Concerns about aspects of the NHS were raised in October by NHS Providers (2019) in a report entitled The State of the NHS Provider Sector. It showed that the current 100 000-plus NHS staff vacancies are undermining patient care and that the failure to invest in social care services for the infirm elderly is fuelling demand for hospital beds. The Care Quality Commission (CQC) (2019), in its State of Care report, similarly revealed that an estimated 1.4 million older people do not have access to all the care and support they need and that funding of social care in the community is at crisis level.
It is against this backdrop that this article discusses strategies to alleviate some of the problems with delayed transfer of elderly patients from hospital, specifically with reference to a factsheet published last August by Age UK (2019a), entitled Hospital Discharge. The factsheet makes an important contribution to the overall process of ensuring optimum discharge from hospital.
In addition, Age UK (2019b) has estimated that the NHS lost 2.4 million bed days in 2018 because frail patients could not be discharged in a timely fashion, attributing this to shortages of support, especially in the community. The study showed that nearly 40% of discharge delays of elderly patients are caused by the lack of social care support. The Age UK figures show that, of the 8% vacancy rate in the adult social care sector, some 76 000 are from the care worker workforce, and this is exacerbated by a staff turnover of more than 30%, equivalent to 390 000 leavers over the preceding 12 months.
Background
In a systematic review of the literature, Landeiro et al (2019) showed that delayed discharge occurs in most countries and that the associated costs are significant, not least because of their impact on patient outcomes. Given the effects of delayed discharge on the running of the NHS, it is no surprise that there is a plethora of policies and procedures to address the issue. The Age UK Hospital Discharge factsheet is the latest attempt to capture all the parameters of discharge among the elderly hospital population.
Optimally, managing the admission and discharge of elderly patients is primarily related to throughput, intake and output. Problems arise in the early and latter months of the calendar year when so-called winter pressures place most hospitals in jeopardy. In the case of frail elderly patients this is double jeopardy: the patients' long-term care is put at risk by both a lack of capacity and delays in discharge. The former—lack of capacity—occurs when hospitals run out of beds because of overwhelming numbers of admissions from the frail elderly population at certain times of the year. This is exacerbated in autumn and winter by seasonal outbreaks of influenza (Public Health England, 2019).
Today, the NHS treats more people than ever before and, of those admitted to hospital, many are elderly with multiple long-term conditions. The Health Foundation (2018) showed that the number of those admitted who were over the age of 65 years rose by 46%, from 4 million in 2005/06 to just under 6 million in 2015/16. The number admitted with at least one long-term condition doubled to over 4.5 million.
According to, the British Medical Association (2019), during the winter months of 2018/19 only 35 trusts in England managed to keep their average bed occupancy below 92%, with one spending 59% of the winter at 100% capacity. This consistent pressure on beds is a serious concern.
To prepare for the pressure on beds throughout the autumn and winter all NHS trusts draw up winter plans that focus primarily on three areas: preparedness, prevention and protection against the major avoidable ill-effects of winter on people's health. During their ‘well-led’ inspections, the CQC (2018) expects to see winter/seasonal pressure plans in place, but it is keenly aware that NHS providers face the challenge of finding the right capacity to meet people's needs.
Winter pressure plans are designed, among other things, to maximise safe patient discharges and transfers and help patient flow. To achieve this, the plans direct staff to ensure they carry out timely reviews of patients, update patient records regularly with an estimated discharge date, and record medical discharge/management plans clearly.
Crucial to the success of winter plans in addressing timely discharge is ensuring that accurate, timely information about capacity is communicated with bed managers or clinical site co-ordinators, whose role is to keep patients moving through the hospital. Bed managers and their staff constantly monitor admissions, patient moves within the hospital and discharges. The National Institute for Health and Care Excellence (NICE) (2015) also recommends the appointment of a health or social care practitioner to co-ordinate individual patient discharges and act as the point of contact throughout the hospital when discharge planning is commenced.
Many hospitals have endeavoured to improve the efficiency and effectiveness of the hospital discharge process for the frail elderly patient population. Hernandez et al (2014) discussed the value of discharge lounges. At the Royal Cornwall Hospitals NHS Foundation Trust (2018), for example, during each 7am clinical site handover meeting, the site manager confirms with individual ward mangers which patients have been identified for discharge and who can then be transferred by a dedicated healthcare assistant to the discharge lounge.
Delayed discharge
However, despite strategies to ensure the smooth and optimum discharge of elderly patients, things do not always go to plan. One of reasons is that, although the patient may be medically fit for discharge, other aspects of care may have changed due to the illness that caused the admission in the first place. For example, an elderly person who may have been able to self-care prior to admission may now need social care assistance. Such delayed transfers of care occur when patients are ready to leave a hospital, but are still occupying a bed due to problems in arranging the discharge to their own home, a care provider such as a residential or nursing home, or when they are awaiting transfer to a community hospital or hospice.
An independent report (Christie and Co, 2018) has shown that the continued demand for care businesses in the UK is being fuelled by an increasing population of elderly people. Market research for Christie and Co, which provides specialist advice on buying and selling businesses, suggests that this section of the population, especially those aged over 85 years, is likely to grow from 1.4 million in 2010 to 4.4 million by 2046.
A shortage of care home accommodation, exacerbated by funding and staffing problems, remains a critical issue in resolving difficulties in the care sector. As a consequence, there are insufficient numbers of appropriately trained staff to meet the increasing health needs of vulnerable older people. With too few staff to meet increasing healthcare needs, home employers face a constant struggle to attract and retain staff. The problems are attributed to low morale throughout the care home sector, combined with poor pay and a lack of career opportunities, leading to understaffing and a transient workforce.
It is against this background that logjams in the discharge process occur, leading elderly patients to languish in hospital unnecessarily. A major obstacle to achieving safe and appropriate discharge is the lack of social care support. The National Audit Office (NAO) (2016) estimated that overall delays in patient discharge are responsible for £820 million of avoidable costs to the NHS.
NHS England (2018) defines a patient as ready for transfer when the following three criteria are met:
If all three conditions apply, but the patient remains in a bed, the term ‘delayed transfer’ is enacted. For older people, in particular, these unnecessary stays in hospital can lead to worse health outcomes and increase their long-term care needs.
A Royal Voluntary Service (2015) survey found that almost 70% of nurse respondents had to delay discharging patients frequently because there was no support in place for them once they left hospital, and this had worsened over the previous year
Poor discharge processes for elderly patients can often be traced back to the point when they are first assessed on admission. In 2013 the Royal College of Physicians recommended that undertaking a comprehensive geriatric assessment was the optimal approach for assessing older people with frailty. However, the NAO reports that implementation of this assessment is limited.
How can delayed transfers of care be alleviated?
The Age UK (2019a) factsheet aspires to address and prevent some of the problems associated with delayed transfers of care by recommending the implementation of 11 steps. Perhaps the most important of these is to commence the discharge process as soon as practically possible and, where an expected date of discharge is agreed with the patient and family, that this is reviewed regularly.
Age UK also recommends the appointment of a discharge co-ordinator to manage patient need when a proposed discharge is likely to be complex. If after assessment patients are found to need social care, staff should work with the family to prepare a care and support plan and arrange a financial assessment to calculate how much a patient may have to contribute towards the costs of care after discharge. A further recommendation is that the discharge plan with all the information about the patient's treatment, medication and ongoing health needs is shared with the patient's family doctor.
When elderly people are admitted to hospital and care is planned following full assessment, the discharge process becomes more predictable. This allows for the right care and the right support to be put in place before hospital discharge to enable patients to leave when they are deemed medically fit to do so.