‘Bedblocking’ is stifling our hospitals. But there are ways to ease the burden | Anna Bawden

Lilian Hemsley, 86, was admitted to Queen’s Medical Centre on the outskirts of Nottingham on 30 December following a fall. Seven days later she was able to return home to Chilwell, south Nottinghamshire with a package of help in place. “The social workers were fantastic,” she says. “I had to have my bed moved downstairs and a commode – I wasn’t allowed home until they were sorted out. But they did it really quickly.” Following some interim homecare, Hemsley is getting help washing and dressing in the morning for four weeks through Nottinghamshire county council’s reablement service. She will soon be assessed for ongoing care needs.

But as last week’s figures from NHS England show, Hemsley was one of the lucky ones. All too often patients are stuck in hospital waiting for a social care package, even though they are fit to go home, including 89-year-old Iris Sibley, whose six months in Bristol Royal infirmary was widely reported. In December alone, across England, the number of patients who were officially recorded as stuck in hospital when they could have been discharged topped 6,000, while the number of delayed transfers of care days reached 195,286.

The issue of patients being fit to leave hospital but not able to be discharged – sometimes called “bedblocking” – costs the NHS some £800m a year. It leads to hold-ups in A&E as people are prevented from having operations and moving into wards. It also has an impact on elective surgery. About 70,000 delayed discharges were caused by social care provision not being in place either in the patient’s home or in nursing homes or residential care. As delayed transfers of care are very tightly defined, the true extent of patients remaining in hospital when they are fit to leave is widely believed to be much higher.

According to research by the Nuffield Trust, the number of patients delayed because they were waiting for a care package to be available at home or in a nursing home had risen 172% and 110% respectively since November 2010.

But Nottinghamshire is bucking the trend. Whereas in December, English councils were on average each responsible for 456 days’ delayed transfer of care, Nottinghamshire county council was responsible for just 65 days’ delay – none of them at Nottingham University hospitals trust, which runs QMC and the city hospital.

NUH is one of the biggest hospital trusts in the country, with 90 wards and 1,700 acute beds. On Friday, when I visit, it has 1,380 adult inpatients; 890 are aged over 65 and 111 are over 90. Each month, there are around 350 patients who need some form of social care on discharge.

Last year, Nottinghamshire county council introduced a “cluster” model that allocates 18 social workers to specific clusters of wards. They are the named care coordinators for those wards. From the moment a patient is admitted, the social workers are responsible for establishing potential care needs after discharge and sorting them out as quickly as possible.

As soon as a patient is admitted, social workers establish potential care needs – and sort them out quickly

“We have a nobody waits approach,” says Nicola Peace, a group manager at Nottinghamshire county council who is in charge of the social workers at both hospitals. That approach starts the moment a patient arrives in A&E. Like many hospitals, QMC is not meeting the target that 95% of patients should be seen within four hours in hospital A&E departments in England.

On Friday, 72.3% were seen within the four-hour window.

On a quiet day like Friday there were just three patients on a trolley waiting to go into one of the 20 dedicated bays where the most unwell patients are treated. Often this emergency assessment area is crammed to the rafters, says Dr Mark Simmonds, a critical care and acute medicine consultant at the hospital. “At one point over the new year, we had 180 patients in the emergency department,” he adds.

It is the community care officer Nicola Todd’s job to help ease the pressure on the emergency department. “Sometimes patients’ conditions could be dealt with in the community if they had a bit of social care,” she says. Todd spends most of her days on the phone organising urgent care packages for people who come through the emergency department’s doors but who don’t need to be admitted. Todd’s job is so demanding, the county council is paying for more temporary workers to help her do this triage.

QMC’s 45 wards are also under a lot of strain. On Friday, it had 93% occupancy, well above the 85% target. Over the winter it has opened 61 extra “escalation” beds and spent £139,000 running and staffing them in January alone.

