Bed Blocking: Can Discharge to Assess Help?
The problem of bed blocking- patients being medically fit for discharge but unable to return home for non-medical reasons- is not new. A lack of timely social care, leading to ‘social care delayed discharges’, is estimated to cost the NHS a staggering £27,000 every hour and accounts for over 1 million bed days per year. But more importantly, it creates uncertainty and immeasurable distress for patients and their relatives, and an increased risk of all that comes with being in hospital for longer than needed including the risk of picking up an infection or developing a blood clot (DVT).
It has been estimated that 10 days of bed rest for healthy older people can equate to 10 years of muscle ageing with corresponding loss of function- in the frail elderly, time spent unnecessarily in hospital can have profound physical not to mention psychological effects. From a hospital perspective, it prevents these beds from being used by patients who need them for direct clinical care, and leads to backlogs in the entire system right the way back to A&E.
The Effect of Covid
The importance of bed blocking came into sharp focus last March when the capacity of the NHS to manage demand was abruptly questioned, more so than at any time I can remember. One response was widespread enthusiasm for the ‘Discharge to Assess’ model (D2A). D2A has been around for some time, but the situation brought on by Covid made it particularly relevant.
In a nutshell, D2A is aimed at ensuring that patients leave the acute hospital environment as quickly as (safely) possible, and that those in need of care services are provided with short-term, funded support to be discharged to their own home or another community setting. Rather than an ongoing needs assessment taking place in hospital, it is done after discharge. This builds directly upon NICE Guidelines that stress the importance of interdisciplinary work cutting across the hospital and community sectors.
Challenges of Implementation
Whilst the principle behind D2A is clear, a key challenge has been how to integrate it within existing systems where the infrastructure, staffing and, importantly, mindset and expectations of many involved is often built around hospital-based assessments. Another difficulty has been allowing the most appropriate source of funding to be identified quickly. Recent guidance from the Department for Health and Social Care clarifies that “the government has provided funding, via the NHS, to help cover the cost of post-discharge recovery and support services, rehabilitation and reablement care for up to 6 weeks following discharge from hospital”. However, there is local autonomy in how this is actioned. For patients who are self-funding, after the 6 week period has finished they are responsible for finding their own care provider and (as per the NHS Constitution and NHS Long Term Plan) should be empowered to choose the service they feel is right for them. This is one of the places where we believe CareCompare can add real value.
The Solution to Bed Blocking?
In my view, D2A is the correct way to go. The less time spent in a hospital of any kind, the better. However, we must ensure that discharge is safe because the consequence of discharging someone when they are not ready is at best costly, and at worst catastrophic.
Social care is complicated not just because the elderly often have complex care needs, but also because of the sheer number of people who must be involved to make care truly holistic- hospital teams, community teams, GPs, family members, social workers, local authorities and more. Unless all of these groups operate in harmony there is a real risk of falling off the delicate knife edge between keeping patients in hospital when they need to be there, but not keeping them in hospital when they don’t need to be there. The tough part is working out what we mean by the word ‘need’.
Please note that the views expressed here are those of the author alone and not necessarily those of any other person or organisation.