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
