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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) Frombed-blockingtodelayeddischarges. 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 patientslengthofstaytoimproveefficiency;theintrinsicmethodologicaldifficultiesof measuringhospitaldelays;andthemostc
ommonreasonsfordelayeddischarges.A descriptionofthecharacteristicsofthepatientsfrequentlylabelledasdelayeddischarge, theircommontraitsandhowthesehavebeenexaminedbypreviousresearchisalso provided.Finally,thisarticlearguesthatthepresenceofhospitaldelaysinahealth systemtendstobeconsideredasanindicatoroftwopossiblesysteminefficiencies:a failureinthedischargeplanningprocess,whichgenerallyblamessocialservices departmentsfornotensuringtimelyservices;orashortageofalternativeformsofcare forthisgroupofpatients. 2 Introduction Overthelastthirtyyears,mostwesternnations,influencedbyneoliberalideologies, embarkedonhealthcarereformsthatareoftencharacterisedasdecentralisationand 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
ernmentofthelate1980sandearly1990s, 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 peopleinthecommunityratherthanmatchingpeoplesneed
stoservices.Voluntaryand privateorganisations(andfamilies)undertooktheprovisionofsocialcareonbehalfof thecouncil,andsocialworkersweregiventheroleofcaremanagers. Therelocationofcarefrominstitutionstothecommunitymeantatransferofthecostof carefromthestatetoothersocialcareactors:users,theircarersandfamilies,voluntary sectororganisationsandfor-profitorganisations.Theearlydischargeofpeoplefrom hospitalorcareinstitutionalsoincreasedthefinancialburdenuponsocialservices departmentsandprimaryhealthcareservices.Furthermore,theconstantdevelopmentof initiativesthatreducedhospital-basedNHScarerepresentedtherelocationoffreecareat thepointofdeliverytocommunityservices,whicharemeans-testedandincurcharges forthepopulation.Inotherwords,theredefinitionofsomeacuteandcontinuingcareas socialcarehadaneconomicconsequencefortheendusersofservicesthatshouldnot beignored. 4 The1990NHSandCommunityCareActcontinuedthehistoricaldivisionbetweenhealth andsocialcare.EligibilitycriteriaforfreeNHScontinuingcareandtheappropriateness ofdischargingvulnerablepatientsfromhospitalbecamemajorpoliticalissuesduringthe 1990s.Withinthisframework,in1997,NewLabourproposedTheNewNHS,aten yearplanfortheNHS.Whilepreservingmanyfeaturesoftheinternalmarket,thiswas intendedtoshiftthefocusofservicesfromcompetitiontocooperation
.Government emphasisturnedtointegratedcareandpartnerships. 1 Inthiscontext,theolddivisions betweenhealthandsocialcarewereidentifiedascreatingparticularobstaclestothe planninganddeliveryofseamlessservicestailoredtoindividualneeds. 2 In2003,anotherinitiativethatattemptedtoreducehospitalbasedcarewasintroduced: theCommunityCare(DelayedDischargesetc.)Act2003. 3 Thispolicymeantthatlocal authoritiesweremadefinanciallyresponsiblefortheaccommodationcosts(hotel services)thatpatientswithsocialneedsreceivewhilstinacutecare.Thisfigurewas calculatedinadailytariffequalforallpatients(£100perday),withtheexceptionof localitiesintheSouthEastofEngland(£120perday).Asaconsequence, administratively,socialservicesdepartmentsweretreatedaspurchasersofaservice (acutecare)fortheirclients,providedbythehospitals. Inthispolicy,thepartnershipethoscollidedwiththeneedforefficiency,whichwas constructedunderaconceptemblematicofthatdivision:theproblemofbed-blockingor delayeddischarges.Thephenomenonisdeep-seatedwithintheproblematic 5 administrative,financialandprofessionaldivisionofhealthandsocialcare.Inorderto investigatetherivalinterpretationsaffectingthetopicofbed-blocking,threekeyfeatures oftheconceptaredescribed:thereductionofpatientslengthofstayasamanagement tooltoimproveefficien
