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promotingaccesstoWhiteRoseresearchpapers WhiteRoseResearchOnline eprints@whiterose.ac.uk UniversitiesofLeeds,SheffieldandYork http://eprints.whiterose.ac.uk/ Thisisanauthorproducedversionofapaperpublishedin HealthServices ManagementResearchJournal WhiteRoseResearchOnlineURLforthispaper: http://eprints.whiterose.ac.uk/id/eprint/77346 Paper: Manzano-Santaella,A(2010) From“bed-blocking”todelayeddischarges. Precursorsandinterpretationsofacontestedconcept. HealthServices ManagementResearchJournal,23(3).121-127.ISSN0951-4848 http://dx.doi.org/10.1258/hsmr.2009.009026 1 Title FromBed-BlockingtoDelayedDischarges:PrecursorsandInterpretationsofaContested Concept Abstract DelayedhospitaldischargeshavebeenidentifiedasaproblemfortheEnglishNational HealthServiceandhavepromptedseveralpolicyandservicedevelopmentresponsesin thelastdecade.However,bed-blockingisanissuesurroundedbyrivalinterpretationson howandwhyhospitaldelaysoccurandthewayinwhichtheyaremeasured.Tobetter understandthiscontestedconcept,thisarticleprovidesabriefdescriptionofthehistorical accountsthatframedtheemergenceofdelayedhospitaldischargesasaphenomenon. Threekeyfeaturesofthebed-blockingconceptarealsoanalysed:thereductionof patients’lengthofstaytoimproveefficiency;theintrinsicmethodologicaldifficultiesof measuringhospitaldelays;andthemostc

ommonreasonsfordelayeddischarges.A descriptionofthecharacteristicsofthepatientsfrequentlylabelledasdelayeddischarge, theircommontraitsandhowthesehavebeenexaminedbypreviousresearchisalso provided.Finally,thisarticlearguesthatthepresenceofhospitaldelaysinahealth systemtendstobeconsideredasanindicatoroftwopossiblesysteminefficiencies:a failureinthedischargeplanningprocess,whichgenerallyblamessocialservices departmentsfornotensuringtimelyservices;orashortageofalternativeformsofcare forthisgroupofpatients. 2 Introduction Overthelastthirtyyears,mostwesternnations,influencedbyneoliberalideologies, embarkedonhealthcarereformsthatareoftencharacterisedas‘decentralisation’and ‘devolution’.Theshiftofresponsibilityawayfromthestatethroughtheintroductionof marketforcesextendedtoallaspectsofgovernance.Throughoutthedevelopmentof Britishwelfarepolicy,thestatewasresponsibleforfinance,ownershipandsupplyof healthcareandsocialcare.Foundedin1948,theNationalHealthService(NHS)wasseen asatriumphofsocialistideology,inspiredbyegalitarianideasasitinstitutionalisedthe principleofallocatingresourcesaccordingtoneed.However,asinmanyotherareasof welfare,astimewentby,theNHSattractedcriticismstypicaltosuchlargepublic organisations:inefficiency,slowtochangeandawasteoftax-payersmoney. Consequently,undertheConservativeGov

ernmentofthelate1980’sandearly1990’s, de-institutionalisation,privatisationofcarehomesanddecentralisationwerekey strategiesunderlyinghealthreformswhichculminatedintheintroductionoftheNHSand CommunityCareAct1990. Thepurchaser-providersystemnowoperatingintheNHSwasacentralpartofthis legislation.Stateprovisionforhealthandsocialcarewastargetedforreplacementwitha quasi-marketorientedapproachtowelfareservicedelivery.Suchasystemisbasedon centralgovernmentraisingthefundsforpurchasingservices,whicharethendistributed toagentswhopurchasetheseservicesonbehalfofconsumers.Theconstructionof internalmarketswasbasedonthebeliefthathealthcareinthepurchaser-providersystem wouldgenerateincreasedcostawarenessandhenceencouragemoreefficientuseof 3 resources.Financialefficiencywastobeachievednotwithincreasedfundsbutthrough betterperformancemanagement,delegatingresponsibilityforthedeliveryofhealthcare tolocallevel. Beforethe1990reforms,thestatewasaproviderofsocialcareformuchofits population:funding,purchasingandprovidingcareservices.Afterthereorganisation, localauthoritiestookonthecharacteristicsofpurchasers.Theemergenceofa management-orientedapproachtocommunitycareplanningmeantthatthestatewas supposedtoenablesocialcare,settingtheemphasisonmanagingpackagesofcarefor peopleinthecommunityratherthanmatchingpeoples’need

