A broken system

Richard Humphries, senior adviser to The Health Foundation sets out his thoughts to William Walter, managing director of social care PR consultancy, Townsend Communications, regarding the government’s hospital discharge programme and his analysis of longer-term plans to keep people out of hospital through care in the community.

News headlines have been dominated by stories of besieged acute hospitals, whose front doors are bursting with very poorly people queuing to get in, some waiting in ambulances outside, while many of the patients inside cannot get out because of delays to their discharge. Away from the media glare, there’s an equally serious but far less visible crisis involving many thousands of people waiting for social care in their own homes. When hospitals are full, the community is usually ‘full’ too. The human consequences of our failing health and care system are immense.

It is to the government’s credit that in five months it has found £750 million to tackle the problem of delayed discharges. But it has been tardy in getting the money out to systems, the funding route has been fragmented between councils and the NHS, and the short-term approach – the latest tranche of money has to be spent within weeks – has stifled progress. Far more could have been achieved if providers and commissioners had been brought together a year or more ago to plan what could be done with such a substantial sum of public money. There would have been no shortage of practical ideas and solutions.

Amid an almost desperate drive to relieve the pressures on hospitals, it is worth remembering that delayed discharges are but one symptom of the failure of the NHS and social care system to offer people the right care, in the right place, at the right time. Attributing the problem to social care alone overlooks the fact many delays are due to internal hold-ups within hospitals such as waiting for prescriptions, transport, referral letters and decision-making ward rounds. The Department of Health and Social Care’s own guidance estimates that at least half of people leaving hospital are ‘simple’ discharges not dependent on further care or support. Less than 5% will need residential care. There are some awkward questions about why some hospitals still struggle with these basic operational issues 20 years after good practice guidance on hospital discharge (which I helped to write). And why the NHS has consistently underinvested in basic community services, intermediate care and rehabilitation that achieve better outcomes for people and reduce the need for acute and long-term care.

It is encouraging that some of these issues are acknowledged in the NHS’s new plan for recovering urgent and emergency care that sets out over the next two years to increase capacity, deliver more out-of-hospital care such as the virtual ward initiative and improving discharge through more step-up and step-down care. All laudable aims, but whether they go far enough in tackling the deeper and long-standing problems afflicting health and social care is questionable. A record number of 165,000 vacancies in social care alongside critical shortages in general practice and district nursing begs the question of where staff will come from. Quick fixes are no substitute for a good long-term plan, including the longpromised reform of social care.