Hospitals at capacity: understanding delays in patient discharge

NHS hospitals are at capacity. Ambulances are unable to handover patients to emergency departments, and tens of thousands of patients are waiting over 12 hours to be admitted to hospital because there are not enough beds or staff. Hidden behind this decline in NHS performance is an increasing proportion of patients facing delays leaving hospital because they are waiting for support to become available from health and social care services outside of hospital.

Most patients admitted to hospital return home, but some patients require additional care from health and social care services such as short-term rehabilitation in a community hospital, a place in a care home, or care at home. In an attempt to free up hospital capacity at the start of the pandemic, national guidance on patient discharge was changed so that all patients who are medically able to leave hospital, but still need care services, are first discharged to the most appropriate setting before an assessment of their more long-term support needs takes place. Even with these changes to the discharge process, an increasing number of patients face delays leaving hospital.

The NHS monitors delays to patient discharge – where patients are considered medically fit for discharge but remain in hospital. Between last December and August this year, the number of patients facing delays leaving hospital increased by 30%. Delays in transfer of care have been a growing issue for the NHS and social care for many years, but the scale of this issue has worsened, although the definition of delayed discharge is not directly comparable to the measure used before the pandemic.

Patients with hospital stays of three weeks or longer are known to have poorer health outcomes, are more vulnerable to infection, and can experience loss of mobility due to inactivity and bedrest. It could also have long-term consequences on their ability to maintain independence. While longer stays in hospital may be necessary, patients remaining in hospital due to delays highlight a key area for improvement of the quality of care provided by the NHS and wider social care system.

The rise in patients facing delays leaving hospital

Our analysis, based on a freedom of information request combined with publicly available data, shows that delayed discharges increased by 57% in the 12 months between April 2021 and April this year, from 8,039 to 12,589. We estimate that in April this year, one in six patients (15%) were in hospital due to delayed discharge (see data notes).

This increase occurred in patients whose initial hospital stay was longer than three weeks. Three out of 10 patients facing a delay had a length of stay longer than three weeks in April 2021. In April this year, these patients made up almost half (49%) of all patients facing delays – see chart below.

For April this year, we estimate that patients with a hospital stay over three weeks were delayed for an additional 14 days on average (see data notes). Patients with an already long length of stay are at risk of developing further health issues due to irreversible deterioration in their health – an additional two weeks due to delays is unacceptable. There is a risk that long delays could create an increased need for permanent support services, rather than short-term reablement and restorative care.

Patients with longer stays are likely to be elderly, frail and/or have more complex health needs that require support after leaving hospital. The cohort of patients whose initial length of stay was over three weeks rose by 14% between April 2021 and April 2022 (data not shown); which anticipates an increased demand for health and social care services in the coming months.

Why are delayed discharges happening?

The aim of the home first approach is to discharge patients with long-term care needs to the appropriate setting, where assessments about what care they need and how it is funded (either by local government, NHS, both, or self-funded) take place. This approach is crucial for maximising health outcomes. Most patients leave hospital to return home with no additional support. However, the majority of patients facing delays require support provided in the community, whether that is in their own home with visits from care staff and support from family, in a short-term rehabilitation setting, or a care or nursing home, as set out in national guidance.

The chart below shows that the biggest reason why patients face delays leaving is because they are waiting for availability of the service most appropriate for them (home care 24%; short-term rehabilitation 22%; care or nursing home 15%) – which suggests there are significant capacity issues across community services.

The need for good community health and care services

We know a large proportion of patients facing delays leaving hospital are waiting for community health and social care services. Timely and appropriate discharge depends on well-functioning community health and social care services. This should both meet the individual person's needs and help to ensure there is capacity in hospital for admitting patients in an emergency. New proposals to pay care homes millions to discharge patients from hospital may solve the latter, but our data shows that 46% of patients facing delays are waiting for care at home or short-term rehabilitation, not a bed in a care home.

There is limited data collected around the quality of social care – making it difficult to evaluate the effectiveness of current discharge policies and whether people are receiving the care they need in the place that is most appropriate. More of the existing data collected by NHS England on reasons for delay should be published routinely. Routine data around outcomes of social care is also needed to understand the quality of services and the experience of patients leaving hospital.  

Social care services are under sustained pressure, with large staff vacancies impacting the delivery of care. The health and social care system needs to ensure patients are being discharged to the place that can provide the best possible health outcomes, sooner rather than later.