17 November 2022

This note can be downloaded as a pdf file here.

A recent analysis by The Guardian of official data claimed to show that on average 13,600 beds across NHS England are occupied every day by patients who doctors say are medically fit for discharge to their home or a care home (Up to one in three English hospital beds occupied by patients fit for discharge). The media and hospital chief executives attribute this situation to a lack of access to social care. The chief executive of the Royal Cornwall Hospital Trust said recently that the main hospital at Treliske was unable to discharge more than 100 patients who were ‘medically fit for discharge’, with the result that the hospital was currently being used as a ‘proxy aged-care facility’, directly limiting its ability to move patients on from the Emergency Department. This in turn impacted on ambulance ‘holds’ and on the Trust’s stroke services, the quality of which had fallen from grade A to grade D.

There is more to this story than meets the eye. These figures are actually for patients whose medical treatment is judged by their doctors to have been completed, so they no longer meet the  ‘criteria to reside’. Those doctors will have little or no knowledge of what awaits patients at home or in a care home. And they will take no account of patients’ physical and mental condition: these are not their responsibility. But as is now well known, stays in acute hospitals not only cure patients but damage them too. During a hospital stay for treatment, especially for older people, physical strength and mental health can deteriorate rapidly. Patients lose their mobility and self-confidence, and their families come to doubt whether they can cope with them coming home. The criteria to reside take no account of this. 

It used to be the norm for local, community hospitals to provide a ‘step-down’ function for acute hospitals, somewhere that recuperating patients could move to immediately after treatment while they were readied by therapists for their return to normal life. But the official guidance no longer highlights this as a pathway for discharged patients. Moreover in recent years NHS England and their cohorts at local level (like the late, unlamented Kernow Clinical Commissioning Group) have been closing beds in community hospitals as fast as they can, despite fierce local resistance in places like Penwith: we used to have two community hospitals, Poltair and Edward Hain, and have now lost both of them. 

Certainly local social care services are under huge stress at the moment. But the real scandal is that doctors and chief executives are pontificating about a situation that they only imperfectly understand, while there is a horrifying lack of joined-up thinking in the NHS. The test for our new integrated care system is whether it will restore the broken ‘step-down’ pathway for recovering patients.