More patients are experiencing delayed discharges from hospitals, but ICBs are working with system partners to develop new and innovative ways to address this. Learn about how Central London Community Healthcare Trust, The Royal Free London, Mid and South Essex ICB and Leeds Health and Care Partnership are approaching this longstanding issue. Kathy Oxtoby reports.
Patient discharge is a well-documented pinch point for the NHS.
According to The King’s Fund, delayed discharges from hospital are ‘a widespread and longstanding problem that can have a significant impact on both patients’ recovery and the efficiency and effectiveness of health and care services’.
And the Nuffield Trust says a huge challenge facing the NHS is that more patients are experiencing delayed discharges. ‘Reversing this trend is a major system priority given rising waiting lists, overstretched A&E services, and the risks that unnecessary long stays in hospital pose to patients,’ it says.
Analysis by the think tank found that the total number of patients in acute hospitals who were ready to leave but were delayed has increased by 43% from an average of 8,545 patients per day in June 2021 to 12,223 patients per day in June 2024. At its peak, in January 2024, there were 14,096 patients delayed in hospital.
The fall and rise of delayed discharges observed this year may be indicative of winter pressures. ‘Every winter sees an increase in A&E admissions and a reduction of staff due to sickness absence that can hinder effective discharge processes within hospitals,’ it says.
Changes in the total number of delayed patients are mainly attributed to increases in delayed patients who have been in hospital for up to 21 days or longer, this analysis shows. These patients are more likely to experience delays in discharge because often their needs are more complex and their care needs outside of hospital are greater, and organising that care takes more time and resources, says Emma Dodsworth, a researcher at the Nuffield Trust.
Dangers of staying in hospital for too long
Prolonged stays in hospital are ‘bad for patients, especially for those who are frail or elderly’, NHS England says. ‘Spending a long time in hospital can lead to an increased risk of falling, sleep deprivation, catching infections and sometimes mental and physical deconditioning.’
Delays to patient discharge impact the wider health system. ‘We know that hospitals are struggling to manage the flow of patients because of the high volume of beds being occupied by people who might be better cared for elsewhere,’ says Ms Dodsworth. ‘When people are struggling to get out of the system it is more difficult to get people into the system – so we tend to see pressures on entry points to health services such as on ambulance services and A&E departments,’ she says.
Delays to patient discharge are also having an increasing impact on community health services and social care, says Ms Dodsworth. She says often, there is a desire to get people out of acute settings and quickly into community settings in the form of a step-down intermediary care package. ‘But you risk putting them into an additional setting that also faces delays with discharge and risk pushing the bottleneck further down the patient pathway,’ she says.
Reasons for delayed discharge
A lack of capacity in social care settings is often cited as a reason for delayed discharge, says Ms Dodsworth. The most common reason for discharge delays experienced by patients who have been in hospital between seven and twenty days is that they are waiting for some form of home care – and this could be due to staff shortages within the sector, says Ms Dodsworth.
And the most common reason for delayed discharges for patients who have been in hospital 21 days or more is waiting for a bed in a nursing or care home – and there is ‘a shortage of places in council-run care homes’, says Ms Dodsworth.
However, the reasons for delayed discharge are also ‘complex and varied’, she says. These can include hospital processes delaying discharge, for example, a discharge summary that needs to be written up or a final assessment or agreement on what further care the patient might need. Delays to these processes could be due to a shortage of healthcare staff, says Ms Dodsworth.
Funding issues
Funding given to help tackle discharge delays can also bring problems.
To reduce delays every winter, in England, it has become normal practice for the government to provide additional one-off funding.
Last year, researchers at The King’s Fund interviewed commissioners and service providers in six local areas who said that while they welcomed extra funding, it came with ‘insufficient advance notice for effective planning, sometimes having to be spent on residential care that was available at short notice rather than developing more services to support people at home’.
Commissioners and service providers also wanted to be able to use the funds to prevent avoidable hospital admissions and ‘strongly criticised burdensome monitoring requirements’, researchers found.
Some areas did manage to use the funding to put services in place and support the social care workforce but were ‘not confident they were spending funding as effectively as possible’.
Central London Community Healthcare NHS Trust: virtual ward and Quick Start initiatives
To reduce unnecessary delays to discharge and needless admissions to hospital, Central London Community Healthcare NHS Trust ‘s (CLCH’s) Hospital at Home Service in Wandsworth and Merton operates as a virtual ward.
One of the first community trust-led virtual wards in the country, it combines technology and face-to-face visits to allow hospital-level care, including diagnostics and treatment, to be carried out in a patient’s own home.