The social workers liaise closely with doctors, nurses, occupational therapists, physiotherapists and dieticians to ensure discharge is not delayed. They attend daily “board round” meetings where patients’ medical progress and potential delays to discharge are discussed. And crucially, they assess patients’ social care requirements well before they are medically fit to go home. Peace says one of the best ways to prevent delayed discharge is to have a dedicated interim homecare service, which can provide services at very short notice, while a longer-term care package is organised.

On the dementia ward, Barry Jones, 83, is having the first assessment of his care needs. He has had a fall and may have heart problems and dementia. Denise Monaghan, a care coordinator based on the dementia ward, is here to do the assessment and to ensure social care doesn’t hold up his discharge when he is ready to return home. Monaghan explains to him that he will need more care and may not be able to go out as much as before. “My job is to make sure you will be safe and looked after at home,” she says. Monaghan checks that Jones wants to be at home and not in residential care. “I want to go home,” he says. Afterwards, Monaghan tells me he will need help getting dressed and ready for bed, and someone to help him with meals. An interim care package can be in place within 24 hours.

The case for reducing delays is overwhelming: on Friday there are 220 patients at QMC and the city hospital who are medically safe to go home, of whom 83 have already been logged as delayed transfers of care – most of them taking up beds because of bottlenecks within the hospital. These are not atypical numbers.

A homecare package costs £50 a day compared with the cost of a hospital bed of about £300. In Nottinghamshire, £818,000 of the health budget in 2016-17 has been redirected into the interim homecare service. This is in addition to £7.68m locally from the government’s Better Care Fund, which is designed to better integrate health and social care.

NUH could save £24.5m a year by cutting all its delays, as well as easing the pressure on the hospital. It has also invested heavily in a state-of-the-art IT system at both hospitals that records and monitors patients in real time. “Before, we used to walk around with pieces of paper and clipboards,” says Simmonds. “Now we no longer need observation charts at the end of patients’ beds. It connects everyone with the same information that’s totally up to date. And crucially it shows us where any delays are occurring.”

The system shows who is in A&E, how long they have been waiting, whether they are going to be admitted – and if so, to which ward. It shows where beds are available and possible pinch points. It is accurate to the minute and also flags up which patients could need social care before they can be discharged and what prescriptions they will need. Launched 18 months ago, this system, from the software company Nervecentre, has seen 6,500 mobile devices issued to all healthcare assistants, nurses, doctors, physiotherapists, occupational therapists and dieticians. They input patients’ medical details, any diagnostic tests or procedures that are necessary and provisional estimated discharge dates. Some social workers also have access to the system.

It is early days and Nottinghamshire has some way to go before it could be classed as the area with the fewest delayed transfers of care for social care. Latest NHS England figures from December show that Darlington reported none, Newcastle six and Rutland 10.

A spokeswoman for NHS England says: “Any increase in delays in being able to discharge patients as a result of pressures in social care affects the ability of hospitals to quickly admit emergency A&E patients, so the NHS is working closely with local councils and community health services to enable older patients to get the support they need after a hospital stay, back at home.”

Paul McKay, service director at Nottinghamshire county council, says: “The hospital discharge homecare service is a good investment as people can leave hospital sooner, and is also meeting the wishes of most older people who tell us they would prefer to live at home independently rather than in a care home setting.”

Liz Sergeant, part of the Emergency Care Improvement Programme (ECIP) at NHS Improve, says: “Our Emergency Care Improvement Programme teams are helping trusts to create teams within A&E and assessment units to allow patients to be treated at home when there is no clinical need for admission, or where the clinical needs can be met by services provided in the community.” Back in Chilwell, Hemsley is starting to feel much better. “I had my hair cut yesterday and tomorrow I’m going to church for the first time since before Christmas,” she says. “I’m really looking forward to that.”

‘Bedblocking’ is stifling our hospitals. But there are ways to ease the burden | Anna Bawden

How memory apps can help people with dementia tap into their past | Anna Bawden

More than 650,000 people in England have dementia and that figure is expected to double by 2040. With wildly differing standards of care across the country, there is growing interest in the role technology could play.

