Healthcare (Delayed Discharges)

Andrew Murrison Excerpts

1st reading
Wednesday 16th March 2022 Commons Chamber

[Dr Andrew Murrison (South West Wiltshire) (Con)]

I beg to move,

That leave be given to bring in a Bill to make provision about expediting the transfer of patients who are medically fit for discharge from acute hospitals to homely settings in the community.

I declare my interest as a doctor.

Twenty years ago, I asked that leave be given

“to bring in a Bill to provide an upper limit on the time that a person who is ready in all respects for discharge must wait before leaving an acute hospital.”—[Official Report, 12 February 2002; Vol. 380, c. 76.]

The context in 2002, as now, was severe congestion in health and social care. Bed blocking is a provocative term that I use to draw attention to the harm caused to patients and the burden on our national health service. At that time, on any given day around 6,000 beds were occupied by people who should not have been in them. Indeed, Tony Blair told the House that

“bed blocking is probably the most urgent problem that we face in the national health service.”—[Official Report, 4 July 2001; Vol. 371, c. 259.]

In November, my mother-in-law died in Salisbury’s renowned spinal unit, but Selma did not have a spinal problem. She had the general frailty and multiple comorbidities of advanced old age. Her overall management was good, in parts, but modern district general hospitals are not configured for the long-term care of the elderly or for terminal care, so a good and gentle person spent her final days in acute medicine’s bewildering freneticism, noise and clamour. It was very far from ideal. She deserved much better. I have seen much better, notably in community hospitals and intermediate care—settings that have, foolishly in my view, been deprioritised under successive Governments.

An acute hospital is no place for an elderly person who is no longer receiving active medical management. I would go further and say that our frantically busy acute units, operating in the white heat of high-tech, cutting-edge medicine, can be unsafe for them. They are in constant danger of the serious iatrogenic consequences of unnecessarily prolonged stays, including hospital-acquired infections, thrombosis, skin breakdown, mental illness and psychological distress. The care pathway must lead frail elderly people to homely settings in the community that are appropriate to their needs, without delay. That long-held conviction, and my recent family experience, has driven me, 20 years after my original Bill, to have another go.

Bed blocking is everybody’s business, because our relatively efficient health system is always running hot, with bed occupancy rates far higher than those in most comparable healthcare economies. The cost to healthcare is enormous: the cost per day of an acute medical bed far outstrips the cost of homely settings in the community, supported living at home, community hospitals or nursing homes. The charity, Marie Curie, puts the annual cost at £1.5 billion. This zero-sum gain is stoked up by an institutional conspiracy of inaction, and that is because there is a baked-in perverse incentive for cash-strapped local authorities to drag their feet when getting people out of hospitals and onto their books. Hospitals save because beds, once freed up, fill up with people requiring treatment and procedures, the costs of which are, of course, front loaded.

In February 2020, an average of 5,370 people per day were bed blocking. We do not know what has happened since as data collection was suspended. Up till then, delays attributed to the NHS were hovering at about 60%. Delays attributable to social care—that is to say local authorities—were consistent at about 30%. The remaining 10% were attributed to failures by both NHS and social care. It would be good to compare and contrast trust performance, but the data are no longer available.

Back in 2002, the main roadblock in the care pathway was different. Speaking to my Bill then, I said that

“insufficient community care and support is the greatest single impediment to timely discharge. The Bill would facilitate a model based on the Swedish approach to delayed discharges. That hugely successful innovation provides for cash transfers and penalties between agencies to achieve bed blocking targets.”—[Official Report, 12 February 2002; Vol. 380, c. 77.]

Indeed, the Blair Government went on to bring in legislation based on the Swedish model a year later in what became the Community Care (Delayed Discharges etc.) Act 2003. The Act permitted NHS trusts to charge local authorities £100 a day from 48 hours after patients were judged fit to leave hospital. A compensating £100 million three-year cash transfer from NHS to social services created a virtuous money circle.

Bed blocking was actually falling before those measures were introduced. However, evidence of the policy’s success came in the wake of the Care Act 2014. The 2014 Act amended the 2003 Act from a local authority “must make a payment” to one in which an NHS body “may” require the authority to pay up, and bed blocking started to climb once again. The number of delayed discharge days in the NHS increased from an average of 114,000 a month in 2012 to more than 200,000 in October 2016.

Covid catalysed the discharge to assess—D2A—and home-first models, first trialled in 2016. The Coronavirus Act 2020 brought a relaxation of the duties around NHS continuing healthcare. This meant the assessment and organising of ongoing care taking place when people were back at home. The immediate utility of D2A became clear in spring 2020: 30,000 acute beds were freed up immediately. Although the longer-term benefit is more difficult to measure in the absence of publicly available data, anecdotally, Marie Curie and other organisations in the field report success.

There are grounds for optimism, too, in the anticipated shift to a more joined-up system of health and social care. Since I introduced my Bill 20 years ago, the main cause of delayed discharge appears to have shifted from local authorities to the NHS, but, wherever the block lies, the new ecosystem encourages collaboration through integrated care partnerships, with more accountability upwards where there has been very little in recent times.

Drawing all this together, my Bill, first, requires lead hospital clinicians to certify daily which of their patients are fit for discharge. Secondly, it defines delayed discharges as a delay of more than 48 hours beyond the date of the lead clinician’s certificate. Thirdly, it establishes delayed discharge as a patient safety issue and includes it under the definition of a qualified incident for investigation by the health service’s safety investigation body, established under health and care legislation. Fourthly, it requires local authorities to transfer to relevant NHS trusts the daily rate it pays for nursing home care for each delayed discharge day attributed by the health service’s safety investigation body to a failure of social care at the point of the move. Fifthly, it transfers the aggregated delayed discharge levies back to social care centrally in a virtuous money circle. Sixthly, it requires delayed discharge data to be published in a league table of NHS trusts and integrated care partnerships every three months. Seventhly, it requires the Care Quality Commission to investigate the worst-performing decile in the league tables within three months of publication to specify the deadline for itemised remedial action, to identify the body or bodies on which actions are placed, and to report to the Secretary of State. Eighthly, the Bill would require integrated care partnerships to include delayed discharges as a standing agenda item.

Finally, Selma’s Bill would have a special category of asterisked delayed discharge for those judged by lead clinicians to be entering their final days. People in this category, which will be reported on as a subset, will be subject to fast-tracking, so that we can speed the transfer of the most vulnerable from inappropriate acute settings to more appropriate, homey settings in the community.

Question put and agreed to.

Ordered,

That Dr Andrew Murrison, Tracey Crouch, Nick Gibb, Steve Brine, Dr Luke Evans and Dr Caroline Johnson present the Bill.

Dr Andrew Murrison accordingly presented the Bill.

Bill read the First time; to be read a Second time on Friday 6 May, and to be printed (Bill 283).