Through on-the-spot blood testing, remote monitoring and face-to-face visits from advanced nurses at CLCH, frailty patients receive the hospital-level care they need safely and conveniently and closer to their support networks, the trust says.
Since its launch in December 2021, the trust estimates the initiative has saved approximately 4,836 hospital bed days in Wandsworth and Merton (as of August 2024).
This approach helps to ease urgent and emergency care capacity pressures by improving patient discharge rates, or avoiding admission.
The trust’s Quick Start initiative brings together CLCH’s Hospital at Home and discharge services to provide ‘the right care to patients at home’, the trust says. Patients can be provided with therapy, medical or social care support dependent on their needs, preventing admission to hospital and supporting earlier discharge from hospital.
CLCH works with acute services at the point of admission to ensure that the package of care a patient needs at home will be ready for them as soon as they are well enough to leave hospital, preventing delays due to the absence of safeguarding support or equipment to help their recovery, the trust says.
Dr John Rochford, deputy chief medical officer at Central London Community Healthcare NHS Trust says: ‘In collaboration with South West London Integrated Care System – our partners in acute, primary and social care – we provide tailored support to care for our communities at home.’
He says CLCH and the South West London ICB are ‘enhancing patient care through the use of virtual wards with a focus on ensuring seamless integration of services, pre-hospital care to help patient flow and improving patient outcomes through prevention and early interventions’.
‘The partnership around virtual wards exemplifies a shared commitment to delivering high-quality healthcare in many areas, such as digital solutions to support clinicians to make quicker and safe bedside decisions, to meet the needs of the community,’ he says.
‘This innovative way of working means that we are able to support more patients to get better in their own homes, helping them to avoid unnecessary and lengthy admissions to hospital, which can have a detrimental impact on their health,’ says Dr Rochford.
‘Patients fare better in familiar surroundings, when they can sleep in their own bed, eat the food they like and have friends, family and pets around them whenever they wish,’ says Dr Rochford.
Mark Creelman, Merton and Wandsworth place lead at South West London ICB, says: ‘Across South West London, there are four virtual ward – hospital at home – services covering our six boroughs, all with face to face and remote monitoring capabilities to provide hospital level care for patients who would otherwise be on a ward, in the comfort of their own home where it is safe to do so.
‘We now have 415 “beds” with a central remote monitoring hub operating 24 hours a day, 7 days a week to support patients’ own monitoring, and we continue developing our virtual wards to improve services, help ease pressures on urgent and emergency care and contribute to reducing avoidable admissions.’
Varying depths of partnership working
Researchers found varying depths of partnership working and that not all have a shared understanding of local causes of delayed discharges and priorities for action. ‘This, together with fragmented and inconsistent data, could hinder their ability to use additional funding effectively,’ the report found.
Key partners – including ICBs and the local authorities – ‘are all trying to work together, but because of different accountabilities don’t always have a depth of partnership’, says Alex Baylis, acting director of policy, events and partnerships at The King’s Fund, and one of the report’s authors.
Affecting these partnerships is a culture of ‘who is to blame for discharge delays’, with some hospitals blaming social care and vice versa, says Mr Baylis.
This year, the money to reduce discharge delays in winter was rolled into the Better Care Fund ‘so we’ll need to see whether there is a better sense of partnership’, says Mr Baylis.
The Royal Free London NHS Foundation Trust: improving the discharge lounge
An extensive refurbishment of the Royal Free Hospital’s discharge lounge has improved patient flow, by allowing more medically fit patients to be transferred from the ward while they wait to be discharged.
Since its refurbishment last year, the usage of the lounge has increased from an average daily attendance of nine patients per day to 31 patients per day, the Royal Free London NHS Foundation Trust says.
Located on the ground floor near the front of the hospital, the lounge has TVs, magazines, newspapers, a full a la carte menu available to patients to receive hot and cold meals, and a self-serve refreshment station, giving it the feel of stepping into an “Upper Class” airport lounge.
All patients leaving hospital don’t need to wait on the ward for transport, medication, or paperwork – they can come to the lounge and wait in comfort, allowing their vacated ward bed to be made ready for a new patient coming into the hospital.
The lounge is staffed with two registered nurses, two health care assistants and an administrator who can help with transport bookings, new and existing.
Since the refurbishment the lounge has much more capacity. Kyle Harding, assistant operations manager, says: ‘We have the capacity to see up to 26 patients which we can turn over every three to four hours.’
Capacity ranges from high, mid and low back chairs, electronic reclining chairs, a dedicated bariatric electronic chair and a trolley space.
