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4th October 2024
More patients are experiencing delayed discharges from hospitals, but integrated care boards are working with system partners to develop new and innovative ways to address this. Kathy Oxtoby reports.
Patient discharge is a well-documented pinch point for the NHS.
According to The King’s Fund, delayed discharges from hospital are ‘a widespread and longstanding problem that can have a significant impact on both patients’ recovery and the efficiency and effectiveness of health and care services’.
And the Nuffield Trust says a huge challenge facing the NHS is that more patients are experiencing delayed discharges. ‘Reversing this trend is a major system priority given rising waiting lists, overstretched A&E services, and the risks that unnecessary long stays in hospital pose to patients,’ it says.
Analysis by the think tank found that the total number of patients in acute hospitals who were ready to leave but were delayed has increased by 43% from an average of 8,545 patients per day in June 2021 to 12,223 patients per day in June 2024. At its peak, in January 2024, there were 14,096 patients delayed in hospital.
The fall and rise of delayed discharges observed this year may be indicative of winter pressures. ‘Every winter sees an increase in A&E admissions and a reduction of staff due to sickness absence that can hinder effective discharge processes within hospitals,’ it says.
Changes in the total number of delayed patients are mainly attributed to increases in delayed patients who have been in hospital for up to 21 days or longer, this analysis shows. These patients are more likely to experience delays in discharge because often their needs are more complex and their care needs outside of hospital are greater, and organising that care takes more time and resources, says Emma Dodsworth, a researcher at the Nuffield Trust.
Prolonged stays in hospital are ‘bad for patients, especially for those who are frail or elderly’, NHS England says. ‘Spending a long time in hospital can lead to an increased risk of falling, sleep deprivation, catching infections and sometimes mental and physical deconditioning.’
Delays to patient discharge impact the wider health system. ‘We know that hospitals are struggling to manage the flow of patients because of the high volume of beds being occupied by people who might be better cared for elsewhere,’ says Ms Dodsworth. ‘When people are struggling to get out of the system it is more difficult to get people into the system – so we tend to see pressures on entry points to health services such as on ambulance services and A&E departments,’ she says.
Delays to patient discharge are also having an increasing impact on community health services and social care, says Ms Dodsworth. She says often, there is a desire to get people out of acute settings and quickly into community settings in the form of a step-down intermediary care package. ‘But you risk putting them into an additional setting that also faces delays with discharge and risk pushing the bottleneck further down the patient pathway,’ she says.
A lack of capacity in social care settings is often cited as a reason for delayed discharge, says Ms Dodsworth. The most common reason for discharge delays experienced by patients who have been in hospital between seven and twenty days is that they are waiting for some form of home care – and this could be due to staff shortages within the sector, says Ms Dodsworth.
And the most common reason for delayed discharges for patients who have been in hospital 21 days or more is waiting for a bed in a nursing or care home – and there is ‘a shortage of places in council-run care homes’, says Ms Dodsworth.
However, the reasons for delayed discharge are also ‘complex and varied’, she says. These can include hospital processes delaying discharge, for example, a discharge summary that needs to be written up or a final assessment or agreement on what further care the patient might need. Delays to these processes could be due to a shortage of healthcare staff, says Ms Dodsworth.
Funding given to help tackle discharge delays can also bring problems.
To reduce delays every winter, in England, it has become normal practice for the Government to provide additional one-off funding.
Last year, researchers at The King’s Fund interviewed commissioners and service providers in six local areas who said that while they welcomed extra funding, it came with ‘insufficient advance notice for effective planning, sometimes having to be spent on residential care that was available at short notice rather than developing more services to support people at home’.
Commissioners and service providers also wanted to be able to use the funds to prevent avoidable hospital admissions and ‘strongly criticised burdensome monitoring requirements’, researchers found.
Some areas did manage to use the funding to put services in place and support the social care workforce but were ‘not confident they were spending funding as effectively as possible’.
Researchers found varying depths of partnership working and that not all have a shared understanding of local causes of delayed discharges and priorities for action. ‘This, together with fragmented and inconsistent data, could hinder their ability to use additional funding effectively,’ the report found.
Key partners – including ICBs and the local authorities – ‘are all trying to work together, but because of different accountabilities don’t always have a depth of partnership’, says Alex Baylis, acting director of policy, events and partnerships at The King’s Fund, and one of the report’s authors.
Affecting these partnerships is a culture of ‘who is to blame for discharge delays’, with some hospitals blaming social care and vice versa, says Mr Baylis.
This year, the money to reduce discharge delays in winter was rolled into the Better Care Fund ‘so we’ll need to see whether there is a better sense of partnership’, says Mr Baylis.
Some £1.6bn has been allocated to social care services for 2023-25 as part of the Better Care Fund, which will include a focus on reducing delayed discharges, says Ms Dodsworth.
And ICSs have put in place initiatives to better handle winter pressures and the delayed discharges that come about during this time, she says.
Initiatives include virtual wards, allowing people to receive hospital care in their own homes, and transfer of care hubs which bring together system partners to better coordinate services to support timely discharge, says Ms Dodsworth.
Mr Baylis says there are examples of good practice around the country, rooted in local organisations – particularly across the NHS and local authorities – having a shared understanding of their specific local issues and the same shared data and plan.
There are also widespread examples of initiatives using the voluntary and community sectors to support people at home after discharge, he says.
In some areas, work is being done around discharge lounges, ‘which are staffed a bit like wards, may have beds, and can help get people off the wards into a lower intensity environment and free up a bed for someone who is acutely unwell’, he says.
Asked how the primary/secondary or social care/secondary care interface are working to better manage the flow of patients, Mr Baylis says: ‘Each general practice is unique, and each care home is independent, so it’s difficult to generalise how they work with hospitals.’
