Understanding delays in hospital discharge

Staying in hospital longer than you need for treatment is bad for patients, and leads to increased risk of infection, worsening mobility and mental health. Delays in discharging patients also impact on wider health services – making it more difficult to admit patients and leading to further pressure across ambulance services and the urgent care system more generally.

A growing proportion of patients are spending longer in hospital. As of December 2022, there were almost 20,000 long-stay patients in hospital in England. Patients staying in hospital for three weeks or more increased by 35% between December 2021 and December 2022. 

Despite this, there is a dearth of information about hospital discharge, and in particular delayed discharges – where a patient is medically fit to leave hospital but is not discharged. Routinely published data is limited to the number of people delayed. We have used data that NHS England collects from acute hospitals, obtained from a freedom of information request, to shed more light on how the reasons for delay vary according to how long patients have stayed in hospital.

The rise in delays has been greatest in long-stay patients

The number of patients who no longer meet the “criteria to reside” has increased, with the increase being most marked in patients who have been in hospital for 21 days or longer.

The number of delayed discharges for people in hospital for up to 20 days has remained relatively stable since October 2020. In contrast, there has been a three-fold increase in the number of delayed discharges for people in hospital for three weeks or more, from an average of 2,350 patients in October 2020 to 6,390 patients in December 2022. As of December 2022, one in six patients (15%) were in hospital due to delayed discharge.

It is also worth noting that the length of time that patients are delayed by has increased in the last year. In December 2022, we estimate that people in hospital for over three weeks were delayed for an additional 21 days on average from the day on which they were identified as being medically fit for discharge (nine days more than in December 2021). 

Why are patients delayed in hospital?

The reasons for patients being delayed might help us to understand where the problem lies, and why the increase in delayed patients has been greater for longer-stay patients. Are those patients delayed for different reasons, or could increasing length of stay be a barrier to discharge in itself, if the patient’s condition deteriorates in hospital?

As shown in the chart below, just under a quarter of patients in hospital for seven or more days are delayed for reasons that can be broadly grouped as being about the discharge process in the hospital. They have been identified as medically fit for discharge, but need further assessment, a discharge summary, or agreement on what further care they need.

Another 25% are waiting for a care package at home – this could be for community health services, social care or both. The data available does not enable us to assess if they need community health services – such as district nursing or occupational therapy – or help with personal care which would be arranged by social services. Many patients may need both community health and social care services.

A further 22% are waiting for a short-term bed, such as for rehabilitation. A further 18% are waiting for a permanent bed in a care or nursing home.

For patients in hospital for more than 21 days, the picture is similar, although a higher proportion are waiting for a permanent bed (25%). Although fewer are waiting for reasons relating to the hospital, the proportion is still substantial – about 17%, or one in six.

The reasons for delay have not changed much during the last year.

Where are the capacity gaps in care outside of hospital?

It is important to note that most patients are discharged home without support, with only 15% of patients discharged between October and December 2022 requiring care at home, a short-term rehabilitation bed, or long-term residential or nursing care. 

However, for patients in hospital for more than three weeks, the proportion of people requiring support increases to almost half. 

For this group there are delays, whether they are waiting for home care, short-term rehabilitation beds, or permanent residential or nursing home care. On average each week in the last three months of 2022, around 1,500-1,600 people who had been in hospital for three or more weeks were delayed for each of these pathways.

The number of people successfully discharged is higher for people receiving home care – although it’s still fewer than half of the people ready to be discharged to that pathway. This proportion falls to 35% for people needing short-term beds, and 28% for people receiving permanent beds.

Conclusions

A growing proportion of delays are faced by long-stay patients. Whether patients have had long or short stays, the reasons for delay are split relatively evenly between delays in organising care outside hospital – whether at home, in a rehabilitation bed, or a care home bed – with hospital factors also being important.  

The capacity challenges are not restricted to either community health services or social care – and the impact on patients and services is also across both sectors. Hospitals are struggling to manage the flow of patients because of the high volume of beds occupied by people who might be better cared for elsewhere. And people struggling to obtain access to social care services are competing with the demands of patients in hospital.