Almost all (98%) of patients have positive experiences with the discharge lounge service as reported through friends and family tests.
Addressing discharge issues
Some £1.6bn has been allocated for years 2023-2025 to social care services as part of the Better Care Fund, which will include a focus on reducing delayed discharges, says Ms Dodsworth.
And ICSs have put in place initiatives to better handle winter pressures and the delayed discharges that come about during this time, she says.
Initiatives include virtual wards, allowing people to receive hospital care in their own homes, and transfer of care hubs which bring together system partners to better coordinate services to support timely discharge, says Ms Dodsworth.
Mr Baylis says there are examples of good practice around the country, rooted in local organisations – particularly across the NHS and local authorities – having a shared understanding of their specific local issues and the same shared data and plan.
There are also widespread examples of initiatives using the voluntary and community sectors to support people at home after discharge, he says.
In some areas, work is being done around discharge lounges, ‘which are staffed a bit like wards, may have beds, and can help get people off the wards into a lower intensity environment and free up a bed for someone who is acutely unwell’, he says.
Asked how the primary/secondary or social care/secondary care interface are working to better manage the flow of patients, Mr Baylis says: ‘Each general practice is unique, and each care home is independent, so it’s difficult to generalise how they work with hospitals.’
‘We found the involvement of general practice in local planning around winter discharge was quite variable, partly because it’s difficult to engage all of the GPs because they are independent. But GPs need to know if they are going to have patients discharged with higher levels of acuity and complexity,’ he says.
‘And in social care, the same happens – they are all independent businesses and charities, so different local authorities have different levels of ability to really engage across the whole social care market.
‘They all want the best thing for the individual patient, but they are not always organised to make it easy to deliver that,’ says Mr Baylis.
As for the role ICBs play in supporting the system in terms of patient discharge, he says they are ‘possibly the most interesting part of the entire health and care system at the moment, because they face in two directions’. ‘They support the local providers and services, but at the same time, they answer back up to NHS England,’ he says.
‘If NHS England puts pressure on ICBs to just get people out of hospital, that can undermine their role in supporting the development of the system as a whole because they are skewed towards those priorities.
‘So ICBs have a really important role to keep the focus on facilitating whole system approaches, and not to withdraw into the priorities that NHS England has specifically for hospital performance. It’s a balancing act,’ he says.
‘ICBs are in a tricky position because the short-term priority is to get people out of hospital. But the long-term solutions will only come from the whole system having a shared understanding, plan and way of working,’ he says.
Mid and South Essex ICB and Mid and South Essex NHS Foundation Trust: home first ethos
High demand for services, more patients with complex care needs, and making sure there is sufficient flow in discharge services, are some of the main challenges facing the ICB and hospital trust when managing patient discharge.
The hospital trust works jointly with the three local authorities to promote a home first ethos.
System challenges are being addressed through ‘shared thinking, shared responsibility, and putting patient outcomes at the heart of all decision making’, the ICB and trust say.
In Mid and South Essex, there is an established Stewardship programme, which is about forming teams that bring together perspectives from the whole cycle of care – from across all services supporting residents moving through the health and care system, from before they enter, to after they step out.
Ageing Well stewards have co-designed a common assessment tool to help identify and meet the needs of older people who often have complex needs. Results have seen more than 12,000 new people with frailty/dementia/end of life needs identified in the first year alone, and more than a 50% reduction in older people with more than 3 unplanned hospital admissions in their last 90 days of life.
Schemes such as Urgent Community Response Teams, can provide two weeks of intensive treatment in a person’s home or care home, are ensuring more urgent care in the community.
Supporting people to get home and become as independent as soon as possible has also been a focus. This has been done through continued partnership working with system partners to offer ‘at home’ reablement and virtual ward services to support people to go home if they are able for ongoing assessment.
Transfer of care hub teams have been working on making sure community services information can be accessed by wards – which is being trialled in a small number of wards on two of the hospital sites – and with support from community matrons to highlight what support community teams can provide on discharge. ‘This is having a positive impact on ward teams’ confidence in discharging residents with complex issues to home, rather than to short term bedded care,’ the ICB and trust says.
Charis Shop provides hospital discharge teams with immediate access to funds to help them discharge a person safely home. The scheme came about to support the delivery of a one-off discharge support package that could help reduce unnecessary discharge delays. It allows those with low level needs to be supported with essential items such as food and fuel vouchers, bedding, small appliances and phone top ups.
