Harm caused by delays in transferring patients to the right place of care

The Department accepts the recommendation. The Department is continuing to lead the overall response across the health and care sector to improve patient access to services and address risks to patient safety.

On 12 August, NHS England (NHSE) set out immediate next steps in increasing capacity and operational resilience in urgent and emergency care ahead of winter. On 22 September the Government published ‘Our Plan for Patients’. These national responses set out a range of measures to improve the urgent care pathway and help the NHS and social care perform at their best for patients.

This includes actions to increase hospital capacity by the equivalent of at least 7,000 general and acute beds, through a mix of new physical beds, virtual wards, and improvements elsewhere in the pathway. Additional bed capacity will help reduce waits for admission from A&E, reducing crowding and improving patient flow along the pathway.

The NHS is also supporting patient access and flow by increasing the provision of same day emergency care and acute frailty services. The NHS winter resilience plan also makes clear that the Directory of Services should be used by staff to direct patients to the most appropriate place, and commits to increasing the number and breadth of services profiled on the Directory of Services to ensure only patients with an emergency need are directed to A&E.

To improve timely discharge across acute, mental health, and community settings, NHSE is working with social care partners and implementing 10 best practice interventions through the ‘100 day challenge.’ A National Discharge Taskforce with membership from local government, the NHS and national government has been established. The department is examining further options to minimise delays to hospital discharge, including identifying capacity to accommodate people who no longer need acute hospital care while continuing to need other forms of support. The Taskforce has provided intensive support to the most challenged areas on discharge, with 14 NHS pilot sites and 12 social care sites so far. This work has identified key and replicable interventions that demonstrably improve flow. These interventions include setting an expected date of discharge and discharge within 48 hours of admission and treating delayed discharge as a potential harm event. The taskforce is in the process of establishing frontrunner sites to test new approaches to discharge, from which it will be possible to identify further replicable interventions to impact delayed discharge nationally, as well as learning further valuable lessons on system working.

Our Plan for Patients sets out further urgent action including £500 million for an Adult Social Care Discharge Fund. This fund can be used flexibly by local health and care systems, targeting the areas facing the greatest challenges and strengthening the sector’s ability to recruit and retain staff. This will help reduce the number of people staying in hospital longer than needed, ensure they get the right care and support in place, and help ensure beds are available for those who need them.

To increase the social care workforce, the Department delivered a National Recruitment Campaign for Adult Social Care last winter, with plans for the next campaign underway. This is alongside working with the Department of Work and Pensions to promote careers in adult social care to jobseekers. To further support local authorities and providers address workforce pressures, care workers have been made eligible for the Health and Care Visa and have been added to the Shortage Occupation List, and we announced on 22 September that we will also invest £15 million this year to boost international recruitment of care workers. Longer term, we announced in our recent People at the Heart of Care White Paper that we would invest in training to boost career opportunities, which we believe will boost the sector’s ability to recruit and retain staff, as well as improve the recognition of our vital Adult Social Care workforce. Building social care workforce capacity will mean patients can be treated in settings that are right for their needs, reducing delayed discharge into social care and creating capacity for those that require hospital treatment, reducing patient safety risks.

To help keep more people out of hospital, everyone aged 50 and over and those most at risk are being offered a COVID-19 booster and a flu jab this autumn under plans to increase protection against respiratory viruses this winter. The flu vaccination programme will also be extended to secondary school children in years 7, 8 and 9. This broad offer will provide necessary protection to those at higher risk of severe illness and will reduce hospitalisations over the winter period, helping ensure sufficient capacity to maintain patient flow along the pathway and ensure patient safety.

We continue to act to increase and support existing NHS workforce capacity, and in the past year we have seen record numbers of staff, including record numbers of doctors and nurses working in the NHS Workforce. The monthly workforce statistics for June 2022 show over 1.2 million Full-Time Equivalent (FTE) staff (which is over 1.3 million in headcount) working in the NHS. In total there are over 29,500 (2.5%) more Hospital and Community Health Services staff compared to June 2021. To help ensure the NHS has the workforce it needs for the future the Department has commissioned NHS England to develop a long-term workforce plan.

There is also action to improve access to out-of-hours GP services, helping to avoid demand on urgent and emergency care services out-of-hours, leaving capacity to treat the patients in emergency departments that really need it. Evening and weekend appointments have been provided by local Primary Care Networks (PCNs) and Clinical Commissioning Groups (CCGs) for several years. From October 2022, these current extended access services are being brought together under one single funding stream through PCNs. This will help to reduce variation across the country and provide a more consistent offer for patients.