‘We found the involvement of general practice in local planning around winter discharge was quite variable, partly because it’s difficult to engage all of the GPs because they are independent. But GPs need to know if they are going to have patients discharged with higher levels of acuity and complexity,’ he says.
‘And in social care, the same happens – they are all independent businesses and charities, so different local authorities have different levels of ability to really engage across the whole social care market.
‘They all want the best thing for the individual patient, but they are not always organised to make it easy to deliver that,’ says Mr Baylis.
As for the role ICBs play in supporting the system in terms of patient discharge, he says they are ‘possibly the most interesting part of the entire health and care system at the moment, because they face in two directions’. ‘They support the local providers and services, but at the same time, they answer back up to NHS England,’ he says.
‘If NHS England puts pressure on ICBs to just get people out of hospital, that can undermine their role in supporting the development of the system as a whole because they are skewed towards those priorities.
‘So ICBs have a really important role to keep the focus on facilitating whole system approaches, and not to withdraw into the priorities that NHS England has specifically for hospital performance. It’s a balancing act,’ he says.
‘ICBs are in a tricky position because the short-term priority is to get people out of hospital. But the long-term solutions will only come from the whole system having a shared understanding, plan and way of working,’ he says.
To help address issues with patient discharge, the Nuffield Trust is calling for the government to ‘stop allocating funding to support discharge via short-term emergency pots that make planning impossible’, says Ms Dodsworth.
‘It means that ICS leaders and local authorities are reluctant to commit to commissioning new services because they don’t necessarily have long-term funding to support their ambitions,’ she says.
‘Needs are becoming increasingly more complex, and so we need system leaders to think about how to ensure the right care is available,’ she says. ‘Sometimes when we’re focused so much on getting people out of hospital, we’re not always thinking about whether we’re getting the patients into the best place that meets their care needs.’
Long-term sustainable approaches need to be rooted in prevention, she says. ‘Often, unpaid carers will feel that emergency admission of their loved ones could have been prevented in the first place if there was better access to support in the community. It’s about reframing prevention as a precursor to good care for people,’ says Ms Dodsworth.
Mr Baylis says there is ‘a good potential to reduce admissions to hospital in the first place’. He highlights NHS England’s Enhanced Health and Care Homes framework, ‘where GPs regularly visit care homes and check up on what can be done to keep people well’. He says this has been shown to reduce hospital admissions, particularly emergency admissions.
There’s also a role for ICB leaders to ‘get under the skin of how to make whole system working effective for reducing discharge’, he says. ‘ICB leaders have great potential to really work as system facilitators and support that partnership approach, which is driven by shared understanding and close working approaches that are fundamental to long-term solutions to discharge problems.
‘And when they do that, the benefits for individuals, staff pressures, and budgets are big. It is skilful work that is all about leadership across systems. And it’s not easy,’ he says.
‘Every area has unique challenges with patient discharge, and there is no “one size fits all” solution,’ says Mr Baylis. ‘That’s why it’s so important to have a shared understanding of the specific local issues, a shared plan, shared data, really close working and a shared view of what good looks like.’
Read more about the inspirational work being done across England to support the smooth and timely discharge of patients from hospital in these case studies:
This feature was originally published by our sister publication Healthcare Leader.
3rd February 2022
Delayed inpatient admission from an emergency department (ED) for longer than 5 hours leads to a greater 30-day mortality. This was the conclusion of a study by a team from the Department of Population Health, New York University School of Medicine, New York, US.
In England, the NHS has a 4-hour operational standard which is a binary time threshold such that patients who remain in ED for longer than 4 hours are deemed to have ‘breached’ the target. There are potentially many reasons why patients have a delayed inpatient admission though one factor identified from research which correlates with a higher ED waiting time is higher inpatient bed occupancy.
In addition, some data shows that a longer mean length of stay within the ED, is associated with a greater risk of short term mortality and admission to hospital in patients who are well enough to leave the department.
For the present study, the US team turned to a large NHS database to examine whether delayed inpatient admission was associated with an increased risk of mortality. They used a cross-sectional, comparative, retrospective design and included all patients admitted from ED and measured the time from the patient’s arrival at the ED until their transfer to an inpatient bed.
They set the primary outcome as death from all causes within 30 days of hospital admission. The team collected data over a 2-year period including patient demographics, including co-morbidities and demographics, together with temporal factors such as month of admission, time of admission. Regression analysis which adjusted for factors such as age, co-morbidities etc, was used to model expected and observed mortality.
Findings
A total of 26,738 514 people visited an ED during the two-year study period but data was available for only 5,249,891 admitted patients and who were included in the analysis. Among this group of delayed inpatient individuals, there were 433,962 deaths within 30 days, giving a crude 30-day mortality rate of 8.71%. The mean time spent in ED was just under 5 hours and the 4-hour breach rates averaged around 38%.
In regression analysis, the risk of death increased in a linear fashion from 5 hours after time of arrival in ED up to 12 hours. The factor with the highest risk of 30-day mortality was the 4-hour breach (odds ratio, OR = 1.35, 95% CI 1.33 – 1.37, p < 0.001).
Commenting on these findings, the authors described how there was a ‘dose-dependent’ association between delayed inpatient admission in excess of 5 hours in the ED and 30-day mortality. They calculated that one extra death occurs for every 82 patients who are delayed for more than 6 to 8 hours in the ED and concluded that healthcare policy makers should mandate timely admission from ED to avoid hospital-associated patient harm.
Citation
Jones S et al. Association between delays to patient admission from the emergency department and all-cause 30-day mortality Emerg Med J 2022.
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