cy;theintrinsicmethodologicaldifficultiesofmeasuringhospital delays;andthemostcommonreasonsfordelayedhospitaldischarges.Finally,thearticle closeswithadescriptionofthecharacteristicsofthepatientsfrequentlylabelledas delayeddischarge,theircommontraitsandhowthesehavebeenexaminedbyprevious research. Bed-BlockingorDelayedDischarge?AContestedConcept Cultural,social,economicandorganisationalcontextsinfluencehowthepatientgroupof theso-calledbed-blockerscouldbedefined.Nevertheless,therearerivalconceptions andinterpretationsofthistermwhichcouldthusbeconsideredtocomeundertherubric ofanessentiallycontestedconcept. 4 Bed-blockingisaninternallycomplexterm,open- endedandbasedonqualitativenotions.Interpretationsoftheconceptaredisputedwith particularlinesofthoughtbeingsustainedbydifferentstandpoints.Inbrief,thepresence ofdelaysinahealthsystemmaybeconsideredasanindicatoroftwopossiblesystem inefficiencies:afailureinthedischargeplanningprocess,whichgenerallyblamessocial servicesfornotensuringtimelyservices;orashortageofalternativeformsofcarefor thisgroupofpatients. 6 Theterm'blockedbed'originatedintheUnitedKingdominthelate1950sanditwas traditionallyusedtoimplythatregularpatientorclientthrough-putwithregardtothat particularbedhasstopped. 5 Synonymousexpressio
nslikeback-up,backlogs,long- stays,outliersanddelayeddischargeswereusedintheUnitedStatesandCanadaand havesimilarmeaningsdespitethecontextualdifferences.Theyallrefertothefactthat averagebeduseisinterruptedbypatientswhostayinhospitalforlongerthanexpected. Whateverthewordsusedtodescribethisgroupofpatients,similartermswereandstill areappliednotonlytoacutehospitalbedsbutalsotobedsinpsychiatric,geriatricand otherhealthandsocialcareinstitutions. Thebeginningofthebed-blockingphenomenoncannotbeseparatedfromthechanging roleofhospitalsinrespectofgeriatricpatients.Originally,bed-blockingconcernswere drivenbyhospitalcliniciansbecomingincreasinglyperturbedwiththeirlimited availabilityofbeds.IntheUKbetween1961and1967,therewasa14percentriseinthe elderlypopulationbutthenumberofhospitalbedsassignedfortheiruseremained practicallythesame. 6 Apparently,therewasstrongcompetitionoverhospitalspace whichledtoadesireonthepartofsomehospitaldoctorstoexcludecareoftheelderly frommajorhospitals.Hall&Bytheway 7 suggestedthathospitaldoctorsfollowedthe prevailing'acuteideology'inmedicineandusedphenomenalikebed-blockingtorestrict olderpeoplesentrytohospital. Therefore,notsurprisingly,earlyinvestigationsintothebed-blockingphenomenon reliedontheopinio
nofconsultantsforthereasonswhypatientsstayedinhospitallonger 7 thannecessary. 89 Doctorsresearchtendedtofocusonthefailureofsocialcareto developtheservicesneededtofacilitatedischarges.Forthisreason,someauthors 10 argue thattheconceptofbed-blockingisanotherexampleofthemedicaldominancethat intrudesintopoliciesandthedailyadministrationofhealthinstitutions. Inthe1990s,withthedriveforefficiencythatdictatedhealthcareinstitutions,theterm bed-blockingwasborrowedbyhealtheconomistswhouseditasanexampleofthe failureofefficientsystemsinhospitals.Indeed,inthedebateover'bed-blocking', economiststendedtosidewithhospitaldoctorsandblameinadequatelocalauthority provision.Insummary,reducingtheboundariesofacutecarehadthepotentialtosuit bothcostconsciouspolicymakersandtheprofessionalinclinationsofmanyhospital doctors. In1994,Styrborn 11 arguedthatbed-blocking,despiteitscommonuse,wasnottobe acceptedasamedicaltermbutasanadministrativeconceptthatwaspartofaneconomic controlsystemcoinedbyhealtheconomists.Heexplainedthatthetermimpliedthatthe patientwassituatedinthewronglocationinthespectrumofcare.Lateron,followinga similarapproach,Wimo, etal . 12 referredtothemisplacementofpeoplewhoare situatedatthewrongcaringlevelandthisnotionincludedtheneedfordive
