What should it cost to get one out of bed?
COVID-19 has the occasional silver lining. One is that the Department of Health and Social Care is finally addressing bed-blocking. On 19th March, the DHSC announced new measures which will release “at least 15,000 beds by 27th March” and thereafter from the NHS stock of around 140,000. Coincidentally, this roughly restores the total hospital bed count to 2010 levels. Unsurprisingly, occupancy has increased from around 85% to about 90% and the peaks in that figure are responsible for long wait times in winter at A&E.
The first problem with the “at least 15,000” claim is that bed-blocking, or, technically, “Delayed Transfer of Care (DTOC)”, only accounts for 4,500 beds. Where are the other 10,500 coming from?
Under the new measures, “Every patient on every general ward should be reviewed on a twice daily board round to determine the following. If the answer to each [of several] question[s] is ‘no’, active consideration for discharge to a less acute setting must be made.” There is a slight fudge between the main text and this quote from Annex B: the latter merely requires consideration to be given to a less acute setting (possibly a community hospital) whereas the main text reads “Transfer from the ward should happen within one hour of that decision being made to a designated discharge area. Discharge from hospital should happen as soon after that as possible, normally within 2 hours.”
About two thirds of DTOC is due to NHS hospitals’ bureaucratic processes. I have two personal experiences of the difficulty of escaping from a hospital bed once cured. Papers must be signed and the necessary signatories fail to show up. Both times, in desperation, I discharged myself but even that is not supposed to take place before signing to say the patient takes full responsibility and preparing such a document is itself a slow process.
Section 3.1 of the new measures requires, inter alia, “At least twice daily review of all patients in acute beds to agree who is not required to be in hospital, and will therefore be discharged. Ensure professional and clinical leadership between nursing, medicine and allied health professions for managing decisions.” And “Social care colleagues should be involved in daily ward reviews.” Since the patients themselves need to agree with the decisions, there will be quite a cohort moving from bed to bed. There is no mention of what records will need to be kept by whom. Stand by for a wave of lawsuits in a year or two!
Another silver lining in all this is eliminating the current protracted argument between local authorities and the NHS over who pays for “Continuing Health Care”. If the post-hospital care is primarily medical, the NHS is supposed to pay, otherwise it falls to the local authority. Committees meet endlessly to debate where the line should be drawn. The new measures give local authorities the benefit of any doubt.
Chucking patients out of wards within an hour of being cured, rather than several days, should save the NHS money rather than costing them more but for reasons unexplained they are being given an extra £1.3bn to do so. If the DTOC figures are correct, that is about £430,000 per bed. I think I would get out of bed for that. We cannot match the Chinese who seem able to build a thousand-bed hospital in a week.
Clearing the beds for which the NHS is itself responsible for the delays is the easy part. The 1,500 DTOCs for which local authorities have responsibility are the difficulty and they have been allocated £1.6bn to deal with their side of the problem. The main 2018/19 reasons are:
Awaiting care package in own home (20.8%)
Awaiting further non-acute NHS care (17.2%) – surely an NHS responsibility?
Awaiting nursing home placement or availability (13.9%)
Patient or family choice (12.4%)
Awaiting residential home placement or availability (12.3%)
Awaiting completion of assessment (11.3%)
The new measures adopt a robust approach to the first item, namely send them home first and worry about the care package second. In the context of the current crisis it is hard to argue with that and maybe, force majeure, we should adopt the Spanish practice of requisitioning empty hotels, re-employing and re-training the hotel staff to take care of the ex-patients. Doing so by 27th March, though, is a bit fanciful.
I have previously accused Matt Hancock of trying to run his department by press releases. Yes, unblocking 15,000 beds by the end of this week may look good in the media but it seems a trifle short on substance.