To improve general practice capacity more generally, the Government and NHSE made £520 million available to improve access and expand general practice capacity during the pandemic. This was in addition to at least £1.5 billion announced in 2020 to create an additional 50 million general practice appointments by 2024 by increasing and diversifying the workforce. Increasing overall general practice capacity helps reduce demand on Urgent and Emergency Care Services, which in turn improves patient flow through hospital ensuring patient safety.

To further reduce pressures on emergency departments a 2-hour Urgent Community Response (UCR) Service national standard has been established. This sets requirements for systems to respond to adults (over the age of 18) who are experiencing a sudden deterioration in their health and wellbeing, who without urgent response are likely to result in a hospital admission within the next two to 24 hours. The service should be available to all people within their homes or usual place of residence, including care homes. The target is to achieve the minimum threshold of 70% of 2-hour crisis response demand within 2 hours from the end of Q3 2022. In July 2022, 80% of urgent community response referrals were managed by community health services within 2 hours, providing urgent care to people in their homes if their health or wellbeing suddenly deteriorated. UCR prevents hospital admissions and A&E attendances, meaning there is capacity for those that really need to be treated in hospital. This provides better outcomes for patients by ensuring patients receive the right care at the right time.

NHS England (NHSE) and the Department continue to collect comprehensive data across sectors to understand patient flow along NHS care pathways and into social care settings, highlighting bottlenecks in the system and informing a range of work to reduce long waits for care.

Ministers are working closely with the NHS and the social care sector and regularly meet to review progress on improving performance.

Actions planned to deliver safety recommendation:

• Increased capacity and resilience, including timely discharge, greater workforce and increased funding made available, implemented from now. Resources in place to deliver action: Increased funding and operational capacity.

Response received on 24 October 2022 and updated on 1 October 2024 below:

The Department of Health and Social Care continues to lead the overall response across the health and care sector to improve patient access to services and address risks to patient safety.

The Health Secretary ordered a full and independent investigation into NHS performance to provide a frank assessment of the issues and challenges it faces. Published on 12 September, the investigation’s findings will feed into the Government’s work on a 10-year plan to radically reform the NHS and build a health service that is fit for the future. This government is committed to returning urgent and emergency care waiting times to the safe operational waiting time standards set out in the NHS Constitution.

NHS England is working with ICBs and providers to ensure that as we head towards the winter period, there is an absolute focus on patient safety, quality of care and patient experience. The key priority remains to minimise long waits wherever possible for patients at home or in the community awaiting an ambulance. This will be addressed through targeted efforts on improving ambulance handover delays, long waits in A&E and discharge delays, in order to improve overarching system flow, as well as an additional action on monitoring where long patient delays arise. Arrangements are now in place at system level through System Coordination Centres to ensure senior clinical leadership is available to support risk mitigation across the system.

These actions are on top of the actions set out earlier in the year to improve urgent and emergency care performance as part of NHS England’s planning and operational guidance for 2024-25. The urgent and emergency care performance targets for NHS England this year are to improve A&E wait times to a minimum of 78% of patients being admitted, transferred, or discharged within four hours by March 2025, and reduce average Category 2 ambulance response times to 30 minutes over 2024-25. NHS England actions for this year include: i) maintaining capacity gains acute hospital beds and ambulance hours on the road that were achieved in 2023-24, ii) increasing the productivity of acute and non-acute services across bedded and non-bedded capacity, improving flow and length of stay of patients, and clinical outcomes to make care better and safer; iii) increasing the provision of community services that can help people with urgent needs get the right support in the right place, without the need for them to go to or stay in hospital.

In addition, we recognise that patient flow through and out of hospitals is impacted by timely discharge of patients once they have completed hospital treatment. A range of measures are being taken to improve this including:

• ensuring that capacity and demand plans (for both home-based and bed-based intermediate care) support NHS plans for preventing avoidable hospital admissions and reducing discharge delays, while improving outcomes for patients.
• keeping intermediate care capacity and demand plans under regular review and taking corrective action where services are not expected to meet projected demand.
• making the most effective use of same-day emergency care and virtual wards to prevent unnecessary time spent in hospital for people who can more appropriately receive acute care in other ways, with support where necessary to enable people to stay in their own homes or their usual place of residence.
• using data on length of discharge delays (from the Discharge Ready Date metrics) and the new data on reasons for discharge delays to understand the incidence and length of discharge delays, what is driving those delays, and what immediate actions can be taken to tackle these delays.
• for people with complex discharge needs, minimising delays in agreeing people’s post-discharge needs and in arranging appropriate post-discharge support, with a focus on enabling people to continue their recovery at home or their usual place of residence wherever possible and full involvement of patients, families and carers.
• supporting NHS winter surge planning, including considering contingency arrangements for a significant flu or COVID-19 wave.