stoservices.Voluntaryand privateorganisations(andfamilies)undertooktheprovisionofsocialcareonbehalfof thecouncil,andsocialworkersweregiventheroleof‘caremanagers’. Therelocationofcarefrominstitutionstothecommunitymeantatransferofthecostof carefromthestatetoothersocialcareactors:users,theircarersandfamilies,voluntary sectororganisationsandfor-profitorganisations.Theearlydischargeofpeoplefrom hospitalorcareinstitutionalsoincreasedthefinancialburdenuponsocialservices departmentsandprimaryhealthcareservices.Furthermore,theconstantdevelopmentof initiativesthatreducedhospital-basedNHScarerepresentedtherelocationoffreecareat thepointofdeliverytocommunityservices,whicharemeans-testedandincurcharges forthepopulation.Inotherwords,theredefinitionofsomeacuteandcontinuingcareas ‘socialcare’hadaneconomicconsequencefortheendusersofservicesthatshouldnot beignored. 4 The1990NHSandCommunityCareActcontinuedthehistoricaldivisionbetweenhealth andsocialcare.EligibilitycriteriaforfreeNHScontinuingcareandtheappropriateness ofdischargingvulnerablepatientsfromhospitalbecamemajorpoliticalissuesduringthe 1990s.Withinthisframework,in1997,NewLabourproposed‘TheNewNHS’,aten yearplanfortheNHS.Whilepreservingmanyfeaturesoftheinternalmarket,thiswas intendedtoshiftthefocusofservicesfromcompetitiontocooperation

.Government emphasisturnedto‘integratedcare’and‘partnerships’. 1 Inthiscontext,theolddivisions betweenhealthandsocialcarewereidentifiedascreatingparticularobstaclestothe planninganddeliveryof‘seamless’servicestailoredtoindividualneeds. 2 In2003,anotherinitiativethatattemptedtoreducehospitalbasedcarewasintroduced: theCommunityCare(DelayedDischargesetc.)Act2003. 3 Thispolicymeantthatlocal authoritiesweremadefinanciallyresponsiblefortheaccommodationcosts(hotel services)thatpatientswithsocialneedsreceivewhilstinacutecare.Thisfigurewas calculatedinadailytariffequalforallpatients(£100perday),withtheexceptionof localitiesintheSouthEastofEngland(£120perday).Asaconsequence, administratively,socialservicesdepartmentsweretreatedaspurchasersofaservice (acutecare)for‘theirclients’,providedbythehospitals. Inthispolicy,thepartnershipethoscollidedwiththeneedforefficiency,whichwas constructedunderaconceptemblematicofthatdivision:theproblemofbed-blockingor delayeddischarges.Thephenomenonisdeep-seatedwithintheproblematic 5 administrative,financialandprofessionaldivisionofhealthandsocialcare.Inorderto investigatetherivalinterpretationsaffectingthetopicofbed-blocking,threekeyfeatures oftheconceptaredescribed:thereductionofpatients’lengthofstayasamanagement tooltoimproveefficien

cy;theintrinsicmethodologicaldifficultiesofmeasuringhospital delays;andthemostcommonreasonsfordelayedhospitaldischarges.Finally,thearticle closeswithadescriptionofthecharacteristicsofthepatientsfrequentlylabelledas delayeddischarge,theircommontraitsandhowthesehavebeenexaminedbyprevious research. ‘Bed-Blocking’or‘DelayedDischarge’?AContestedConcept Cultural,social,economicandorganisationalcontextsinfluencehowthepatientgroupof theso-called‘bed-blockers’couldbedefined.Nevertheless,therearerivalconceptions andinterpretationsofthistermwhichcouldthusbeconsideredtocomeundertherubric ofan‘essentiallycontestedconcept’. 4 Bed-blockingisaninternallycomplexterm,open- endedandbasedonqualitativenotions.Interpretationsoftheconceptaredisputedwith particularlinesofthoughtbeingsustainedbydifferentstandpoints.Inbrief,thepresence ofdelaysinahealthsystemmaybeconsideredasanindicatoroftwopossiblesystem inefficiencies:afailureinthedischargeplanningprocess,whichgenerallyblamessocial servicesfornotensuringtimelyservices;orashortageofalternativeformsofcarefor thisgroupofpatients. 6 Theterm'blockedbed'originatedintheUnitedKingdominthelate1950’sanditwas traditionallyusedtoimply‘thatregularpatientorclientthrough-putwithregardtothat particularbedhasstopped’. 5 Synonymousexpressio