Using the fund in this way supports people – who might otherwise have had an extra day or two in hospital waiting for assessment or support from other agencies – to be discharged and receive a follow up from statutory or voluntary services if needed once they are home.
Within the last year, the Integrated Discharge Teams have supported the distribution of more than £19,000 of grants to 155 people through the Charis fund.
Michelle Stapleton, integrated care operations group director for Mid and South Essex NHS Foundation Trust says: ‘We now focus on a patient’s discharge journey from the moment they are admitted. Using same day emergency care services has enabled us to treat and transfer or discharge at the front door, reducing the need for stays in hospital. Work to reduce length of stay is important in increasing flow across the hospital and we can only do this by working in an integrated way with our wider health system partners.
‘There have been some bumps along the way, but we must remember our ethos of home first. Patients will always feel better if they can recover with support in their own homes,’ she says.
Dr Matthew Sweeting, executive medical director for NHS Mid and South Essex, says: ‘Supporting effective discharge is not a one-size-fits-all process, and as a system we are focussed on ensuring smooth and timely discharges that consider the holistic needs of patients and maximise health outcomes.
‘We know that beds in residential settings are not always the answer to supporting people to get home at the right time. We need to continue to support our community teams across health and social care to work together and have strong networks to help our residents to remain or regain independence after a stay in hospital. It’s important to reduce unnecessary admissions by having care at home and using community home-based services such as our Urgent Community Response teams (UCRT) and virtual hospital.
‘We recognise that discharge planning starts on admission and that in working with our partners across the system, we need to ensure our discharge pathways flow well and that teams can work together to problem solve and support our residents. One team cannot solve this on their own,’ he says.
Long-term sustainable solutions
To help address issues with patient discharge, the Nuffield Trust is calling for the government to ‘stop allocating funding to support discharge via short-term emergency pots that make planning impossible’, says Ms Dodsworth.
‘It means that ICS leaders and local authorities are reluctant to commit to commissioning new services because they don’t necessarily have long-term funding to support their ambitions,’ she says.
‘Needs are becoming increasingly more complex, and so we need system leaders to think about how to ensure the right care is available,’ she says. ‘Sometimes when we’re focused so much on getting people out of hospital, we’re not always thinking about whether we’re getting the patients into the best place that meets their care needs.’
Long-term sustainable approaches need to be rooted in prevention, she says. ‘Often, unpaid carers will feel that emergency admission of their loved ones could have been prevented in the first place if there was better access to support in the community. It’s about reframing prevention as a precursor to good care for people,’ says Ms Dodsworth.
Mr Baylis says there is ‘a good potential to reduce admissions to hospital in the first place’. He highlights NHS England’s Enhanced Health and Care Homes (EHCH) framework, ‘where GPs regularly visit care homes and check up on what can be done to keep people well’. He says this has been shown to reduce hospital admissions, particularly emergency admissions.
There’s also a role for ICB leaders to ‘get under the skin of how to make whole system working effective for reducing discharge’, he says. ‘ICB leaders have great potential to really work as system facilitators and support that partnership approach, which is driven by shared understanding and close working approaches that are fundamental to long-term solutions to discharge problems.
‘And when they do that, the benefits for individuals, staff pressures, and budgets are big. It is skilful work that is all about leadership across systems. And it’s not easy,’ he says.
‘Every area has unique challenges with patient discharge, and there is no “one size fits all” solution,’ says Mr Baylis. ‘That’s why it’s so important to have a shared understanding of the specific local issues, a shared plan, shared data, really close working and a shared view of what good looks like.’
Leeds Health and Care Partnership: a person-centred home-first model
Work is taking place across the West Yorkshire Health and Care Partnership ICS to help address patient discharge issues.
A person-centred ‘home-first’ model of intermediate care across Leeds that is joined up and promotes independence is the vision of the HomeFirst programme run by Leeds Health and Care Partnership – one of the five places under the ICS.
The programme was prompted by the need to improve the delivery of intermediate care in Leeds. ‘As partners working in Leeds, we knew that by working together we could support people better and that they were not always getting the best possible outcomes,’ says Megan Rowlands, programme director for the Leeds HomeFirst programme.
In Autumn 2022, more than 200 people across the Leeds system worked together to complete a system-wide diagnostic review of outcomes from the intermediate care available and the interaction of acute, community and social care services.
The diagnostic work involved the detailed review of over 220 cases, data analysis of more than 50,000 patient journeys, the views of over 600 patients, service users, families and carers, and input from eight organisations across Leeds.
The findings from the diagnostic review included that too many people were spending more time in hospital than they needed to or could have avoided hospital altogether.
