Hospital Discharges or the Lack of Them


I’ve written a few times about some of the difficulties about managing and organising discharges from hospital so forgive me for reiterating previously presented points but I couldn’t resist because  there’s an article about it in The Guardian who commissioned a survey of doctors. ‘Bed blocking’ refers to difficulties in discharging patients home from hospital for various reasons when they are ‘medically fit’ to go home.

251 (50%) said the problem known as “bed blocking” – which costs the NHS tens of millions of pounds a year and forces needier patients to wait on trolleys – was worse now than a year ago, while 200 (40%) said it had not improved.

The poll was conducted for the Guardian by Doctors.net.uk, an online professional network to which 90% of UK medics belong.

My bed

I’ve previously mentioned my distaste for the term ‘bed blocking’. I continue to hold that view. It seems to create a sense of misplaced guilt. There is a much longer term failing of systems that leads to this problem and there are often genuine fears, risks and complications that make discharges more difficult than initially presumed.

Having been on the end of many countless angry telephone calls from doctors and nurses about ‘my patients blocking their beds’ – and – please forgive me if I repeat an oft-spoken personal anecdote – having heard a doctor actually blast off to a patient about the cost of keeping her in hospital (it may have been a valid point but it shouldn’t have been made on a ward with other patients within earshot), I think it didn’t need a survey to know that things are getting worse.

For me, the problem lies with higher initial criteria for accessing lower level support at home and the increased charges.  The removal of virtually all preventative services will lead to a higher strain in acute services.

I just wonder where the 10% who thought the problem had improved came from.

It’s obvious that a reduction of the eligibility criteria (FACs) will lead to more people not being entitled to care at home. The other, perhaps more important aspect is the increases in fees that local authorities are charging for care. Some people just don’t think they should be paying for care and there is a mentality that grew up with the establishment of the welfare state that believes absolutely in the ‘I’ve paid in so I should be able to take out when I need’ that resents paying for what is needed.

I’m not making a moral judgement about that, by the way. I absolutely support a social ‘trampoline’ that sits underneath us to not only catch us when we fall, but to help us bounce back up to a level that allows us all to participate in society at a dignified level.

Going back to the Guardian article

One respondent to the survey said patients with severe dementia were spending months in beds intended for those with acute medical problems because the NHS does not have enough places in wards specialising in dementia care. Another said that as many as 80% of the patients they see on an elderly ward “are fit to leave an acute bed but there is nowhere else to go”.

I can think of many examples from my own caseloads and certainly on my teams’ caseloads which concur with these statements. Far worse though are the months spent in psychiatric hotels when no suitable placements have been found. We have a serious shortage of beds not helped (obviously!) by a few wards which had specifically cared for older adults being closed down in a money-saving rush. Money saving? It all spills over. Now there is nowhere to transfer some of those patients in the general hospitals. There are people who need hospital admissions who cannot access beds or are placed on inappropriate wards. It costs a lot.

While there are initiatives that have helped ease some of these problems – the re-enablement service that provides a spike of (yes, free) home care support to help someone in the weeks out of hospital and the provision of both interim and intermediate short term residential and nursing placements while a solution to find someone either a longer term placement or some rehab to get them home.

Neither of these services in our area at least, have been sufficiently tailored to people with dementia. There is a general wider feeling in general services that when someone has dementia they may not be able to get the most from a rehab service.

This is my concern about Lansley’s push into promoting intermediate care and speeding up hospital discharges.

The Department of Health said it was making an extra £162m available between now and the start of April to help patients leave hospital sooner and live independently at home. “It’s really important, particularly at this time of year, that we help people to leave hospital as quickly as they can, when they are ready. The latest figures show that 2,575 beds are unavailable due to delayed transfers of care,” said Andrew Lansley, the health secretary.The money is intended to free up hospital beds by helping older people get more support before and after they leave and to reduce the high number who return to hospital soon after discharge.

The problem in my eyes, and yes, I accept that I see a particular area of social care in focus due to the nature of my job , is that not everyone can live independently at home and there is a lack of good quality local placements which has as much led to a delay in discharge. Subsidising home care for six weeks just masks the issue that people are being asked to pay for their own home care in the longer term. Sometimes the issues relate to unsuitability of housing and no-one can sit out a housing waiting list in a hospital – nor can the intermediate or interim beds accommodate them.

Locally, I can say absolutely that we need more resources available to people with dementia. We need wider work on understanding and supporting people with dementia by care staff. It isn’t an easy job and a lot of people don’t necessarily want to do it – especially at minimum wage and poor contractual terms.

I think the government’s NHS ‘efficiency’ savings may come unstuck by failing to comprehend the links and costs between health and social care. There’s been a perfunctory nod in the direction of social care by the ‘additional money promised’ by the Health Secretary and Care Services Minister  but anyone who thinks that that money will be safe in the face of cuts and non-ring fenced local authority spending is living on a different planet.

It isn’t good. It isn’t looking good. No matter what Lansley says to people who don’t see this situation every single day and whom he manages to fool (indeed, maybe he has fooled himself and truly believes his own figures), things are not going to get better.

And from someone who desperately wants to be an optimist at heart, it’s difficult for me to say that.

4 thoughts on “Hospital Discharges or the Lack of Them

  1. “The problem in my eyes, and yes, I accept that I see a particular area of social care in focus due to the nature of my job , is that not everyone can live independently at home and there is a lack of good quality local placements which has as much led to a delay in discharge”

    You sound institutionalised yourself! I have very significant experience of extra care – including for people with dementia – and there is not a problem here, except those set up by attitudes and habit.

    Every locality should have a full singing and dancing extra care service with excellent links to local and specialist health services, co-operatively run and person centred, with the professionals working with each other and the local clients. They would no longer work for health or social services or housing but for their local community.

    • In theory, yes, of course you’re right. In practice where I work there is no such service for people with dementia. It exists on paper and in the mind’s eye of the commissioners. Reality though is very different and I have to write from and around my own realities.

  2. It’s terrible these days that people are “thrown out” of hospital so quickly, often before they are ready, or without adequate backup at home. It’s all about targets, figures, never mind the people behind them. It isn’t the Nurse, Doctor or Social Workers fault, it’s the system. However I do think we should all have a little more backbone and tell the Managers and Government what they can do with their targets!

  3. Pingback: “Care” in the NHS « NHS Madwife

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