nslike‘back-up’,‘backlogs’,‘long- stays’,‘outliers’and‘delayeddischarges’wereusedintheUnitedStatesandCanadaand havesimilarmeaningsdespitethecontextualdifferences.Theyallrefertothefactthat averagebeduseisinterruptedbypatientswhostayinhospitalforlongerthanexpected. Whateverthewordsusedtodescribethisgroupofpatients,similartermswereandstill areappliednotonlytoacutehospitalbedsbutalsotobedsinpsychiatric,geriatricand otherhealthandsocialcareinstitutions. Thebeginningofthebed-blockingphenomenoncannotbeseparatedfromthechanging roleofhospitalsinrespectofgeriatricpatients.Originally,‘bed-blocking’concernswere drivenbyhospitalcliniciansbecomingincreasinglyperturbedwiththeirlimited availabilityofbeds.IntheUKbetween1961and1967,therewasa14percentriseinthe elderlypopulationbutthenumberofhospitalbedsassignedfortheiruseremained practicallythesame. 6 Apparently,therewasstrongcompetitionoverhospitalspace whichledtoadesireonthepartofsomehospitaldoctorstoexcludecareoftheelderly frommajorhospitals.Hall&Bytheway 7 suggestedthathospitaldoctorsfollowedthe prevailing'acuteideology'inmedicineandusedphenomenalikebed-blockingtorestrict olderpeople’sentrytohospital. Therefore,notsurprisingly,earlyinvestigationsintothe‘bed-blocking’phenomenon reliedontheopinio

nofconsultantsforthereasonswhypatientsstayedinhospitallonger 7 thannecessary. 89 Doctors’researchtendedtofocusonthefailureofsocialcareto developtheservicesneededtofacilitatedischarges.Forthisreason,someauthors 10 argue thattheconceptof‘bed-blocking’isanotherexampleofthemedicaldominancethat intrudesintopoliciesandthedailyadministrationofhealthinstitutions. Inthe1990’s,withthedriveforefficiencythatdictatedhealthcareinstitutions,theterm ‘bed-blocking’wasborrowedbyhealtheconomistswhouseditasanexampleofthe failureofefficientsystemsinhospitals.Indeed,inthedebateover'bed-blocking', economiststendedtosidewithhospitaldoctorsandblameinadequatelocalauthority provision.Insummary,reducingtheboundariesofacutecarehadthepotentialtosuit bothcostconsciouspolicymakersandtheprofessionalinclinationsofmanyhospital doctors. In1994,Styrborn 11 arguedthat‘bed-blocking’,despiteitscommonuse,wasnottobe acceptedasamedicaltermbutasanadministrativeconceptthatwaspartofaneconomic controlsystem‘coinedbyhealtheconomists’.Heexplainedthatthetermimpliedthatthe patientwassituatedinthewronglocationinthespectrumofcare.Lateron,followinga similarapproach,Wimo, etal . 12 referredtothe‘misplacement’ofpeoplewhoare situatedatthe‘wrongcaringlevel’andthisnotionincludedtheneedfordive

rsecare alternatives.StyrbornandWimo etal .’sapproachfocusesondefiningthebed-blocking problemastheneedforadifferentplaceorsitewherepatientscouldbelocated.Reasons forrelocatingpatientsrangefromadministrativedecisionsandpoliticalpoliciesto changesinpatients’healthstatus.Mostimportantly,thistypeofconceptualexplanation 8 leadstosolutionstotheproblemthatarebasedonincreasingtheavailabilityof ‘locations’,sites,orspacesforthesepatients. Intherecentyears,theuseoftheadjective‘bed-blocker’torefertopatientshasbeen consideredinappropriateintheUK.Itwasarguedthatthisterminsinuatedthatpatients themselveswereresponsiblefortheirsituation:‘Thewholenotionofbedblockingseems toimplythatolderpeopleenterhospitalandthenwilfullycontinuetooccupyabed which,intheviewsofstaff,theynolongerrequire’ 13 .Thetermwasconsidered politicallyincorrect,deemedoffensiveforpatientsandrejectedbytheHealthSelect Committee.Instead,theexpressions‘delayedtransferofcare’or‘delayeddischarge’ wereproposedtoreplaceit.InApril2001,theDepartmentofHealthissuedastandard definitionandintroducedthesenewterms: Adelayedtransferoccurswhenapatientisreadyfortransferfromageneraland acutehospitalbedbutisstilloccupyingthatbed.Apatientisreadyfortransferwhen: aclinicaldecisionismadethatthepatientisreadyfortransfer

