National Priorities 2003-04
NHS Lothian – Delayed Discharges.
DRAFT
(a)
Title of Service:
(b)
Local Position
DELAYED DISCHARGES
The delay experienced by people awaiting discharge from hospital continues to be a
major issue for NHS Lothian and its partner Local Authorities. In 2002/03 the Lothian
Delayed Discharge Partnership (NHS Lothian and Lothian Councils) spent around £13
million directly on this issue. The extra £30 million made available throughout Scotland
by the Scottish Executive is a welcome initiative to reduce the effect of the problem on
NHS systems. The Lothian Partnership, under its Joint Delayed Discharge Action Plan
for 2002 / 2003, is applying these new funds, alongside other Partnership funding
sources. These combined resources are used to jointly address the immediate service
pressures caused by delays in discharge and reduce the overall number of delays as
well as planning long-term action to provide the additional capacity required across the
whole system to properly address this complex problem.
In addition to the Delayed Discharge Joint Action Plan the partnership’s ‘Moving On’
action plan, our overarching whole systems plan to address the full range of factors that
affect people’s admission to hospital and their journey of care back to the community, is
now established. Four key working groups are making progress in delivering key
elements of the plan and wider development work is also underway flowing from this
plan.
A person whose discharge is delayed is an inpatient in an NHS bed who has been
judged clinically ready for discharge by the responsible clinician in consultation with all
agencies involved in planning that patient’s discharge, and who continues to occupy the
bed beyond that date (ready for discharge date). A local Lothian agreement, in common
with many areas in Scotland, allows up to six weeks for discharge arrangements to be
put in place and completed. This timescale for discharge planning is common across
most of Scotland and is the target time in the Lothian Discharge Standards for patients
requiring social care in a care home and for patients requiring NHS continuing care. It is
important to recognise that our joint performance in relation to meeting agreed delayed
discharge targets is currently measured by including all patients who have been
declared ready for discharge in the count, regardless of whether, or nor, they are within
the six week discharge planning period. For this reason the Lothian Partnership places
particular value in achieving reductions in the total number of people who have
experienced a delay in discharge of six weeks or greater. At the same time however
every effort is made to achieve earlier discharge dates whenever this is achievable.
NHS Lothian and Lothian Local Authorities have established joint local targets for the
reduction of delays in discharge from hospital. Our joint targets also incorporate the
national targets to which the Lothian Partnership will contribute. The Lothian partners
therefore aim to reduce (and sustain the reduction of) the total number of patients
awaiting discharge from hospital to a level of 388 by April 2003, a reduction of 160 from
a baseline of 548 in January 2002. This overall reduction target will include a reduction
in the number of cases delayed for over one year and a reduction in those delayed in the
acute sector.
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It is expected that further targets for 2003 / 2004 will be established during the spring of
2003.
Total number of Patients ready for discharge as a percentage of occupied beds
(PAF 2.10.02).
Progress against the national quarterly average - Lothian’s performance in 2002 was a
little (2 to 3%) above the national average. See below for actions taking place to
address this. Lothian had a total level of 519 patients awaiting discharge at 15 October
2002. This represents approximately 14.7% of all occupied NHS Lothian beds.
Figure 3.3.2 shows the level of patients awaiting discharge in Lothian, by reason for
delay, over time.
Trend Analysis of Patients Awaiting Discharge from hospital in Lothian
since October 2000, using ISD Quarterly Census Data
600
527
500
454
541
503
519
433
463
400
Number
548
300 254
254
382
335
385
371
347
351
79
77
102
66
252
289
200
113
102
72
100
100
121
115
111
87
77
61
74
71
0
October00
62
January01
April-01
July-01
October01
Quarter
January02
Number of Delayed Discharges
Social Care Reasons
47
April-02
Health Care Reasons
July-02
October02
Patient/Carer/Family Reasons
Initial (as yet unverified) results for the January 2003 census of patients awaiting
discharge in Lothian (as part of the national ISD exercise) show a total number of 433
patients awaiting discharge. This figure, along with the entire Lothian dataset for
January 2003, will be verified by March 2003 by ISD Scotland and published toward the
end of March 2003.
Percentage of patients experiencing a delay in discharge of 6 weeks or more (PAF
2.10.01).
Results from the October 2002 ISD census of patients awaiting discharge from
hospital in Lothian show 290 (55.87% of the total) were beyond the six-week
planning period, accounting for 8.2% of all occupied NHS Lothian beds.
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Figures from all national quarterly census exercises conducted in 2002 of
patients awaiting discharge in Scotland (fully validated data) reveal that the
Lothian Partnership performs consistently better than the national average in
relation to the percentage of those outwith the six-week locally agreed discharge
planning period. This assertion is illustrated in the table below.
