The Complexities Of Bed-Blocking

Cardiff and Vale NHS Trust is the largest NHS trust in Wales, providing health services to half a million people in Cardiff and the Vale of Glamorgan. It also provides specialist health services – such as paediatric, renal, cardiac, neurological services and bone marrow transplantation – to patients from across Wales.

It has a total income in excess of £576m and it employs approximately 13,500 staff. The trust runs two acute hospitals – the University Hospital of Wales and Llandough Hospital – both of which bear the brunt of bed-blocking. The trust has consistently had some of the highest levels of delayed transfers of care – the figures for March show that 8.3% of its beds are currently blocked.

The Western Mail spoke to key members of staff at the trust to discover the true impact of bed-blocking – on patients, staff, families and the trust itself.

Dr Rhian Morse is a consultant physician in geriatric medicine and clinical director for rehabilitation at Cardiff and Vale NHS Trust. She said: “There are probably two to three key factors to bed-blocking – we are living through major demographic change and although it is viewed as negative, it is actually a positive thing as people are living longer.

“Illnesses in old age are more complex so the length of stay in hospitals is longer, especially when compared to a younger person with the same condition. The average age of patients in general medical wards is now 74, compared to 65 in 2001. It is also important that patients receive rehabilitation following an acute illness.

“But health and social care services are lagging behind in grasping that investment is required as a result of this increased demand – more investment in secondary, primary and social care areas. The problem is not that we can’t just get people out of hospital – we could shorten stays before patients undergo more intensive rehabilitation, but then they would have to go on to another service and there are considerable delays there.

“There are also delays in people accessing social care packages – the whole process has become more lengthy in terms of assessment. It can sometimes take a month for assessment to take place. Often we try and predict when patients will need assessing, but it’s common for people to be sitting and waiting – and that’s just the first step.

“Care home places are the biggest constraint in terms of discharge and for patients it is an unsettling period because they are neither at home or at their final place of residence. Cardiff has probably one of the lowest number of care home places per head of population in Wales – capacity is very small and that means that choice is limited.

“You could even say that there is no drive to increase standards because there is no competition among care homes in terms of attracting individuals. Going into long-term care is a big life decision to make. When it is made after illness it can be a stressful time. People have to come to terms with the fact that they will not be going home and then they are faced with a lengthy process.

“Going into long-term care is the last-resort measure. Hospitals are risky places, in terms of infections and the risk of falls. While these risks are also there in care homes, the environment in the majority is more homely than a hospital. There is definitely an optimum time to be in hospital – in the early stages of treatment when there is a lot going on and a period of rehabilitation.

“But then it’s time to move on, as the risks of being in hospital outweigh the benefits and people can lose their independence. For patients who are mobile, delays are very, very bad, but for the very frail there can be concerns about moving them into long-term care and whether the level of care will be adequate.

“Families often express concerns about the standards of care in homes and they can feel reassured by the level of care which is provided on long-term rehabilitation wards in hospital. There is a lot of frustration and there’s the risk that the patient is seen as a problem and that ageist attitudes, about older people taking up too much resources, are reinforced.

“Elderly people are high users of hospital care and deservedly so – it is right that they should have access to all that a hospital can offer them. Ideally we wouldn’t want to see occupancy greater than 85% – at the moment it is running at 98% and that means that we cannot move patients around the system, which further compounds the situation.

“There are constant crises in the service – the stresses on staff are huge in terms of trying to deal with patients who have very legitimate causes for being in hospital but who they can’t get out of the system. Everyone does their best every day. This is not about older people blocking beds – the system has not adapted to the fact that we have an ageing population.

“Older patients are, medically, much more complicated to deal with, but they deserve access to what hospitals can offer them. But there must be a way out for them too. We have to enhance rehabilitation services within the hospitals setting and we have to adapt to the increasing numbers of people needing care, but that has to be accompanied by a whole systems approach.”

Lynne Topham, acting directorate manager for rehabilitation at Cardiff and Vale NHS Trust. She said: “For some patients the prospect of going into a nursing home is a huge decision to make. It’s bad enough having to go into one for some, but then they have to play the waiting game to find a home that is suitable, which can be difficult – it’s a double whammy.

“We have had situations where matrons from a care home will decide that they don’t want to take a patient and they get moved down the list again. I suspect the reason for this is that they now have the choice of who they want to accept. I have a patient who is 12th on the list for a certain nursing home place – it takes a year to get into that home. We had another patient who waited for eight months to go into a home, then the matron decided that she couldn’t take the patient, who had to wait another eight months.