;amulti-disciplinary teamdecisionhasbeenmadethatthepatientisreadyfortransfer;andthepatientis safetodischarge/transfer. 14 Sincethen,theexpression‘delayeddischarges’hasbeenwidelyadoptedintheBritish governmentalandresearchliterature.Althoughithasbeenconsidereda‘moreneutral term’ 15 ,thenewlycoinedexpressionsupportsacleartheoreticalposition.Itimpliesa shiftfromfocusingonmacroeconomicfactorstomicroorganisationalsystems.The exclusivefocusonthetimecomponentofthedischargeprocessshiftedthedebatefrom 9 theavailabilityandsuitabilityofthenextlocation(space),totheinstitutionalprocessof discharge(time).Bedsarenotblockedbutpatients’dischargesaredelayed,which impliesthatsomebody(generally,socialservicesdepartments)shouldworkatafaster pacetoavoidthosedelays. Inaddition,whenredefiningtheneedforrelocationofpatientsintotheneedforspeeding upthedischargeprocess,attentionisdivertednotonlyfromtheavailabilityofother formsofcarebutalsofromothersignificantaspectsofthetransitionsbetweenhospital anddischargedestinations.Someoftheseissuesarethelong-termoutcomes(forthestate andforthepatient)asaconsequenceofrapiddischarges;thequalityandadequacyofthe newenvironmenttowhichpatientsaretransferred;theinvolvementoftheindividuals andtheirfamiliesinthedischargeprocess.Althoughthereareindicationsofthecost- effectivene

ssthatdischargeplanningprogrammesofferwhentheyresultindecreased lengthsofstayandreadmissionrates 16 ,thesecalculationsdonotconsidertheexpenseof additionalcommunityservicesandspecialiststafforthecosttofamiliesandcarers. Indeed,thespeedydischargeofpatientsisnotconsideredbyallcommentatorsasthebest caremodel.Delayedtransfersofcareareparticularlyassociatedwitholderpatientswith complexneedsandgeriatricmedicineoftenpurposelydeceleratestheprocessof dischargetoachievebetterlong-termresults . 17 Theseauthorsexplainthatreducedstays cannotbeusedasmeasureforefficiencyinallpatients.Gainsmadeintheefficiencyof treatingtheacutecarepatientsfasterdonotnecessarilyimplyimprovementsintheir long-termoutcomes.Thesegainsmayevenbemadeattheexpenseofpushingalarger 10 fractionofthepatientsintopermanentcare.Insummary,thereductionoflengthofstay toimprovehospitalefficiencyisamanagementchoicethatisnotalwayssupportedby clinicalevidenceinallpatients. ReducingLengthofStaytoImproveHospitalEfficiency Thephenomenonof‘delayeddischarges’maythusbeunderstoodinthetermsof organisationalmanagementchoice.Healthcareplanners,confrontedwithanincreased numberofpotentialusers,choosetoensurearapidpatientflowasanewtooltoimprove efficiency.Millard&McLean 17 usedtheanalogyofatoytraintoexplainhowanacute hospitalworks.Thehospitalwascomparedwitha24hou

rtraincirclingatrackat constantspeed.Toimprovethepassengercarryingperformanceseveralchoiceswere given: a) Toaddmorecarriages(i.e.morebeds) b) Tostoppassengersgettingonboard(programmestoreduceadmissionsintheover 75’s) c) Tostoppassengersstayingovernight(increasedayserviceslikedaysurgeryand othertreatments) d) Topersuadethepassengerstogetoffthetrainearlierandcontinuetheirjourney elsewhere(earlydischarge,intermediatecareandtransfertosocialcarehomes). AlthoughintheUK,thenumberofhospitaladmissionskeepsgrowing,thepossibilityof increasingthenumberofbedsseemsalwaysomittedfromtheequation.Moreover,the 11 numberofacutebedsinEnglandhasbeenconsistentlyreducedandsolutionsalongthe linesofb)c)andd)aretheonesfrequentlyusedbytheprogrammesimplemented subsequenttotheNHSplan. 18 Otherpossiblesolutionsoutsidethelogicthatthecircular trackrepresentsarealsorejected.Theperformancetargetissimplifiedtothefactthat patientscanonlyenterhospitalifotherpatientsleaveandtherefore,oncepatientsarein, theyshouldbeprocessedoutofthesystemasfastaspossible.Thereduction ad absurdum ofthislinearthinkingisthatnobedswilleventuallybeneededtotreat patients. 19 Whenreductionoflengthofstayschemesareinplace,twodifferentcategoriesof patientsaregenerated:patientswhoneedtoenterorstayinhospitalandpatientswho needtoexit.Thefirstarewelcome,thelatterareno