rsecare alternatives.StyrbornandWimo etal .sapproachfocusesondefiningthebed-blocking problemastheneedforadifferentplaceorsitewherepatientscouldbelocated.Reasons forrelocatingpatientsrangefromadministrativedecisionsandpoliticalpoliciesto changesinpatientshealthstatus.Mostimportantly,thistypeofconceptualexplanation 8 leadstosolutionstotheproblemthatarebasedonincreasingtheavailabilityof locations,sites,orspacesforthesepatients. Intherecentyears,theuseoftheadjectivebed-blockertorefertopatientshasbeen consideredinappropriateintheUK.Itwasarguedthatthisterminsinuatedthatpatients themselveswereresponsiblefortheirsituation:Thewholenotionofbedblockingseems toimplythatolderpeopleenterhospitalandthenwilfullycontinuetooccupyabed which,intheviewsofstaff,theynolongerrequire 13 .Thetermwasconsidered politicallyincorrect,deemedoffensiveforpatientsandrejectedbytheHealthSelect Committee.Instead,theexpressionsdelayedtransferofcareordelayeddischarge wereproposedtoreplaceit.InApril2001,theDepartmentofHealthissuedastandard definitionandintroducedthesenewterms: Adelayedtransferoccurswhenapatientisreadyfortransferfromageneraland acutehospitalbedbutisstilloccupyingthatbed.Apatientisreadyfortransferwhen: aclinicaldecisionismadethatthepatientisreadyfortransfer
;amulti-disciplinary teamdecisionhasbeenmadethatthepatientisreadyfortransfer;andthepatientis safetodischarge/transfer. 14 Sincethen,theexpressiondelayeddischargeshasbeenwidelyadoptedintheBritish governmentalandresearchliterature.Althoughithasbeenconsideredamoreneutral term 15 ,thenewlycoinedexpressionsupportsacleartheoreticalposition.Itimpliesa shiftfromfocusingonmacroeconomicfactorstomicroorganisationalsystems.The exclusivefocusonthetimecomponentofthedischargeprocessshiftedthedebatefrom 9 theavailabilityandsuitabilityofthenextlocation(space),totheinstitutionalprocessof discharge(time).Bedsarenotblockedbutpatientsdischargesaredelayed,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 Thephenomenonofdelayeddischargesmaythusbeunderstoodinthetermsof organisationalmanagementchoice.Healthcareplanners,confrontedwithanincreased numberofpotentialusers,choosetoensurearapidpatientflowasanewtooltoimprove efficiency.Millard&McLean 17 usedtheanalogyofatoytraintoexplainhowanacute hospitalworks.Thehospitalwascomparedwitha24hou
rtraincirclingatrackat constantspeed.Toimprovethepassengercarryingperformanceseveralchoiceswere given: a) Toaddmorecarriages(i.e.morebeds) b) Tostoppassengersgettingonboard(programmestoreduceadmissionsintheover 75s) 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,whenarepatientsexitsappropriate. 20 Those unwelcomepatientsaretheso-calleddelayeddischarges,aby-productofadopting economictheoriesthatrecommenddecreasinglengthofstaytoimprovehospital efficiency. TheUKGovernmentmadethechoiceofselectingreductioninlengthofstayasatoolfor efficiency,statingthatitwasoneofitssixdimensionsofperformance 1 .Despitethe officialchoicetouselengthofstayasameasureforefficiency,thecausalrelationship 12 betweenlengthofstayandqualityofcareisnotstraightforward.Traditionally,muchof theliteratureinthisareaexplainsthathealthoutcomesarenotaffectedbyshorterstays andthatextendedstaysarelinkedtoincreasemorbidity.However,authorslikeClarke& Rosen 21 exposethelackofevidenceoftheassociationbetweenlongerlengthofstayand poorerhealthoutcomes.Theyexplainhowtensionsbetweenreducingstaysinorderto increasepatientsthroughputandmaintainingtheappropriatenessofcarearerarely appreciatedbythosekeentoseestaysreducedasamarkerofefficiency. Inaddition,reductioninthelengthofpatientsstayhasalsothepotentialtoincreaseth
e complexityofthedischargeprocess. 22 Healthcareworkisfrequentlyhighlyproblematic duetotheunexpectedandoftendifficulttocontrolcontingencies,stemmingnotonly fromtheillnessitself,butalsofromahostofworkandorganisationalsourcesaswellas frombiographicalandlife-stylesourcespertainingtopatients,relativesandstaff members. 23 Theshorteningofhospitalstayscouldaddtothatcomplexitywiththe potentialofmorecontingenciesoccurringduetothelackoftimehealthcareworkershave tofamiliarisethemselveswiththepatientscircumstances. TheMeasurementofDelayedDischarges:TensionsandChallenges Themethodologicalliteraturestudyingdelayeddischargesraisesseriousquestions relatedtocoreconceptualissuesaboutwhatconstitutesahospitaldelay.Thislackof consensusisillustratedbyfourmaintensionsinthedefinitionofdelays: 13 a) Thefirstapproachdefinesdelayasthetimeperiodestablishedbyahospital dischargeplannerwhichismeasuredbythetimedifferencebetweenapatientbeing medicallyreadyfordischargeandtheactualtimeofdischarge. 24 Consequently,the resultingfigureisaperiodoftimedefinedsubjectivelybyresearchers,medical practitioners,healthandsocialcarestaffor,insomecases,apanelofexperts.This approachisamorerefinedderivationofthetraditionalarbitraryapproachusedby consultantsinthe1960sbutitstillseemstoprivilegeopiniono
