From Bed Blocking to Delayed Transfer of Care
By Nathan Davies, on 20 December 2017
In this post Dr Catherine Jackman an ST6 inGeriatrics and General Medicine talks about the bed blocking we saw in the 1960s through to modern day ‘delayed transfer of care’ or becoming known once again as ‘bed blocking’.
“NHS bed-blocking rises 42% in a year…”
“NHS ‘bed-blocking’ rises for sixth month in a row”
“’Bed-blocking’ patient left waiting three and a half years to be discharged…”
At a time when the NHS faces unprecedented change and challenges there is barely a day which passes when the media doesn’t comment on bed blocking (or as it is called today – Delayed Transfer of Care) and the huge number of older patients unnecessarily ‘stuck’ in hospital.
Delayed transfer of care (DToC) refers to the long term occupation of hospital beds, often by older patients, who are medically fit to be discharged but are unable to leave due to a shortage of available care options elsewhere. The consequences of this are significant; there is a huge added cost to the NHS, beds are not appropriately utilised and many other patients may wait long hours in A&E for a free bed on the ward. DToC patients suffer physically, in terms of hospital acquired infections, and psychologically. They are at risk of becoming institutionalised and, in addition to this, staff morale takes a hit.
Evidence would suggest however that this has been a problem the NHS has had to deal with for many years. Geriatric medicine has evolved over the past 60 years and the provision of care available to our older population has changed, but bed blocking and DToC continues.
Departmental reports from the geriatric medicine department in Stoke in the 1960s-1970s comment on the challenge of patient demand exceeding the facilities available to provide adequate care. At that time there were, on average, 700 long stay beds for elderly patients in the Stoke area. They functioned as the equivalent of today’s care homes but often without recreational or rehabilitative facilities. Patients would also be admitted for “holiday respite” so that their family could have “a well-earned rest”. Despite requesting relatives sign a “contract” to state they would take the patients back home this often did not happen. One report is of an 87 year old widow who was admitted as a “holiday spell” and a form guaranteeing re-acceptance was signed by a son. After admission the patient was found to be active, alert and continent. After a month long admission the family refused to accept her home and involved a solicitor. The patient then had to join a long waiting list for local authority provided accommodation instead.
Another patient report from the long stay facility is of a 76 year old woman whose son wrote “mother and I have not got on very well for years. She has led a very useless life…Naturally, I feel very bitter about this…As you are aware the proper authorities will provide for her if you will only apply to them. I cannot do anything more in this matter.” This patient again joined the waiting list, “blocking” the hospital bed in the meantime.
The length of stay of these patients on the wards could often exceed 1 year. And, as is the case today, many died or deteriorated whilst awaiting local authority funded welfare housing or placements.
Fast forward 20 years to 1986, a BMJ paper entitled “Bed blocking in Bromley” reported that more than 1 in 10 of all acute patients were classified as bed blockers – rising to 1 in 5 of medical patients. The authors commented “bed blocking seems inevitable in wards attempting to cope with the steadily increasing proportion of elderly patients”. They defined bed blocking as patients who remained in hospital for 4 weeks or longer, and in the opinion of the medical staff, no longer required the facilities provided there. Reasons suggested in this study were similar to those of the earlier reports i.e. social and administrative problems as well as relatives refusing to have patients home.
After the 1980s there was a change away from long stay geriatric wards and care of our older population is now integrated into the acute hospital setting. Additionally there has been far more emphasis on social care with social workers very much integrated into the hospital teams. Since 2003 local authorities have been fined if they fail to organise care in a timely fashion.
The late 1990s and early 2000s was a golden period when the government tried to transfer the focus of care into the community and social care expanded. However, following the financial crisis of 2008, in 2010 the government introduced a period of austerity and the rate support grant to local authorities has been reduced every year. So, with cuts to their budget, there has been less social care spend despite an increasing demand exacerbated by steadily rising patient numbers and a declining number of beds. Inevitably this has increased pressure on hospitals to provide the necessary care and resulted in the return of “bed blocking”.
A solution to the recurring problem of bed blocking, or DToC, has not been developed by any government as yet. A proper integration of Health and Social Care would seem to be needed with joint funding. This would involve a major upheaval/reorganisation which, as the King’s fund reports, is extremely difficult in a time of decreasing budgets.
Dr Catherine Jackman