twelcomeinhospitalanymore. Peoplechangestatusastimegoesby.Thetransformationfromwelcometounwelcome patients,however,isnotstraightforward.Thereareimportantdebatableconcepts attachedtothisissue,suchaswhodecidesthatpatientsshouldexitthehospital,howthis decisionismadeand,insummary,whenarepatients’exitsappropriate. 20 Those unwelcomepatientsaretheso-called‘delayeddischarges’,aby-productofadopting economictheoriesthatrecommenddecreasinglengthofstaytoimprovehospital efficiency. TheUKGovernmentmadethechoiceofselectingreductioninlengthofstayasatoolfor efficiency,statingthatitwasoneofitssixdimensionsofperformance 1 .Despitethe officialchoicetouselengthofstayasameasureforefficiency,thecausalrelationship 12 betweenlengthofstayandqualityofcareisnotstraightforward.Traditionally,muchof theliteratureinthisareaexplainsthathealthoutcomesarenotaffectedbyshorterstays andthatextendedstaysarelinkedtoincreasemorbidity.However,authorslikeClarke& Rosen 21 exposethelackofevidenceoftheassociationbetweenlongerlengthofstayand poorerhealthoutcomes.Theyexplainhowtensionsbetweenreducingstaysinorderto increasepatients’throughputandmaintainingtheappropriatenessofcarearerarely appreciatedbythosekeentoseestaysreducedasamarkerofefficiency. Inaddition,reductioninthelengthofpatients’stayhasalsothepotentialtoincreaseth

e complexityofthedischargeprocess. 22 Healthcareworkisfrequentlyhighlyproblematic duetotheunexpectedandoftendifficulttocontrolcontingencies,stemmingnotonly fromtheillnessitself,butalsofromahostofworkandorganisationalsourcesaswellas frombiographicalandlife-stylesourcespertainingtopatients,relativesandstaff members. 23 Theshorteningofhospitalstayscouldaddtothatcomplexitywiththe potentialofmorecontingenciesoccurringduetothelackoftimehealthcareworkershave tofamiliarisethemselveswiththepatients’circumstances. TheMeasurementofDelayedDischarges:TensionsandChallenges Themethodologicalliteraturestudyingdelayeddischargesraisesseriousquestions relatedtocoreconceptualissuesaboutwhatconstitutesahospital‘delay’.Thislackof consensusisillustratedbyfourmaintensionsinthedefinitionof‘delays’: 13 a) Thefirstapproachdefines‘delay’asthetimeperiodestablishedbyahospital dischargeplannerwhichismeasuredbythetimedifferencebetweenapatientbeing medicallyreadyfordischargeandtheactualtimeofdischarge. 24 Consequently,the resultingfigureisaperiodoftimedefinedsubjectivelybyresearchers,medical practitioners,healthandsocialcarestaffor,insomecases,apanelof‘experts’.This approachisamorerefinedderivationofthetraditionalarbitraryapproachusedby consultantsinthe1960sbutitstillseemstoprivilegeopiniono

verevidence. Physicians’opiniontendstoprevailuponothermembersofthemultidisciplinary teamanditisconsideredthe‘goldstandard’.Additionallyvariabilityinresultsoccurs dependingonphysicianseniorityandwhetherthepanelwasmadeupofgeneral practitionersorspecialists. 25 b) Thesecondconceptualframeworkestablishesthatahospitaldelaycanbe numericallyquantifiedinanobjectivemanner.Inanattempttoovercomethe subjectivityofthefirstapproach,delaysaredefinedwiththeconstructionofa mathematicalnorm.Thisstatisticalcalculationisgenerallybasedontheindividual lengthofstayforaparticularagegroup,consultantanddiagnosiswhichisgreater thanastandardisedthresholdformeanlengthofstaybytherespectiveconsultantand conditionderivedforthewholepopulation.However,thistypeofsingleaverage measurereliesonlengthofstayasanappropriatemeasureofperformance.Thishas beendisputedbysomehealthanalystswhoarguethatsingleaveragesofbed occupancy,bedemptinessandaveragelengthofstaydonotrepresenthospital activity.Instead,theyproposetheuseofmixedexponentialdistributionsasabetter 14 wayofunderstandingbedusage.Thismeansthatpatientsflowthroughmedicalcare followingdifferenttimestreamsaccordingtothecomplexityoftheirillnesses, psychologicalandsocialcircumstances. 26 Thesetypesofcriticismhighlightalsothe useofmeandurationofstayasmisleadingwhendealingwithgeriatr