ISD Census
January 2002
April 2002
July 2002
October 2002
Total
Number
548
541
503
519
Number over 6 weeks:
Lothian
291, 53%
296, 55%
319, 63%
290, 56%
Number over 6 weeks:
Scotland
2,075, 67%
1,957, 66%
2,032, 70%
1,902, 68%
Tackling the reasons for delay in discharge
Sixty eight percent of the total number of patients awaiting discharge from NHS Lothian
hospitals in October 2002 were waiting for social care arrangements to be made, either
in a care home place or care support at home. 13% of the total were delayed because of
a complex number of reasons commonly involving legal and financial disputes and
choice of care setting. Twenty percent of patients awaiting discharge at October 2002
are waiting within the NHS to be admitted to the next stage of their planned hospital
care.
Currently a wide range of services to address delayed discharges are provided by NHS
Lothian and Lothian Local Authorities additional to the services provided by mainstream
hospital, community health and social care services. These include additional discharge
co-ordination, bed management, therapy services, out of hours services in the NHS and
Social Care as well as other types of initiatives designed to support our care homes in
managing a higher level of need. NHS Lothian has also opened additional primary care
hospital beds at the Eastern General Hospital, to provide extra capacity in the NHS
system as part of a planned programme of transfer of patients to more appropriate
settings in social care. These NHS beds, alongside other such beds in the Lothian
system, are used almost exclusively for patients awaiting discharge to further care
provided outwith the NHS. It is important to note however these beds are still counted
into the Lothian delayed discharge figures each quarter despite being in place simply to
allow waiting for patients whose future social care pathway is already agreed. In
addition, Lothian NHS Board has also appointed to the new post of Patient Discharge
Manager. This dedicated resource is designed to help facilitate the appropriate
discharge of patients and improve effectiveness of existing discharge policies and
procedures.
(c)
Changes to Improve Services
To address this issue, NHS Lothian and its partners are undertaking a range of joint
planning and implementation work. This work includes a focus on increasing social care
capacity in both the short and long term and improvements in pathways to care and
treatment, assessment, co-ordination and discharge arrangements. The local Joint
Delayed Discharge Action Plan, which captures the joint work, has been developed with
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all partners to fit with existing local strategies relating to discharge management, older
people and joint working.
Increasing social care places available in the short to medium term, improving
operational and joint working processes across the whole system and commissioning
additional social care places for the long-term are the agreed priorities of the Lothian
Partnership. NHS Lothian and Lothian Local Authorities have invested £13.4m in
2002/2003 and plan to invest approximately £16m in 2003/2004. During 2003
specifically we will be implementing jointly commissioned additional short-term social
care places (73 places in 3 care homes), some to open by May 2003 with the last in
August 2003. In addition to the three short-term care homes further provision is being
made available in Council care homes where possible. We will also be focussing on
longer delays in discharge and working to enable those who are funding their own care,
those delayed for legal reasons and those delayed for family reasons to move-on to a
more appropriate care setting. We will do this by employing dedicated social work staff
for this purpose. We will also continue to develop the NHS and social care capacity
planning and implementation work with Lothian Local Authorities, including work with
private care homes in Lothian, where required, to help manage placement capacity. The
Partnership’s longer-term plans include commissioning of 240 additional social care
places in Edinburgh City (broadly four, 60 bed care homes) and similar units in West
Lothian (on target to open in January 2004) and Midlothian. Detailed capacity planning
work is underway in East Lothian and will be reporting shortly.
(d)
Outcomes
The principal outcomes are to reduce the numbers of patients being cared for in the
wrong setting with regard to their assessed needs and to free up hospital beds to enable
planned admissions to take place and to reduce the pressures on acute NHS inpatient
beds. The Lothian Partnership aim to jointly achieve agreed reduction targets in the
number of people whose discharge is delayed in NHS Lothian hospitals by April 2003.
This target will be independently measured by the NHS Information Services Division
Quarterly Census of Patients Awaiting Discharge from Hospital. Data from this census
forms part of the NHS Lothian Performance Assessment Framework and features in
Lothian Local Authority performance measures.
In 2003 / 2004 the Lothian Partnership will successfully conclude the commissioning of
the new interim care homes and will open these and provide full increased capacity in all
new projects by August 2003. This work will include work to assist the successful
migration of the New Royal Infirmary of Edinburgh to its new base at Little France. In
addition to this the Partnership will gain the maximum use of existing local authority care
home capacity and will seek to maximise the use on independent sector care home
accommodation wherever possible.
During 2003 / 2004 it will be crucial to complete the initial commissioning work for the
new 240 places in the City of Edinburgh and to appoint a project manager to oversee
this process, and to move to appointment of contractors and project leads for the various
initiatives. The Partnership will also develop its plans for recruitment, staffing and
retention of staff in new and existing facilities.
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The Partnership will also continue to develop best use of Primary Care Hospital bed
facilities, including joint exploration of the potential to jointly provide services or flexibly
use upgraded NHS accommodation as registered social care provision.
Under the ‘Moving – On’ whole systems action plan implementation the Partnership will
develop further work relating to better discharge management, rehabilitation and
assessment, keeping well and targeting specific reasons for delay in discharge.
During 2003 / 2004 we will fully implement Delayed Discharge action plan projects and
further pursue delivery of the outcomes associated with these service projects in addition
to encompassing any new targets for the Lothian Partnership that may be established
with the Unified Board or the Scottish Executive.
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