NHS England’s response to the new austerity embodied in Rishi Sunak’s spending review from last autumn has been to slash Hospital Discharge Programme (HDP) funding for the accelerated discharge of patients.
As a result almost every hospital trust, facing huge financial pressures this financial year, has opted to axe the additional support that many admit had helped to free up beds so that emergency and elective patients can be admitted.
The system, often branded “discharge to assess” was never perfect. Funding was introduced in March 2020: but in August new DHSC guidance to hospital trusts announced that the additional funding to support out of hospital “post discharge recovery and support services” would cease … six weeks after patients had been discharged.
And despite this system being widely branded as “discharge to assess” it soon became clear that it was often basically “discharge regardless.” In many areas assessments were delayed – or resources were lacking to provide for the patients’ assessed needs. A year later, the Association of Directors of Adult Social Services (ADASS) published a survey of almost all 152 social services councils in England, revealing a backlog of 75,000 disabled and older people waiting for help with their care and support.
But now, since April 1, even that limited support has been pulled away, creating an extra financial and service nightmare. Bath Swindon and Wiltshire CCG has said HDP funding last year was £30m, and the loss of it has resulted in “Difficult conversations with system partners…”.
Lancashire Teaching Hospitals Trust, facing a £100m deficit, now warns of the need for “a plan to right size the bed base and/or seek additional funding. … This work needs to incorporate the impact of the termination of the hospital discharge funds.”
Norfolk & Waveney CCG, starting the financial year with a £50m underlying deficit, notes more than a fifth of this (£11m) is due to loss of Hospital Discharge Funding.
Hampshire and Isle of Wight CCG, forecasting a £105m deficit this year – if £159m of “efficiency savings” can be achieved – notes that the local system’s finances were only balanced last year through £200m of “non-recurrent measures (Elective Recovery Funds … Hospital Discharge Programme … surge funding and non-recurrent efficiencies)”.
With trusts and commissioners facing the need for short-term savings, few feel able to look to longer term investment in the support services – community health and social care – that could free up more hospital beds and improve the quality of care for patients.
Meanwhile the most recent statistics show almost 18,000 patients had been in acute beds for more than 21 days on April 22, and 27,000 for over 14 days. NHS hospitals are becoming like the Hotel California, where “You can check-out any time you like, But you can never leave.”
The result is the queues of ambulances seeking in vain to hand over emergency patients, while too many hospitals, like Salisbury, are simply silting up, with beds filled by patients who through no fault of theirs are now branded “No Criteria to Reside” (NC2R) because they have completed their treatment and care episode and are deemed able to be discharged.
Salisbury hospital has 396 beds, of which NC2R patients filled almost a third in the month of April. Its May trust Board heard “As a consequence of this the hospital has significantly reduced ”patient flow” and cannot properly function as clinically intended.”
Add this pressure to the 4,300 beds still taken up by Covid patients as of May 26, and the 3,000 fewer acute beds occupied in England in January-March this year compared with the same quarter prior to the pandemic, and we can see that potential NHS front-line capacity is effectively reduced by around 25,000 acute beds (25%) that cannot be used to admit emergency or elective patients, as the ambulances queue and the waiting list soars.
Instead of focusing efforts on creating so-called up to 5,000 “virtual beds,” for which funding will only be available for two years, and the viability of which is in any case limited by the lack of clinical and care staff, NHS England’s priority surely needs to be on freeing up existing beds, as well as reopening the beds that have been lost as a result of infection control measures and reorganisation to separate Covid patients.
This needs capital to remodel and refurbish hospital buildings, and a revenue budget that allows the restoration of HDP funding – and a real terms pay increase to attract recruits to work in the NHS at a time of relatively full employment and rampant inflation.
The stark warning over the future of ambulance services flagged up by West Midlands Ambulance trust’s nursing director, as revealed in the HSJ last week, is worrying enough. Mark Docherty told the HSJ that 17 August is the day he thinks the trust’s services will all fail, because if things continue to decline as they have been, “that date is when a third of our resource [will be] lost to delays, and that will mean we just can’t respond.”
Equally if not more worrying is the pathetically inadequate and misguided responses to this growing crisis from all those charged with leading and scrutinising the NHS, none of whom seem to realise that it’s not so much a crisis of ambulance services but much more a systems failure in hospital and social care.
Only by putting the system right can hospital trusts and West Midlands and other ambulance trusts have any confidence that they will not face the tipping point of total failure. Rishi Sunak has proved he can still access the magic money tree to help save Boris Johnson’s skin and alleviate the cost of living crisis: he must be persuaded now to come up with the cash to save the NHS.
* John Lister’s new book with Jacky Davis NHS Under Siege, The Fight to Save it in the Age of Covid is published by Merlin Press. A 25% discount is available until July 17 for orders using the code NHS1948 at checkout via the online web page.
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