icor rehabilitationpatientsbecauseasmallnumberofpatientswithverylongstayscan skewthedistribution. c) Avariationofthesingleaveragesystemistheuseofstandardmeasurement instrumentswhichlistclinicalreasonswhyapatientshouldstayinhospitalandlater on,thesefactorsarescrutinisedinthepatients’medicalrecords.Examplesofthese instrumentsaretheIntensity-Severity-DischargeReviewSystemwithAdult Criteria 27 ,andtheOxfordBedStudyInstrument. 28 However,McDonagh etal . 25 claimedthatfewoftheexistingtoolshavebeentestedforreliabilityandvalidity.The bestvalidatedtool,knownastheAppropriatenessEvaluationProtocol(AEP) 29 ,was originallydevelopedintheUnitedStatesandlateradaptedinSwitzerlandforusein Europe;butitsvalidityandreliabilityforotherEuropeancountrieshasalsobeen questioned. 30 Althoughstudieswhichusedvalidatedtoolstendtobeconsideredthe mostevidence-based,Vetter 20 foundthatallmeasurementtoolsarepoor,lacked validityandreproducibility.Theyalsotendtobeappliedretrospectivelyand,most significantly,theystillrelyonsubjectiveinterpretationsofdelaysandtakenoaccount oflocalcircumstancesortheavailabilityofalternativeservicestothehospitalbed. 31 15 d) Thefourthapproachistheoneofauthorshighlightingthelackofconsensusin definingdelaysandtherefore,thedifficultyincomparingresearchfindings.They acceptthatestablishmentofwhoandwhenhospita

lpatientsaredelayedisan essentiallysubjectivetask.Theyexhibitthemethodologicallimitationsofthe decisioncriteriaemployedbydischargeplanners,clinicalpractitionersorresearchers. Forinstance,Carter&Wade 32 acknowledgehow: Itisdifficulttodefinepreciselywhenapatientis‘readyfordischarge’or‘nolonger inneedofourmedical/surgicalexpertise’.Wesimplyreliedontheopinionofthe clinicalteamresponsibleforthepatient;theynolongerfeltresponsibleforthe patient’smanagement.[…]itwasnoteasytoestablishthereasonfordelay.We simplyrelieduponclinicaljudgement,identifyingtheonefactorthatseemedmost important,butinpracticetherewereoftenseveralinter-relatedreasons’. (p.319) Styrborn&Thorslund 33 considerlocalcircumstancesasdecisiveforthedefinitionof delaysandforanyattemptedsolutions;andtheyalsorefertotheimportanceofa consistentdefinitionofthebed-blockerconceptwhencomparingovertime.Vetter 20 reinforcestheaboveargumentanddeemstheassessmentofinappropriatebedusageas being‘besetbyproblemsoflackofdefinition’and‘dominatedbysubjectivity’.Glasby et al . 31 followthesamelineandtheyalsoemphasisetheimportanceoflocalcontextsand historyindifferentareasforthestudyofdelayeddischarges. Allthefourtensionsidentifiedabovefacenotonlytheproblemoflackofacommon definitionofdelaybutalsoconcernsabouttheaccura

cyoftherelatednumericaldatathat 16 iscollectedforperformancepurposes.TheDepartmentofHealthstartedcollectingdata ondelayeddischargesin1997butastandarddefinitionofdelayeddischargeswasonly issuedin2001.Althoughthisrepresentsasteptowardscommonmeasurement,itdoes notguaranteeit.Definitionscanalsohaveambiguouselements,bemisinterpreted, misappliedornotfollowed.In2003,theNationalAuditOfficereportedthatonly27per centofhospitalssurveyedwerefollowingthe2001definitioninfull.Discrepancies betweendatareportedbyacutehospitalsanddataprovidedbyprimarycaretrustswere alsonoted. 34 Anothersignificantdifficultywiththewayinwhichdelayeddischargesdataiscollected isthefocusonacuteandgeneralbedsandtheexclusionofothernon-acute,mentalhealth andcommunitybed. 35 Finally,withsomeexceptions,literaturerelatedtodelayed dischargesoftenfailstoincludepatientandcarerperspectives. 36 MostCommonReasonsforDelayedDischarge Aspreviouslyexplained,delayeddischargescanbeconsideredasanindicatorofa shortageofalternativeformsofcareortheycanbeseenasaconsequenceof inefficienciesinthedischargeplanningprocess.Interestingly,thesecondstandpoint dominatedresearchondelaysthroughthe1980’sand1990’swithdischargeplanning receivingmostoftheattention.Researchonthecausesfordelayeddischarges concentratedonwhichorganisationwastoblamefortheproblem,socialservic