When Robert Armstrong was admitted to The Uplands care home in Shrewsbury, he had a habit of waking up in the middle of night and wandering about. At first staff thought he was just a poor sleeper, but the 68-year-old would become very aggressive when care workers tried to guide him back to bed. He would often need medication to calm him down. It wasn’t until care workers started working more closely with the family to map his life history that they discovered Armstrong had been a milkman for 40 years and thought he was getting up to go to his job. “So when he woke up at 3am, the night staff gave him a cup of tea and biscuits and then he did his ‘rounds’,” says Mandy Thorn, managing director at Uplands. “Robert had a milk crate in his room and he went round leaving milk bottles outside all the residents’ doors. At 6am he had breakfast and went back to bed, while staff picked up the bottles and put them back in his crate, ready for the next day.”

The more that you know about an individual, the easier it is to care for them

Thorn says the effect was instant and transformed Armstrong’s quality of life until his death in early 2015. “We had no more aggression and no need for medication to calm him down. And he was really happy until the day he died.”

Thorn hopes the delay in finding out such crucial information will soon be a thing of the past. From September, Uplands will be using RemindMeCare, an app that uses reminiscence therapy to get people with dementia talking about their memories. Its software automatically creates content that matches the person with dementia’s life story. In addition to photos, the system pulls images of events, favourites places, films and music from the web to create a detailed multimedia profile of the person. This is then used to help stimulate conversation and memories enabling carers to build a better relationship with the individual. For group activities, the software can work out shared interests and help several residents to take part. And family members can upload relevant information to their relative’s profile and be actively involved in their care. “The more that you know about an individual, the easier it is to care for them,” says Thorn. “It will transform our business, make us more efficient, so staff spend more time with our residents, not on paperwork. With ReMindMeCare you have a digital record [of activities and interventions], you don’t have to worry about writing it all down.”

RemindMeCare is the brainchild of Simon Hooper and Etienne Abrahams, who both had family members with dementia. When his mother got dementia, Hooper started to put her life story on to a tablet for her carers to use. “I realised that early memories were the key to communicating with those with dementia and to improving person-centred care, and that it needed tech to record them, so that the memories would not be lost and would be available to each carer in turn,” he says. On meeting Abrahams at a party and discovering that he was building software to store his grandmother’s memories, photos and favourite music, they both realised there was a gap in the market and decided to develop a business. After a year’s planning, they raised money from care experts and crowdfunding and RemindMeCare was born in November 2015.

Samir Patel, owner of Oaklands Rest Home in the New Forest, Hampshire, which has been using the system since May, says: “It’s had a huge impact on our residents. It’s a nice way to engage with your loved one. You can still contribute to their life in a really positive way.”

Not all dementia apps are designed for use in care settings. This month saw the launch of two new apps that people with dementia can use independently (as well as with a carer, if they choose).

Book of You and Playlist for Life use photos, words and music to enable those with dementia to reminisce with carers, family and friends, about things that were important in their lives. These apps are part of a dementia citizens project run by the innovation charity Nesta. Both apps also aim to foster in-depth research on how technology can empower people with dementia to lead more fulfilling lives. Academics at Bangor and Glasgow Caledonian universities, who developed Book of You and Playlist for Life respectively, will conduct regular surveys with 500 users of the apps. “We want to show that technology improves the lives of those with dementia,” says John Loder, head of strategy at Nesta’s health lab. “Who do these apps really work for and how?”

The data may also challenge stereotypes. Early testing for Playlist for Life found that dementia patients did not necessarily want to listen to West End musical hits or the Beatles. “It is very easy to make assumptions about people with dementia and what they are going to like. The only thing they really wanted to listen to was Adele,” says Loder. “They liked the fact that they are listening to the same music as their children and grandchildren.”