“Patients become quite demoralised – sometimes they feel stuck in a bed that should be given to someone else. Tensions also evolve between the families and staff – everyone gets fed up. It can also be psychologically draining on the patient as every week they have to see the social worker or look at another home. The impact on staff is significant, especially as every patient who goes through rehabilitation has to go through the assessment process – paperwork has increased over the last year or so.

“The whole issue of bed-blocking can change the case mix on a ward – for example on a ward of 23 patients it may be that 15 require nursing home level of care. When you get huge blocks in the system it puts huge pressure on the nursing team to manage such a group of patients.

Nurses have the skills to manage these patients but some angst comes in because they can sometimes feel that they are not able to practise their skills. We need more specialist community services and social services so more people can have care in their own homes. We should be focusing our efforts on enabling people to go home.”

Simon Jones is the chairman of Cardiff and Vale NHS Trust. He said: “We are still running, and have been for a good number of months, somewhere in the region of 200-210 people in our hospitals who either shouldn’t be in hospital or should be in other parts of the hospital which are more appropriate for their needs. But they are unable to be transferred because, for example, someone else is in the rehabilitation setting who should be out of hospital.

“The impact that has on the service is felt in a range of different ways, some of which hit the headlines, such as not being able to get people into the hospital and ambulances outside hospital for longer. But as we move through the system we find that people are having their initial care in areas that were not designed for it – for example, someone having to wait on a trolley in a corridor.

“Further into the hospital we can have emergency medical patients in places like the ambulatory care unit because we don’t have anywhere else to put them – this happens more often overnight when we aren’t using the centre, but even so, thatfacility is not designed for that sort of care. What the health service does best is it copes, but in coping that means we probably don’t provide the optimum care that we would hope to provide.

“As we move further again into the hospital we have a lot of outliers – because the hospital is so full, we have to put patients on wards they wouldn’t usually be on. For example, emergency medical care patients are put on surgical wards. As a consequence, they might be nursed by people who do not have the appropriate skills. Consultants, instead of having to visit just one ward, may have to visit patients spread out across the hospital.

“If we have patients in inappropriate beds, that has an impact on how many people we can bring in for elective surgery. We ring-fence orthopaedic beds because as soon as we put a medical patient in, there is a risk of cross infection. But if we have medical patients in general surgical beds we can’t bring in someone else for surgery, which is why we have a lot of people who have had cancelled operations.

“The whole system is affected by how it runs in terms of bed occupancy – there is no flexibility to do what we want to do or to move people around to be cared for in the most appropriate setting. Since September we have seen peaks in demand on the system but in terms of pressure, this has been there for years. We no longer see a tailing off of this pressure in the summer months.

“No hospital or trust is ever going to say that it anticipates that it cannot cope, because we have to – the consequences of not coping are very serious. Instead we have to look at ways of how we can cope. There are only three solutions to this problem – we have to understand, much better, what is happening in terms of demand, and if we do, we must introduce measures to tackle the demand as it happens, such as putting some sort of something between the GP surgery and the hospital which can take care of a percentage of what comes in here.

“With immediate effect we have to find ways of getting those people who shouldn’t be in hospital, out of hospital. And whatever the solution is, we can’t do it on our own – GPs can’t do it on their own, the ambulance service can’t do it on their own. It is only after we have identified what’s happening that extra resources will become useful – if we just go through resources at increasing capacity, that capacity will just see more demand.

“We are getting better at keeping people alive for longer and people are getting better at understanding what lifestyle choices they need to make to keep themselves alive for longer. But the evidence is as plain as the nose on my face that the older we get the more we consume hospital resources. There is no doubt that Cardiff has a particular problem in terms of care home places, because it is much easier for owners to realise their assets as a result of the high property values and it is harder for care homes to retain the staff they need on an ongoing basis.

“At the moment there is no plurality of provision in Cardiff and the Vale of Glamorgan – we are wholly reliant on the private sector and we lack imaginative ways to develop other places. Even when new provision is available the cost is such that even those people who qualify for full state funding will still have to find a not inconsiderable amount of money to top that funding up.

“Where do people find that kind of money if they are in a council house and have no property of their own to sell? Even people who have been on very good incomes all their working lives are still going to run out of money. The whole system is out of balance and the safest place for people in the meantime is hospital.

“Whoever the new Health Minister is, he or she has to look at how we develop a coherent strategic response to this problem which establishes why this is happening and puts in place solutions. At some point we also have to look at what other resources are needed to enable us to keep up with an ever-growing number of people who will require emergency care.”