The spread of COVID-19 will have a profound impact in the UK. The latest modelling shows that it will be a significant challenge to meet the national requirement for hospital beds. The demand for ICU beds will outstrip current surge capacity by almost 100%, even general hospital bed capacity will be insufficient to meet demand. The NHS has responded with urgent guidance requiring all providers to increase critical care capacity by emptying hospitals of any dischargeable patients. Crucially, to be able to discharge patients from acute hospitals, it means increasing capacity in community services.
Challenges stopping patient discharge
Often unintentionally, patients remain in hospital long after they have received treatment, those with a length of stay (LOS) of seven days or more are considered to be "stranded". These patients require additional support and a more complex pathway than other patients, whether it is support from community care, mental health, therapy services or social care. It is not possible to simply discharge these patients without a support network in place. In normal times there are many reasons why hospitals struggle to discharge these patients. This includes:
- a lack of clarity around the pathways that exist
- a lack of capacity in community care services
- a lack of understanding of demand and capacity across the system
- poor relationships between health and social care services
A large proportion of bed days are used by frail complex patients who require a well thought out support plan. If care is made available in the community for complex elderly patients, a significant opportunity can be created to free up the acute bed capacity necessary for the treatment of COVID-19 patients. Recent data from HES shows that the number of super-stranded patients (those spending more than 21 days in hospital) are highest amongst the over-70's who are also in the high-risk group for COVID-19. The over-70's have a significantly higher likelihood of requiring hospitalisation due to COVID-19, with 24% of symptomatic cases in 70-79-year-olds and 27% of symptomatic cases in over 80s requiring hospitalisation.
The coronavirus is likely to amplify these challenges in various ways, not least due to the fact that the majority of patients requiring ITU admittance for ventilation are complex or older adults. These same patients are more likely to become super stranded once in hospital thus enhancing the need for community input. Furthermore, additional demand on ITU capacity due to COVID-19 related admissions will lead to reduced capacity to manage other acute illnesses, creating a further imperative to scale up community capacity to keep complex patients out of acute settings as much as possible.
These challenges will be somewhat mitigated by the removal of certain blockers that often delay the discharge of super stranded patients, including the removal of the requirement for patients to fund self-care places, removing the need for a funding assessment. The patient choice agenda has also been suspended, meaning that patients and families are unable to refuse a placement generating delays. These measures alone however will not be sufficient to reach the levels of discharge necessary.
A whole system solution
We suggest that in order to deal with this unprecedented challenge a whole system approach will be essential including:
- Capacity planning and coordination
- Coordination of investment
- Discharge models
It will also be important to capture the learning from these rapid changes during the crisis to ensure that this can be used in the future. This will allow the drastic short-term measures essential during the crisis to be translated into longer-term transformation to strengthen our health and care system moving forwards.
1. Planning and coordination of available community beds and capacity
There is an urgent need to understand and manage capacity across the system to prevent services becoming overburdened. This requires a system wide approach supported by sophisticated analytics. To allow coordination, it is necessary to have a daily view of demand and capacity across the system as well as a daily list of patients, discharge type and destination.
This information would allow demand and capacity across social care providers to be smoothed and managed to ensure no provider is overwhelmed, thus slowing down discharge. It will also allow the coordination and early planning of discharge to ensure patients are directed to the most appropriate service.
2. Cross-system coordination to make the best use of the new investment to get patients out of hospital
The emergency investment in the NHS and public services will need to be coordinated effectively to ensure that capacity can be created to meet the demand from patients requiring treatment for COVID-19. This will require cross-system working between health care services and services in the community as well as effective leadership and clear prioritisation.
The coordination of investment will need to be informed by modelling of demand and capacity across the entire pathway to ensure that investment is directed where it is most needed and will have the greatest effect.
3. Ensuring an adequate workforce, through both the redeployment of existing staff and the effective use of the new volunteer workforce
There are several key challenges that need to be addressed to ensure a sufficient workforce to allow effective discharges into community care. The first challenge is an ongoing shortage of staff in community services even prior to the crisis, this is particularly true since Brexit which had a significant impact on the carer workforce. This challenge will be amplified by the need to ramp up the scale of discharges from hospital and to provide care in community settings. This will include multi-disciplinary staff for hospital discharge teams and to man significantly more rehabilitation care home beds. This challenge will only be compounded as increasing numbers of community care staff are forced to take sick leave or go into self-isolation due to COVID-19.
In all, this presents a significant challenge requiring a co-ordinated cross-system response to meet these resource needs. A key temporary solution will be to focus on building capacity in community beds through the use of temporary hotels. Although bed-based care is less cost-effective than home-based care under normal circumstances, during the current crisis it is a more efficient use of the available staff. When considering the longer-term implications of the crisis it is, however, important to note that this response may lead to an increased ongoing requirement for residential placements due to a loss of independence amongst patients who do not return home.
A further option in the short term is the redeployment of the existing workforce from elsewhere. This will require modelling of the necessary skill mix and volume of staff in each service and what is available across the system based on demand and capacity modelling outputs
Alongside this, community care can make use of the growing volunteer workforce, who will be able to provide services such as transport and support for those discharged and able to return home.
A key challenge that must be addressed in both of these solutions is the need to ensure co-ordinated working in a blended workforce from different services and including volunteers. Furthermore, the challenge of increasing numbers of community care staff requiring sick leave during the crisis will require further modelling and forecasting to ensure that alternative resources can be identified and put in place as required.
4. Coordinated and rapid MDT discharge planning and community care models
Effective discharge pathways and planning for complex patients are crucial to freeing up ITU capacity. This will require existing models of care to be rapidly scaled up at different stages of the care pathway from admission to discharge and reablement.
Some examples of the necessary models include:
- Discharge to assess models which provide short-term care and reablement in people’s homes reducing the time required in an acute setting for monitoring and assessment
- Multi-disciplinary discharge teams in hospitals to coordinate discharge planning and ensure that patients are monitored, and services are in place in advance of them being fit to leave to prevent unnecessary delay
- Shifting clinical risk to the community to resolve traditional difficulties getting frail patients out of hospital due to the idea that they are safer in hospital. It is necessary to lower the risk threshold for transfer to the community setting. This is particularly crucial as not only are patients at a higher risk of infection from the coronavirus whilst in hospital, the population as a whole is at greater risk due to the reduction in the available acute bedded capacity
It is clear that a focus on community care is critical in the management of the COVID-19 crisis. For this to be effective however, it is crucial that demand and capacity are well understood to allow accurate planning. This will support the coordination of Investment across the system to maximise its efficacy and the tackling of workforce shortages. These co-ordination measures will create the opportunity for discharge models to be rapidly ramped up, accelerating the rate at which patients can be discharged from hospitals.
Whilst these measures are an urgent necessity in the current crisis, the learning that they will provide also presents an opportunity to look forwards to the longer-term and what measures might be used to continue to reduce length of stay and stranded spells in the future.