On a single day in mid-January, 14 ward spaces were occupied by people who were medically fit to be discharged, but had chosen instead to remain in hospital.
Their decision to stay was either because they had yet to find - or had been unable to secure a place at - a care facility into which they were happy to move.
A recent governors' meeting of the Greater Preston and Chorley and South Ribble clinical commissioning groups (CCGs) heard that the practice was having an effect throughout Lancashire Teaching Hospitals (LTH) - from reduced capacity for pre-planned operations to overcrowding in A&E - because of its effect on the availability of beds.
Chorley GP Dr. John Cairns, a Chorley and South Ribble CCG director, questioned why the situation was being tolerated.
“It doesn't seem reasonable that you can hold up the flow [through] a major teaching hospital because you’d prefer to go to one nursing home over another.
“I’m a big fan of patient choice - but [not] if your Mum’s choice of care home stops my Mum’s care for breast cancer,” he said.
Governors heard that patient choice accounted for around one in six of the 80 beds occupied by patients whose discharge from hospital had been delayed when sample data was taken at LTH during the third week of January.
At that time, nine percent of all beds at the trust were filled with patients who were ready to leave, but had not yet done so - the majority of whom were unable to move on because of delays outside their control, such as hold ups in assessments of their social care needs.
But lay governor Geoff O’Donoghue stressed that even those who had chosen to remain in hospital were likely to have done so only as a result of “incredibly difficult” circumstances.
“For many families, the place where their relative ends up might be permanent - so they’ve got an awful lot to consider,” he said.
The Lancashire Post understands that so-called “delayed transfers of care” were high on the agenda at a summit of health and social care bosses late last month to discuss winter pressures.
Measures taken to reduce delays include increasing the number of patients who can be safely discharged at the weekend and regular “forensic reviews” of individuals whose discharge is overdue.
Bed occupancy at LTH last month was pushed to 100 percent, against what was described as a “conservative target” that no more than 93 percent of beds should be used at any one time. It meant that escalation areas had to be opened up, including in theatre recovery and surgical units - even though winter demand had not reached expected levels.
The CCGs' director of transformation, Jayne Mellor, said that NHS rules meant that “patient choice trumps staying [longer than necessary] in an acute bed”.
However, she described it as “completely unacceptable” that beds were being used as holding bays while patients decided about a care home place - and said that an approved process which meant patients and their families should be given a set timeframe to make suitable arrangements was not always being followed.
“It’s been described to me by Lancashire County Council [which is responsible for social care] as like the school application process - you list your top three preferences, but don’t always get your first choice. The question is why they don’t apply the same principles to care home places [as they do schools],” Ms. Mellor said.
She added that the CCG was planning to ringfence around half a dozen beds at the three intermediate care facilities in Fulwood, Leyland and Longridge in order to provide places to which patients can be discharged while care home decisions are made.
But Denis Gizzi, chief officer of the CCGs, said the underlying cause of the problem had to be confronted.
“We keep saying patient choice, but this isn’t patient choice - a patient is somebody who is ill. When that person is ready to be discharged, they are no longer a patient, they are a citizen - and and another patient needs that facility.”
However, Dr. Ann Robinson, a Chorley GP and a director on the area's CCG, cautioned against an overly-critical analysis of why a hospital patient might opt to stay put for longer than medics deemed necessary.
“We’re assuming that all these people have capacity to make decisions. If not, then you have to wait for family to come in - and we’re assuming that people can have time off work and that families get on and are making a joint decision.
“So it’s very complicated when you take it down to a granular level,” Dr. Robinson added.
A new process for determining a patient’s ongoing care needs when they are discharged from hospital was introduced across Lancashire just over a year ago. It means individuals return to their own home as soon as they are fit to leave to their hospital bed - and are assessed there on the same day by a social care team to see how they cope back in the domestic environment.
They are then provided with whatever level of support they require - including round-the-clock care for up to 72 hours or hour-long daily visits - while therapists work with the patient in an attempt to restore them to their previous level of mobility.
In Central Lancashire, there are 12 so-called “home first” slots available each day - but along with the associated reablement service - there is spare capacity in these community-based care options.
Jayne Mellor, director of transformation at the area’s two CCGs, said the situation amounted to a financial double whammy for the organisations, which are responsible for securing healthcare services across the region.
“We have to assure ourselves as a governing body that we are getting the best value for those community services - and right now I don’t believe we are.
“That’s because we’re paying excess bed days tarrifs for those in hospital who shouldn’t be and also for community services that have got capacity. We need to reset the whole system.”
Ms. Mellor added that sending a patient back to their own home rather than into residential care should be the “first choice” when the individual was living independently before they were admitted to hospital.
However, there are almost 60 rehabilitation or “step down” beds available across Central Lancashire for patients who need more intensive support to give them the best chance of being able to regain that independence - 27 at Meadowfield House in Fulwood, 16 at Broadfield House in Leyland and 15 at Longridge Community Hospital.
It is from within this number that half a dozen ringfenced beds will be created for patients who would otherwise be stuck in hospital while making a decision about - or securing a place in - the preferred care home.
The CCGs are also about to commission a further 15 places for those requiring round-the-clock nursing care and specialist rehabilitation after a stay in hospital in order to enable them eventually to return home
The same beds could also be used, when appropriate, to prevent some patients from having to be admitted to hospital in the first place.
BED SHORTAGE BLIP?
Officially-verified statistics about delayed discharges from hospital are published by NHS England several months after the period to which they relate. While the more up-to-date figures revealed at the latest CCG meeting suggest a spike in the problem within Central Lancashire in recent weeks, the long-term trend across the county as a whole is in the right direction.
In November 2019 - the latest month for which confirmed statistics are available - there were 3,056 so-called "delayed days" in Lancashire, equating to the number of days spent in hospital by patients who were medically fit to leave. That figure was down by just under 400 on the same month in 2018 and by almost 1,500 since November 2017.
In each of those months, more delays were attributed to being caused by the NHS than social care.
In statement on behalf of the Central Lancashire integrated care partnership (ICP) of health and social care organisations - including the local NHS and Lancashire County Council - chief officer of the Greater Preston and Chorley and South Ribble CCGs, Denis Gizzi, said:
“The winter period always brings additional demand for NHS and social care services and thus increased pressure on our hard working and dedicated staff who continue to deliver their best for people.
“We recognise that reducing the number of people who are delayed in hospital is a challenge in central Lancashire but we are committed to working together as a whole health and care system to address this.
“We know that once people no longer need hospital care, it is best to support them to return home or to a community setting to recover as quickly as possible. Nobody wants to stay in hospital longer than is necessary and it can have a detrimental effect on their health - especially older people. It also means people who are acutely unwell may be unable to access services if some hospital beds are occupied by people who no longer need to be in them.
“Wherever possible, people will return to their own home when they leave hospital. However, some people with significant health and care needs may need additional support out of hospital and we work closely with them and their families and carers to support them to understand their options and access the most appropriate service.
“Whilst we always try to make sure people are able to be discharged to the most appropriate community setting, this may not always be immediately available. In these cases, an alternative option is explored with people and their families or carers. Although this may not be ideal for the person concerned, our teams always continue to work towards the person’s preferred choice of accommodation and endeavour to transfer people at the earliest opportunity,” added Mr. Gizzi, who was speaking after the recent summit on addressing winter pressures in the health and social care system.