Some names have been changed

How memory apps can help people with dementia tap into their past | Anna Bawden

How collaborating with individuals improves hospital care | Anna Bawden

Curtains in Royal Berkshire’s intensive care unit had been modified from vibrant blue to pale green to assist reduce patients’ hallucinations. Photograph: Martin Godwin for the Guardian

When Louise Lusby came round soon after a lifesaving operation at the Royal Berkshire hospital in Studying she was hallucinating. “The very first issue I don’t forget was getting in a superb, soft, warm fluffy bird’s nest. As I acquired much more conscious of my surroundings, I imagined I was in a area station and that the nurses were weightless since they had been moving so slowly,” she recalls.

Hallucinations are typical amid intensive care individuals. When Lusby had the opportunity to take portion in a new project exactly where sufferers and personnel worked jointly to enhance services in intensive care, she leapt at the opportunity to decrease what she had found to be a strange and bewildering experience.

After discussions between staff and patients, the hospital published an details booklet and DVD for family members about how to reply to hallucinations. It also altered the curtains in the intensive care unit (ICU) from vibrant blue to a soft pale green, due to the fact so many patients said the blue colour created their hallucinations worse. “The vibrant shiny blue reflected issues, so I considered all the blond nurses had silver hair,” explains Lusby.

The process also recognized bettering the care provided to ventilated patients, who can not speak whilst they are on a ventilator. Matt Wiltshire, who spent 46 days in intensive care at the Royal Berkshire with acute pancreatitis, says: “When the patients explained how voiceless they felt 1 of the nurses came up with the thought of using an iPad with application they presently utilised for patients with autism or studying disabilities to aid them talk.” The iPad has symbols so sufferers can say they are hungry or thirsty and a keypad so they can sort words, which are then “spoken” by the software program. “Now ventilated individuals can talk with their family members and the medics,” says Wiltshire.

Lusby and Wiltshire are amid 27 patients at the Royal Berkshire taking portion in the project, made by academics from Oxford university’s health experience analysis group, which studies patients’ expertise of sickness. Functioning with professor Glenn Robert at King’s College London, who had produced a new technique to help the NHS make greater use of patient suggestions, the Oxford academics compiled short video clips about patients’ experiences of intensive care and lung cancer companies.

The movies were drawn from Oxford University’s healthtalk on the web archive of more than 3,000 patients talking about their illnesses. They formed the basis for small group discussions among health care staff, managers, patients and relatives who identified priorities for alter.

Jane Woodhull, a cancer clinical nurse expert at Royal Berkshire, says numerous of the changes in lung cancer providers would not have been feasible had patients and employees not been functioning collaboratively. One particular change involved making a quiet area, where individuals and relatives can go soon after a lung cancer diagnosis. “Someone gave up their workplace to develop the quiet room for individuals. That wouldn’t have occurred if a manager had said ‘you will give up your room’. But because they had noticed what a variation it would make to individuals, they were content to.”

The task is also taking spot at the Royal Brompton and Harefield NHS trust in London, where noise and rest deprivation have been identified as priorities for modify in intensive care. Previously individuals had been woken early in the morning to be washed, but now they are washed in the evening to aid help rest and sleep. “We’re also making an attempt to make ICU quieter but that requires a a lot more fundamental cultural adjust,” says Ruth Tollyfield, an intensive care sister at Harefield hospital.

NHS England says the venture, which was relatively low-cost to employ, has caught the interest of other hospitals. Neil Churchill, improving patient expertise director at NHS England, says: “Trusts ought to be acting on patient feedback types and delivering little enhancements as a matter of regimen. But [this strategy] is really valuable when the sought after improvement in patient encounter needs more challenging or basic changes to services.”

Royal Berkshire is searching at how it can be extended to other components of the believe in. “There’s no explanation why it couldn’t be utilized in most places of a hospital,” says Louise Locock, director of utilized research at Oxford university’s overall health experiences research group.

A single of the legacies of the undertaking has been participants’ private satisfaction. Lusby says it was her likelihood “to give anything back to the hospital because without having them I would not be here”.

How collaborating with individuals improves hospital care | Anna Bawden