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Good progress is being made by the Department of Health and other health and social care bodies in ensuring that older people who have finished treatment in acute hospitals are discharged promptly. According to the National Audit Office, however, more needs to be done to meet the Government’s target to end widespread delays in patient discharge by 2004. The shortage of places in care homes is the most significant constraint on meeting that target.

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Head of the NAO Sir John Bourn reported to Parliament today that hundreds of thousands of older people are successfully discharged from hospital each year, but on any given day more than 4,000 people over the age of 75 remain there despite being declared fit to leave. However, the figure for September 2002 – some 4,100 people over the age of 75 (just under 9 per cent of the total in hospital) – was down from almost 5,700 people (12 per cent) 12 months earlier.

Although for many the delay was short, 34 per cent of those affected were delayed for more than a month. There were a range of causes, including poor procedures within hospitals, inadequate co-operation between the health and social care sectors, and a lack of capacity in appropriate post-hospital care. Delays can have knock-on effects for others awaiting treatment and can significantly affect a patient’s physical and mental well-being.

The NAO’s study found that improvement in different parts of the health and social care system were leading to real reductions in the levels of delayed discharge. Actions already taken include the distribution of £300 million of Building Care Capacity Grant to local authorities linked to targeted reductions in delays in hospitals in their area, and over £800 million by 2003-04 within the NHS to develop intermediate care facilities. Further measures are being developed, and the Government recently introduced into Parliament a bill to create a system of reimbursement of hospitals for delays caused by social services departments.

However, the NAO identified the need for further work in three main areas. Firstly, within NHS acute Trusts, improvements to discharge planning have been made by many since the last NAO examination in 1999 but more needs to be done. More Trusts should start discharge planning earlier, and more should undertake assessments of care pathways for older patients to identify potential obstacles to discharge. The major cause of delays remains the length of time to carry out ‘needs assessments’, often the result of a continuing shortage of skilled therapists. The introduction of a Single Assessment Process (in 2004) is seen as crucial for improving patient flow. In addition, the NAO is concerned by evidence of inconsistency in how acute trusts define “delayed discharge” and problems with the accurate collection of data about delayed discharges since April 2002.

Secondly, in terms of co-operation between health and social care bodies, there are encouraging signs of improvement despite their separate histories, often incompatible administrative systems, and lack of common geographical boundaries. However, there has been limited use of opportunities for integration of older people’s services offered by the Health Act 1999 and limited progress made in establishing Care Trusts.

And finally, additional funding has allowed an expansion of support for older people in the community and residential care, but shortfalls in capacity remain. Alternatives such as intensive home care, and intermediate care that can avoid the need for residential care, are developing, though slowly, and there are significant variations in provision of intermediate care services that should be addressed. Numbers of care home places are falling, and private sector care providers cited poor commissioning practice, financial pressures and high property prices as reasons for this. Primary Care Trusts and social services need urgently to develop a strategic overview of providers in their areas to address shortfalls in service provision, especially through better relationships with the independent sector.

The report also recommended that:

  • delays in the non-acute sectors of the NHS (not just the acute) should be investigated further;
  • the Department should vigorously pursue the development of integrated care records and, in the meantime, encourage hospitals and social services to share information more effectively;
  • Trusts should examine current practices for involving patients and carers in discharge decisions to ensure they are meeting expectations; and
  • NHS Trusts and Primary Care Trusts should involve private sector care providers more in the planning and development of older people’s services.

"Many tens of thousands of older people each year find themselves unable to leave hospital, even though their treatment has been completed. This significantly reduces their quality of life and undermines the ability of hospitals to treat more patients and meet testing targets.

"The Department of Health has made strides in the last 18 months to address this problem but the pressures on the health and social care systems are unrelenting. This is a classic case of the need for ‘joined-up government’ with the NHS, local authorities and private and voluntary sector care providers working together. The Department should ensure that it is doing everything it can to allow this to happen."

Sir John Bourn

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