The review also found that short-term care in the community was provided across many different services and that people also spent more time than they needed to in many of these services. Capacity challenges in these services meant many people who could benefit from intermediate care were going straight into long-term care with lower levels of independence than they might otherwise have achieved.
There was a relatively high use of bed-based care, and more people could have been supported to stay at home with a greater level of independence. And many older people could have reduced or avoided the deconditioning that has an impact on their independence and long-term care needs, the review found.
To help address these issues, five core projects have been established within the HomeFirst programme, starting in May 2023.
- Active Recovery at Home has involved redesigning the home-based intermediate care offer to maximise capacity and deliver the best outcomes for people accessing these services.
- Enhanced Care at Home is about transforming preventive services to avoid escalations in need with a specific focus on avoidable acute admissions.
- Rehab and Recovery Beds has involved transforming bed-based intermediate care to improve outcomes and minimise length of stay in short-term beds.
- Transfers of Care has involved redesigning the discharge model to minimise discharge delays and ensure the most independent outcomes for people leaving hospital.
- And System Visibility and Active Leadership is about making use of the data in the system to produce system and service-level dashboards while establishing the right cross-partner governance to make effective decisions using these.
Within each project, design groups of system experts have come together to shape the changes required. These range from progress changes, digital tools and new ways of working through to new models of service delivery.
These changes have then been piloted and iterated with individual teams, using evidence gathered on the performance of key measures, staff feedback and patient/service user feedback, before being scaled up across the system.
As of June 2024, 100 more people were able to go home after their time in intermediate care instead of a long-term bedded care per year. There was a 7.3 day reduction in the average length of stay in short-term beds. Some 478 additional people have benefitted from reablement each year. There are 422 more people going directly home each year after their stay in hospital instead of a bedded setting. And 1,082 fewer adults are being admitted to hospital each year.
‘Supporting more people to go home rather than into long-term residential care is better for people and often what people want. People are more independent and supported in their own environment,’ says Ms Rowlands. The HomeFirst approach ‘allows us to use our resources more effectively, and hospital beds are freed up sooner’, she says.
A huge enabler to the success of the programme has been building on the culture and relationships across all partners in the system, including healthcare organisations, social care providers and third sector organisations. ‘It’s been a real team effort,’ says Ms Rowlands. ‘All of our partners – not just at executive level but also those involved in delivering services – have been working together to deliver the programme,’ she says.
She says similar initiatives are happening across West Yorkshire to help address similar challenges with patient discharge and supporting people at home.
One of the initiatives that compliments HomeFirst is the Carers Hospital Discharge Toolkit.
NHS West Yorkshire ICB’s unpaid carers programme has produced the toolkit and resources to support NHS trusts in carrying out their statutory duty to involve unpaid carers in discharge pathways and to improve unpaid carers’ experiences of discharge through increased identification, support, signposting, and referral. The toolkit has been co-produced with NHS staff, voluntary sector carer organisations and people with lived experience.
The toolkit also supports reducing health inequalities for Core20PLUS5 populations with its co-production and engagement from ethnically diverse carers and young carers. Post-launch evaluation of the toolkit has already shown that 80% of carers stated they were more involved in conversations about discharge, and as a result, 71% of carers felt more prepared for the discharge of their family member they supported.
A carer who was involved in developing the toolkit says: ‘I really welcome this resource. It’s so important that carers are kept informed and involved when those they care for are in hospital, especially when they’re due to be discharged. They may leave hospital needing additional care or new equipment, for example, so their carer may need advice or extra support. They may not even have thought of themselves as carers previously, or they may be new to caring, so making sure they’re aware of services that can help is vital.’
‘Collaboration is pivotal in addressing patient discharge challenges across West Yorkshire,’ says Helen Lewis, director of pathway integration for the Leeds Health and Care Partnership. ‘It’s great that the HomeFirst model we have introduced in Leeds has already made a difference. Providing the right care at home and better ways of working on the wards means more people are getting out of hospital sooner into places where they can continue their recovery safely and enhance their longer-term wellbeing. We are also improving our alternatives to admission, supporting people to stay at home rather than be admitted to a hospital bed,’ she says.
‘Although we recognise the ongoing challenges in workforce and funding, by implementing a person-centred, HomeFirst model and enhancing intermediate care services in Leeds, we are not only improving patient outcomes but also promoting greater independence and reducing unnecessary days in hospital. We are seeing similar initiatives across West Yorkshire, reflecting our shared commitment to delivering high-quality, sustainable care for our communities.’