esor hospitals.Thiswasapotentialdistractionthatmovedattentionawayfromthemacro 17 problemsthatcreatedresourceshortagesoreventhereasonswhybed-blockingwas constructedasaproblem.Micro-levelconcernsdroveresearchonassessingdischarge planningproceduresandschemes.Moreover,oneofthelimitationsofresearchon dischargeplanningisthatitdoesnotnormallyspotlightthereasonsfordelaysbutthe waysofimprovinginternalorganisationalprocesses. Theoriginofthebed-blockingphenomenonisinpartresponsibleforthemain assumptionsembeddingtheresearchstudyingcausesfordelayeddischarges.Clearly,the firstdoctorsinthe1960swhoconductedbed-blockingstudiesbelievedthatsomepatients werestayinginhospitallongerthannecessary,forreasonsotherthanmedical.Indeed, delaysweregenerallyperceivedtobetheresponsibilityofsocialservicesdepartments. Thismedicalstandpointispresentintheresearchonthistopicmainlybecauseitwas drivenandperformedbythecliniciansthemselves.Typically,investigationsconcentrated onidentifyingpredictorsfordelay(age,illness,etc)andcostsgeneratedbythese patients’delaysduetotheirsocialcareneeds.Inthe1990’s,withtheintroductionof healthmanagementtheoriesandperformanceindicatorsasaformofgovernance,cost efficiencyanalysisdroveresearchintoclinicalpathwaysandwhypatients,withor withoutsocialneed,weredelayed.Thescrutinyoftheinternalclinicalsystemsr

evealed thathospitalorganisationalfactorswerethecauseofasignificantproportionofdelayed discharges. 37 Patientswaitingforresultsofinvestigations,consultantsinput,assessment fromspecialisthealthstaff,transportorpharmacyweretypicalefficiencyorprovision failures. 18 Significantly,studiesthatexaminedelaysfromthesocialstandpointseemtoalso reproducethehistoricaldivisionsbetweenhealthandsocialneed.Roberts&Houghton 38 conceptualisedelaysasbeencausedbythehospital,socialservicesor‘delaysbeyond controlofeitheragency’.Intheresearchliteraturecommonreasonswhydelaysare allocatedtosocialservicesare:delaysinallocatingsocialworkers,complexityof assessmentcriteria,delaysinallocatingfunding.Itseemsthat,ingeneral,theresearchon causesfordelaysconcentratesonwhotoblameinsteadofacceptingthecomplexand multi-facetednatureoffactorscontributingtodelayedtransfer.Thisperspectiveisa continuationofthehistoricalpreoccupationofbothsocialandhealthsectors,tofocuson ‘who’(shouldprovideservices,whosefaultisit?,etc.)morethanon‘what’theyshould provide. 6 IntheUK,between2000and2004,onlytwoliteraturereviewsconcentratedonstudiesof rateandcauseofdelayeddischarges.Glasby etal . 31 analysed21documentsonreasons fordelaysbetween1993and2003.Theyconcludedthatcausesfordelayeddischargesare extremelydiversebuttheyidentifiedthre

emainreasonsfordelays:a)internalhospital factorsasaprimecausesuchaswaitingforanotheropinion,aplannedinvestigationora decisionfromanotherconsultant;b)lackofrehabilitationservices;c)otherfactors,such aswaitingforsocialcareassessmentsorfunding,issuesrelatedtopatientsandcarers,or factorssuchashousing.Similarly,Hubbard etal . 39 ,inareviewofstudiespublished between1984and2005,concludedthattherewasnoconclusiveevidencetodemonstrate thatdelayeddischargeswerecausedbyproblemsinanyonepartofthecaresystem,and theyarguedthatacombinationoffactorscontributetotheproblem.Problemsinhealth 19 andsocialcaresettingsassociatedwithdelayeddischargesidentifiedwere:lackofhome support;unavailabilityofconvalescentorrehabilitationfacilities;delaysincommunity careneedsassessmentsorhomecarepackages. Localvariationsintherateandreasonsfordelaysseemtobeacommonalityacrossthe UK.In2002theoverallfiguresfordelayeddischargesrevealed‘significantregional variation.LondonandtheSouthareparticularlyaffected,whereastheproblemis generallylesspronouncedinthenorthofEngland’. 35 However,studiesintheareaof dischargeplanninganddelayeddischargestendtoignorelocalhistoricaland administrativecontexts.Instead,patient’scharacteristicsattractmuchmoreattention. Theseindividualfactorsareexploredinthefollowingsection. PatientsinBlockedBeds:WhoAreThe

