Delayed discharges from hospital

Background

A huge challenge facing the NHS is that more patients are experiencing delayed discharges – whereby someone is deemed medically fit to leave hospital but is not actually discharged. Reversing this trend is a major system priority given rising waiting lists, overstretched A&E services, and the risks that unnecessary long stays in hospital pose to patients. 

Most people admitted to a hospital will be discharged home without any additional support, however some may require formal support in their own home, a short-term bed or a permanent bed in a care home. Discharging patients at the right time to the right location requires a well-coordinated system that can adequately meet the needs of patients. Delays arise when discharge processes in hospitals are slow and when capacity is constrained in out-of-hospital care. 

Patients with a longer length of stay in hospital (considered three weeks or more) tend to be in poorer health and may require more support. It is therefore useful to understand how delayed discharges differ by length of stay and where demand is most pronounced. 

Responding to and reducing the number of delayed patients in acute hospitals has been a top priority for the government. The NHS delivery plan for urgent and emergency services recognises the need to improve discharge processes in hospitals and expand capacity in both intermediate care and social care. In January 2023, the government announced £250 million allocated to NHS services to increase capacity in step-down care providing reablement among other types of support. This is in addition to the Better Care Fund allocating £1.6 billion for 2023-25 of funding to social care services to reduce delayed discharges. 

This indicator explores the number of patients experiencing delayed discharges and the reasons why they were delayed according to their length of stay. We then explore where some of the bottlenecks are for those in hospital for three weeks or more. 

This indicator replaces a previous page on delayed transfers of care (DTOC) that is still accessible although no longer being updated. DTOC data is no longer being collected and due to changes in the way this metric was measured it is not comparable with the discharge delays data presented on this page. 

Delayed discharges by length of stay

The total number of patients in acute hospitals who were ready to leave hospital but were delayed has increased by 59% from an average of 8,007 patients per day in May 2021 to 12,751 patients per day in April 2023. At its peak in January this year there were 14,710 patients delayed in hospital. 

The increase has been most noticeable in patients who have been in hospital for 21 days or longer. Since May 2021, there has been a three-fold increase in the number of delayed discharges for these long length of stay patients from a daily average of 2,325 patients in May 2021 to 6,629 patients in April 2023. The number of patients who were in hospital for 20 days or less has remained relatively constant since the dataset began at a daily average of 6,264. Growing numbers of delayed patients with a long length of stay would suggest squeezed capacity particularly in formal care services providing long-term and comprehensive care. 

The impact of winter on the number of delayed patients is apparent with peaks seen in January 2022 and 2023. Every winter sees an increase in A&E admissions and a reduction of staff due to sickness hindering effective discharge processes within hospitals.

Reasons for delay

Identifying the reason for delay helps us to understand where failures in discharge occur and whether they differ by length of stay. 

In April 2023, just over a quarter of patients in hospital for seven days or more were delayed for reasons that could be attributed to the discharge process in hospital. These patients had been identified as medically fit for discharge, but needed further assessment, a discharge summary, or agreement on what further care they might need. 

The most common reason for delay for patients in hospital for seven days or more was waiting for further support provided at home (24%). This type of care can be organised by both NHS community services and adult social care. An additional 22% were waiting for a short-term bed for support such as step-down care and reablement, and 18% were waiting for a permanent bed in a care or nursing home. 

The picture is slightly different for patients in hospital for more than 21 days. Many patients in hospital for three weeks or more require more support upon discharge than those with a shorter length of stay. We see a higher proportion of delays attributed to services organised predominantly by social care. In April 2023, 23% of delays for longer stay patients were due to waiting for a short-term bed and 24% due to waiting for a permanent bed in a care home. Although fewer delays were attributed to the hospital (further assessment needed) compared with patients with a shorter length of stay, 18% (one in five) long-stay patients were delayed because of discharge processes within hospital.

Delays by discharge setting

Only looking at reasons for delayed discharges can mask the scale of the problem for different discharge settings. Here, we present the proportion of patients due to be discharged to a particular setting who are delayed. This gives us an indication of which discharge settings patients are struggling to access the most and therefore represent the tightest bottlenecks.  

Patients waiting to be discharged to a permanent bed in a nursing or care home are the most delayed with a weekly average of 70% experiencing delays in the first three months of 2023. At its peak in June 2022, just shy of eight-in-ten (79%) patients were delayed in hospital waiting for a permanent care home bed. This discharge setting has also seen the biggest increase in demand; a 13-percentage-point increase since May 2021 (data not shown). Care homes were particularly affected by the Covid-19 pandemic which resulted in reduced care home capacity. Continued infection outbreaks along with staff shortages has meant care home occupancy remains below pre-pandemic rates.

In April 2023, a weekly average of 62% of patients waiting for a short-term care bed were delayed, having increased 10 percentage points from May 2021. Whilst the proportion of patients requiring home care who were delayed has been consistently lower than other types of support, around 52% of patients are delayed waiting for home care. Therefore, all three of these settings represent significant bottlenecks for being discharged out of hospital. 

Pressures on social care services are well acknowledged. Growing demand, staff shortages in both domiciliary care and care homes, and under-investment have greatly reduced the capacity to provide care.