Despite best efforts from NHS trusts and the wider system, the number of patients who are medically fit to be discharged but remain in hospital is still high. Here we analyse the data to understand the challenge and the impact it is having on services.
This analysis is part of our weekly piece looking at the urgent and emergency care sitrep review and the monthly performance statistics analysis.
On 13 December 2021, NHS England released a letter in preparation for the Omicron variant and other winter pressures, outlining that:
“...those patients who do not need an NHS bed, because they do not meet the reasons to reside criteria, must be discharged as soon as practically possible. Every system will need to put in place sufficient measures in order to reduce by half their own number of patients not meeting the reasons-to-reside criteria.”
This was subsequently reiterated in January by regional teams, with targets of reducing the number of patients by 30 per cent by mid-January and 50 per cent by the end of the month.
Despite the best efforts of NHS trusts and the wider system, including social care and services in the community, the number of patients medically fit to be discharged but remaining in hospital is actually higher than it was when the letter was first sent, with 12,312 patients who are fit for discharge remaining in hospital (seven-day average of 12,387) compared to 10,236 on 13 December.
So what does the latest data tell us about why are discharges are proving such a problem and what is the impact on services?
The number of patients medically fit to be discharged who remained in hospital was 12,387 on an average day week ending 6 February. This is up compared to 12,257 last week.
An average of 42.7 per cent of patients fit to leave were discharged each day, a slight increase on 42.2 per cent last week. This is the best since week ending 26 December, when there were fewer patients no longer meeting the criteria to reside (average of 19,325 per day, compared to 21,362 last week).
Based on total adult beds open, this means patients fit to leave account for over 13 per cent of the acute beds available.
The total number of days of delayed discharge from mental health services fell in the early stages of the pandemic. In May 2021 it was at 21,525, and from there they have continually increased. By November 2021 the number of days is 27,021, a 26 per cent increase, however there is variation across the country. The number of days of delayed discharge are now largely back to pre-pandemic levels. In the context of high bed occupancy rates and increases in demand for mental health services, this is concerning.
There are several reasons attributed to delayed discharge, but one of the key reasons is finding appropriate housing or accommodation post discharge. This is not a new issue and members of the Mental Health Network have raised this as a concern before the pandemic, but it is increasing.
The total number of days of delays to discharge linked to housing was 4,286 in April 2021 and has continued to increase over the year and were 5,769 in November 2021, an increase of 35 per cent.
The number of days of delayed discharge attributed to patients awaiting a care home with nursing placement or availability has also continued to increase from 3,884 days in April 2021 to 5,238 days in November 2021, a 35 per cent increase.
There has been a significant increase in the number of children and young people needing specialist mental health support during the pandemic and related pressures on inpatient beds. The number of days of delayed discharge attributed to a child or young person awaiting social care or family placement has risen significantly during 2021.
The number was 192 days in January 2021 and has risen to 580 in November 2021, a 202 per cent increase. Whilst the numbers of patients involved are relatively small, they are likely to have complex needs so finding a suitable placement for them can be challenging. With the increase in demand for inpatient beds, the impact on service providers will be significant.
Impact and member feedback
Discharge is a complex area involving a number of organisations, as well as the need to take into account the wishes of the patient and their family. Patients waiting to be discharged can be waiting on a range of services, from a bed in a nursing home to adaptations to housing or awaiting a rehabilitation bed in the community.
Delayed discharges affect flow within hospitals, adding significant pressure to the availability of beds. Challenges in securing packages of care and community or nursing home placements, as well as lack of availability of beds in community hospitals cause an increased length of stay in hospital with more patients becoming ‘super stranded.’ 1
The data released today shows that on an average day week ending 6 February, 17,387 patients had been in hospital for more than 21 days, and of those, 5,968 were medically fit to be discharged. This is considerably higher than last year, when 11,625 patients had been in hospital for more than 21 days in the equivalent week, but more comparable with 2019/20 (16,399). 2
Feedback from our members shows the impact this is having, with ‘unprecedented delays to discharge’ due to a lack of capacity elsewhere in the system.
Members have been finding ways to manage this, converting wards into specific areas for patients who are medically fit for discharge, using personalised budgets to provide packages of care for patients and to enable family members to take time off to care for them, as well as using digital solutions to support patients at home through remote monitoring.
NHS Confederation viewpoint
In order to improve discharge, there needs to be greater, longer term, investment in social care and community care services. Workforce challenges have a particular impact on the ability to discharge patients to other settings, including the availability of social workers to co-ordinate those packages of care. While we welcome the recruitment and retention fund announced by the government in November 2021, to support the retention of social care staff over the winter months, this does not address longer term more systemic funding issues.
Similarly, across the NHS staff are working to support timely and safe discharges, however, workforce is a constraining factor across heath and care and a long term workforce solution is needed if a reduction in discharges is to be accomplished.
The Operational Planning Guidance 2022/23 had a significant focus on maximising the use of virtual wards and expanding the Hospital at Home programme. The £200m available to support the implementation of virtual wards will also help with discharge.
You can also read our further analysis of today’s monthly performance statistics and winter sitrep.