
are not the appropriate place for people awaiting care home placements. The Committee
believes that there should be a presumption that those unable to access their
first choice home should wait in interim placement settings unless there are genuine
clinical reasons to suggest this would be unwise. However, careful monitoring
would be needed to ensure that local authorities did not exploit this artificially,
to limit access to good quality homes.
Registered
care homes, including those providing nursing care, are an important element in
considering options for care; but that provision should not be regarded as the
easy option simply because in a given area the capacity is there. To this extent,
closure of care home places can act as a further spur to the development of care
at home.
The
Committee recommends that the DoH conducts a cost-benefit analysis of facilities
such as those on offer at Hartrigg Oaks and Berryhill, with the emphasis placed
on active community and independent living. The costs of such schemes should be
compared with the costs to the state of both additional hospital admissions and
stays, and the costs of other forms of care.
The
Committee agrees with the Audit Commission that further work is needed to provide
guidance on the effective commissioning of equipment services to social services,
primary care trusts and strategic health authorities.
Change
from more of the same
Telecare solutions
have a major contribution to make as part of the strategy for developing alternatives
to hospitalisation. The Department should establish a national strategy to promote
the systematic development of telecare solutions as part of care at home, perhaps
beginning with some properly audited pilots. Telecare has the potential not only
to achieve cost savings, but also to allow people the choice of staying longer
in their homes, with the attendant benefits of such an option.
The
fact that almost 30% of discharge delays can be attributed to waits for care home
placement might suggest that the obvious solution would be rapid development of
further residential and nursing home capacity. The Committee does not support
this conclusion on the grounds that it would constitute developing “more
of the same”, instead of developing alternative service models.
The use of ‘Cash for
Change’ resources appears to have been successful, but may not be sustainable.
The increase of 6% per annum in social services funding offers an opportunityu
for longer term planning.
The
experience of medical insurers in the USA has demonstrated that financial penalty
incentives can deliver rapid change in delayed discharge, albeit in a very different
health culture, but the Committee cautions that there are risks that a system
of cross-charging to deal with delayed discharges might undermine partnerships
which have taken considerable time to develop.
Evidence
from a survey by District Audit, indicates that much creative intermediate care
service development is taking place, involving a diverse range of schemes. Ensuring
that this diversity becomes part of the mainstream and takes place within the
context of the whole health and care system will be a challenging task.
Workforce development needs
to be tackled creatively. The Committee recommends the development of a joint
workforce plan and training strategy that brings together the NHS Training Confederation
and the new sector skills councils.
The
Committee calls for a full and widespread debate on the case for the integration
of health and social care, and their linkages with related services such as housing.
Pilots should be established to test ways of integrating health and social services,
perhaps based on the leader commissioner model.