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Continuing Healthcare

February 13, 2017

What factors make a hospital more at risk of pressure and escalation? Taking a look at the evidence

By Harry Bourton

With a focus on the relentless pressure facing the NHS currently, it may be valuable to approach the issue from a slightly different angle. While the whole system is under enormous pressure, it is also apparent that some hospitals are at greater risk of escalation and delayed discharges. Why might some hospitals have higher or lower levels of risk?

Researchers from the University of York’s Centre for Health Economics considered this in a major study published last summer, entitled Delayed discharges and hospital type: evidence from the English NHS Researchers looked at data for delayed discharge over a three-year period for all hospitals to see whether any patterns were apparent according to hospital type.

They concluded hospitals that are foundation trusts had lower rates of delayed discharges and suggested this could reflect better practice among foundation trusts. They also found a correlation between local availability of care home beds and lower rates of delayed discharges.

Overall, mental health trusts had the highest rates of delayed discharges, perhaps reflecting lack of services and variation in service availability within the community, researchers suggested.

The close correlation between availability of long term care beds in the local community and delayed discharges is cited several times in the report. However, the authors do state: “Hospitals can also reduce bed blocking by good discharge planning and communication with long term care providers.”

In other words, while there are factors which are out of hospitals own hands, there are measures that can be taken to achieve greater control over discharge.

The Health Service Journal also recently produced data which illuminates the theme from a different angle. They considered which trusts had declared level three and level four alerts, the highest escalation under the OPEL framework (Operational Pressures Escalation Levels Framework) from December 1, 2016 to January 20, 2017. During this period, hospitals issued a total of 830 OPEL alerts.

They found ten trusts were responsible for more than a quarter of all level three and four alerts. The south of England region was particularly over-represented, producing more than half of all alerts. Yet London hospitals produced a tiny proportion of total alerts, issuing just five during the measure period.

What does this tell us? Debate which followed the data suggested London hospitals are under-reporting pressure, perhaps due to their view of what issuing a level three or four alert will achieve. Why is the south of England so over-represented among hospitals reporting the highest levels of pressure? This perhaps correlates to the University of York’s hypothesis that delayed discharges are associated with lower availability of care home beds in the local community. Certainly, there is an acute shortage of care home beds in many parts of the south of England, although equally, this is a problem that is not confined to the south and is widely evident elsewhere.

Some commentators suggested the best measure of real pressure would be a figure not yet widely used: for each trust, the percentage of blocked beds as a proportion of the hospitals overall (non specialist) bed numbers. This seems a measure which would be very helpful. The question that follows from that would be: looking at those blocked beds, is expediating discharge within the control of the health and social care system? Working in this area for 20 years, we would argue that while some factors like provision of community beds in care homes may be outside of control, discharge management can be improved with the focused, dedicated services we provide. This includes working very closely with care homes to establish exactly what availability there is and partnership working to optimise the use of those community beds.