y? Whateverthetermchosentodescribethem,bed-blockersarepeople.Theyarehospital patientsadmittedintowardsduetoillness.Thesepeoplemaybeconsideredproblematic bythehospitalbecausetheadministrativejungleofinstitutionalresponsibilitiesand specialisationscategorisedthemasbeeninthewronglocationatsomespecifictime.If we,however,acceptthatdelayeddischargeisanadministrativeandnotmedicalterm, thenthebed-blockersarelikelytobedifferentsortof‘people’dependingonthelocality andthehospitalwheretheyareadmitted. 20 Significantly,Glasby etal . 31 pointedoutthatcausesfordelayvarysubstantiallyfrom areatoareaasdothedelayeddischargesrates.Althoughsomestudieshaveexaminedthe socialcaremarketsituation,hospitalfactorsandpatients’characteristics,researchon ‘inappropriate’hospitalstayshasatendencytofocusonmicroindividualcharacteristics ofpatients.Studiesgenerallyaimtogeneratepatients’profiles,analysemainly demographic,socio-economicfactorsandclinicalcharacteristicsofpatientslikeage, gender,livingarrangementspriortohospitalisation,dependencyfordailyliving activities,etc.However,attentionontheindividualcharacteristicsofpeoplewith prolongedstaysmayattributetheinstitutionalneedforrelocationtopatient’s circumstances.Theobjectiveofmostresearchconcentratingonpopulationcharacteristics istoestablishpredictorsof

delay,regardlessofhowdelayisconceptualised. Consensusseemstobeachievedintheliteratureidentifyingspecificgroupofpatients thatgeneratemoreobstaclesforafasterhospitaldischargethanthegeneralpopulation. Thisisthecaseforolderpeoplewhoseemtomakemoreinappropriateuseofhospital beds,demonstratinghigherdelayratesthantherestofthegeneralpopulation 25 .These delaysaregenerallycausedbyhigherlevelsofhospitaladmissionsinolderpeople, increaseddisabilityandrelatedsocialneedsinthatsectionofthepopulation.Other identifiedgroupswhoareoftenthoughttoblockacutecarebedsmorefrequentlyinclude patientswithchronicillnessesandpeoplewithmentalhealthillnessorcognitive impairments.Thispopulationseemstocreatemoredelaysduetolackofappropriate communityfacilitiesthatcouldmeettheirneeds. 40 21 Althoughdelayeddischargesaregenerallystereotypedasolderor/anddisabledpeople becausetheystatisticallyrepresentthebiggergroupofusersofacutecare,patientswho areoutsidethisbiggergroupmaystillblockbeds.Moreover,manyshortdelaysfromthe elderlypopulationmaybelesscostlythatonesinglecaseofayoungerpersonwhostays inhospitalforalongtime.Fromthoselimitations,peoplelabelledasdelayeddischarges aregenerallydescribedas fragile,dependentpersonswhoneedhelpfromothersfortheir dailylivingactivities.Thesepatientsoftenhaveamultiplemedicalconditionsandsymptoms afterbeinglistedas

medicallyreadyfordischarge.However, althougholderpeople,those withmultiplepathologiesandthosewithsomespecificclinicalconditions(suchas neurologicaldeficitandstroke)mightbemostatriskofdelayeddischarge,itisnota clinicalcondition perse whichcausesthedelaybutthewaysinwhichorganisationsare managingorprovidingservicestocareforpeoplewiththeseclinicalconditions. 40 Conclusion Thedelayeddischargesproblemisacomplexfabrication,consequentuponthe institutionalseparationofhealthandsocialneeds.Inthemostrecentdecades,witha renewedmanagementdrive,themaineconomicincentiveusedinpublichospitalsto reduceexpenditureistominimisehospitalbedusebyreducingthelengthofstayofthe patients.Asaconsequence,keepingpeopleinhospitallongerthannecessarywas constructedasanindicatorofpoorpublicperformance.Theconstructionofmeasuresto analysethisindicatorischallengedthough,bytheconceptualsubjectivityofwho,when, whyandforhowlongpeoplestayinhospitalforlongerthanexpected. 22 Theanalysisofhowdelaysaremeasureddemonstratesalackofconsensuswhichaffects manyofthestudiesthatsoughttomeasureinitiativestoamelioratetheproblem.Rival conceptionsandinterpretationsofthisphenomenonareapparentandembeddedinall investigations.Finally,themainconcerninmonitoringdelayeddischargeshasbeenwith whotoblameandwiththenumbersratherthanwiththereasonswhytheseoccur. However,thesim

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