Intended for healthcare professionals

Opinion Acute Perspective

David Oliver: Will block purchasing care home beds solve the urgent care crisis?

BMJ 2023; 380 doi: (Published 12 January 2023) Cite this as: BMJ 2023;380:p83
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter @mancunianmedic

On 9 January Steve Barclay, England’s health and social care secretary, announced some urgent actions to tackle the extreme pressures on emergency ambulance and hospital care.1 This followed the prime minister’s “summit” on 7 January, where Rishi Sunak consulted leading healthcare figures on potential solutions for urgent, elective, and primary care.2

Barclay’s central announcement concerned an additional £200m for the NHS to buy 3000 beds in care homes, hotels, independent hospitals, hospices, or hotels. The previous week, the i newspaper had reported that three NHS areas in the south west planned to discharge patients into hotels to “ease bed blocking and the A&E crisis.”3

It’s easy to see the rationale behind this. Of just over 100 000 general and acute beds in England, around 13 000 are occupied by patients who are medically fit to leave hospital but are awaiting step-down health and social care services.4

We already have the lowest per capita bed base among developed nations, and hospital wards are so full that every day is a struggle to find beds.5 This knocks on into overcrowding and long waits in emergency departments, delayed ambulance handovers, and worse ambulance response times as a result. All of these things place patients at risk—especially the old and frail ones—and put further pressure on the system. So, why not try to move some patients out of hospital sooner?

Also, during the pandemic the “covid discharge fund” and new rules to streamline processes around care transfers had enabled more people to leave hospital sooner, until those community services got saturated (as these services have workforce and capacity gaps of their own) and the funding stream was ended.

Assessment processes

But what’s the substance of Barclay’s announcement, and can it help the system or the patients transferred into these settings? His predecessor, Thérèse Coffey, had pledged £500m to help with hospital discharges back in September,6 but it was slow to arrive in the system and only £200m was given to the NHS, making the “new money” look like sleight of hand.

The experience with the original covid discharge fund in 2020-22 was mixed. There were considerable concerns about mass transfer of untested or infectious patients to care homes, risking covid outbreaks. The need for speed meant that normal assessment processes and choice about destination set out in the 2014 Care Act were subverted.7 And how much actual “assessment” came with “discharge to assess” beds?

A recent study in the Health Service Journal found that many patients had been “warehoused” and “lost in the system,”8 with little focus on ongoing reassessment, rehabilitation, or medical input and little information on how many of them then managed to return home or to a care home of their choice. We have to ensure that this doesn’t happen all over again.

Only around 15% of “medically fit for discharge” patients are awaiting a permanent placement in a care home. The rest are waiting for personal care at home, for ongoing NHS or joint NHS/social care rehabilitation and support in their own home or community facilities, or for funding and needs assessment, equipment, or end of life care.

As a geriatrician looking after such patients daily, I know just how medically complex, frail, and vulnerable many of them are, often with a combination of functional and cognitive impairment, multiple long term conditions, and considerable stress and concern among their (often elderly) family caregivers. We should not underestimate the needs of people deemed fit enough to be discharged into hotels for support and supervision. Those who need rehabilitation and not just care will need physiotherapy, occupational therapy, and rehab assistants—professions that also have workforce gaps. For patients who need medical review, there’s not enough GP, geriatrician, advance practitioner, or district nursing time to guarantee it.

For those who are trying to return to their own home with support, how will transferring them from one bedded facility to another help them regain their independence, as opposed to further institutionalising them? And, at the end of the care home stay, how do we avoid just moving the “exit block” from hospital to care home? Although Barclay announced four week limits, there will still be problems moving people on at the end because there’s no increase in the workforce needed to do this.

Competing for staff

We already have insufficient hospice capacity.9 The care home market is under sustained pressure with little spare capacity, and the overall number of nursing and residential home places is shrinking.10 What’s more, the social sector is short of 165 000 workers, about 8% of the workforce.11 It’s now competing with other low wage sectors, and with the NHS itself, for staff. Brexit and points based immigration rules have made things harder still.

Meanwhile, despite its latest sticking plaster gimmick, the government has completely failed to address long term social care funding or provision, or the gaps in community health services that could support people at home.12

I’m sure that the money and the beds will help some people leave hospital sooner. But they are no panacea. And we should not forget to find out what happens to those people once they’ve left the hospital estate.