verevidence. Physiciansopiniontendstoprevailuponothermembersofthemultidisciplinary teamanditisconsideredthegoldstandard.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,thesefactorsarescrutinisedinthepatientsmedicalrecords.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: Itisdifficulttodefinepreciselywhenapatientisreadyfordischargeornolonger inneedofourmedical/surgicalexpertise.Wesimplyreliedontheopinionofthe clinicalteamresponsibleforthepatient;theynolongerfeltresponsibleforthe patientsmanagement.[ ]itwasnoteasytoestablishthereasonfordelay.We simplyrelieduponclinicaljudgement,identifyingtheonefactorthatseemedmost important,butinpracticetherewereoftenseveralinter-relatedreasons. (p.319) Styrborn&Thorslund 33 considerlocalcircumstancesasdecisiveforthedefinitionof delaysandforanyattemptedsolutions;andtheyalsorefertotheimportanceofa consistentdefinitionofthebed-blockerconceptwhencomparingovertime.Vetter 20 reinforcestheaboveargumentanddeemstheassessmentofinappropriatebedusageas beingbesetbyproblemsoflackofdefinitionanddominatedbysubjectivity.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 dominatedresearchondelaysthroughthe1980sand1990swithdischargeplanning 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 patientsdelaysduetotheirsocialcareneeds.Inthe1990s,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,socialservicesordelaysbeyond controlofeitheragency.Intheresearchliteraturecommonreasonswhydelaysare allocatedtosocialservicesare:delaysinallocatingsocialworkers,complexityof assessmentcriteria,delaysinallocatingfunding.Itseemsthat,ingeneral,theresearchon causesfordelaysconcentratesonwhotoblameinsteadofacceptingthecomplexand multi-facetednatureoffactorscontributingtodelayedtransfer.Thisperspectiveisa continuationofthehistoricalpreoccupationofbothsocialandhealthsectors,tofocuson who(shouldprovideservices,whosefaultisit?,etc.)morethanonwhattheyshould 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.In2002theoverallfiguresfordelayeddischargesrevealedsignificantregional variation.LondonandtheSouthareparticularlyaffected,whereastheproblemis generallylesspronouncedinthenorthofEngland. 35 However,studiesintheareaof dischargeplanninganddelayeddischargestendtoignorelocalhistoricaland administrativecontexts.Instead,patientscharacteristicsattractmuchmoreattention. Theseindividualfactorsareexploredinthefollowingsection. PatientsinBlockedBeds:WhoAreThe
y? Whateverthetermchosentodescribethem,bed-blockersarepeople.Theyarehospital patientsadmittedintowardsduetoillness.Thesepeoplemaybeconsideredproblematic bythehospitalbecausetheadministrativejungleofinstitutionalresponsibilitiesand specialisationscategorisedthemasbeeninthewronglocationatsomespecifictime.If we,however,acceptthatdelayeddischargeisanadministrativeandnotmedicalterm, thenthebed-blockersarelikelytobedifferentsortofpeopledependingonthelocality andthehospitalwheretheyareadmitted. 20 Significantly,Glasby etal . 31 pointedoutthatcausesfordelayvarysubstantiallyfrom areatoareaasdothedelayeddischargesrates.Althoughsomestudieshaveexaminedthe socialcaremarketsituation,hospitalfactorsandpatientscharacteristics,researchon inappropriatehospitalstayshasatendencytofocusonmicroindividualcharacteristics ofpatients.Studiesgenerallyaimtogeneratepatientsprofiles,analysemainly demographic,socio-economicfactorsandclinicalcharacteristicsofpatientslikeage, gender,livingarrangementspriortohospitalisation,dependencyfordailyliving activities,etc.However,attentionontheindividualcharacteristicsofpeoplewith prolongedstaysmayattributetheinstitutionalneedforrelocationtopatients 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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