Bed-blocking is a deadly crisis for patients and the NHS – so what’s the cure?

This time a year ago, a 90-year-old widow, blind and deaf, found herself trapped in Salford Royal Hospital. She had been admitted on October 28, after what seemed to be a small stroke. Four days later, she was ready to be sent home. But by the beginning of December, she was still there, a victim of a phenomenon which was beginning to seep through the NHS like glue, and which has now succeeded in gumming it up from top to bottom: delayed discharges. Or, to use that more familiar yet somewhat misleading term, bed-blocking.

Bed-blocking makes it sound as if it’s patients themselves who are unwilling to move. In fact, most of them are frail but medically well and desperate to get home. Since the end of the pandemic, however, the NHS’s ability to discharge such patients has collapsed. “My mum feels like she is being punished, she’s lashing out at my sister because she thinks we don’t want her to come home,” the 90 year-old’s daughter said at the time. “She can’t understand why she’s not allowed home, she feels like she’s in prison.”

“She wants to go home and is blocking the bed of someone who really needs it,” her son-in-law added. “Realistically she doesn’t have long left; it would be nice if we could make her comfortable at home. It’s what she deserves. But it’s like they’re just waiting for her to die.”

Eventually, more than a month later, the elderly woman was discharged, but with a catheter, her family was later told, that was wrongly fitted and which led to a bladder infection. “It’s just basic,” her son-in-law said. “This has been a living hell for her. And lots of people will be in the same position. We’re worried she could die at the hands of the NHS.”

In the year since, however, the situation has deteriorated. And the patients of Salford Royal, where the widow felt she was “in prison”, are suffering most of all. According to Telegraph analysis of NHS England statistics, the Northern Care Alliance NHS Foundation Trust, which runs Salford Royal along with The Royal Oldham Hospital, Rochdale Infirmary and Fairfield General Hospital in Bury, is the worst trust in the country for bed-blocking. Latest figures suggest that each day, a staggering 92.4 per cent of those patients ready to go home end up staying. On the last day of October, of the 285 patients ready to leave, only 25 did. 

The figures reflect an astonishing irony besetting an NHS enduring an unprecedented crisis: while many people try desperately to get into its wards, spend countless hours in A&E waiting rooms, or hope against hope that their much-needed operations won’t be delayed yet again, an increasing number are suffering the opposite fate. They can’t get out.

Bed-blocking is not new. Dr Ben Maruthappu remembers the phenomenon well from his days as a doctor in London several years ago. “There was an incident which brought it home for me – an older patient had been in the care of the elderly ward for a number of weeks,” says Dr Maruthappu, “and he was ready to be discharged, but unfortunately it took a tremendous amount of time. He ended up catching an infection from the patient next to him. And very sadly, he passed away.” What’s different today is bed-blocking’s scale and significance.

That is partly because overall bed numbers have fallen by almost half, from 181,000 overnight general and acute beds 30 years ago to 103,184 today. Latest figures show that in 21,770 of those beds, patients “no longer meet the criteria to reside” as the NHS jargon puts it. But of those, only 8,196 leave. In other words, just 40 per cent of those deemed fit to leave are actually discharged from the NHS on any given day.

It is a figure that has grown dramatically from the easing of the pandemic to this day. In April 2021, there were 8,000 delayed discharges, according to analysis by Sarah Scobie, deputy director of research at the Nuffield Trust. Over the following 12 months that total increased by 57 per cent. “Around 15 per cent of people in hospital are medically fit for discharge,” says Scobie today. “That’s obviously having a big impact.”

Indeed. That impact is shattering, on both the NHS and its patients. For the former, it can be measured in cost and delays. At an estimated £400 per bed per night, the NHS effectively becomes an incredibly expensive hotel, with the taxpayer picking up the £2 billion annual tab. Some parts of the country are far worse than others. The North is particularly afflicted – Liverpool, Stockport and Doncaster join the Northern Care Alliance as four of the top five trusts for delayed discharges. While London discharges almost half of patients when they are ready, the South West and North West only manage a third. Like a blocked pipe, the system simply backs up.

“Hospitals become fuller and fuller,” says Scobie. The consequences cascade through the whole organisation. “People have to wait at A&E longer because they can’t be admitted.” As a result, staff can’t take patients from ambulance staff, so ambulance staff wait outside departments instead of heading out to deal with new emergencies. Waiting lists for elective surgery – things like hip replacements – get worse because without beds for recuperation the operation cannot go ahead. “It’s creating a plague of problems,” says Dr Maruthappu.

All of which might explain why hospitals are getting less and less efficient. Analysis this week shows that, despite extra funding, the NHS is actually carrying out 5 per cent fewer treatments than in 2019, despite hoping to be carrying out significantly more. According to the National Audit Office, “activity so far in 2022 has continued to lag behind the pre-pandemic level and is well below the planned trajectory.”

For those patients trapped in hospitals, meanwhile, the outcomes are grim. After a certain point, the NHS admits, hospital stays become actively bad for your health, notably for the elderly, whose muscles waste making them bed bound or prone to falls, who become sleep deprived and mentally disconnected and who risk infection and death. Despite this, hundreds of thousands spend more than three weeks in hospital each year. For some, such stays are not a route to better health, but a needless death sentence.

It is a crisis that has overwhelmed the NHS in the way that Ernest Hemingway described the onset of bankruptcy in The Sun Also Rises: “gradually, then suddenly”. “A lot of these problems are very long standing,” says Scobie. But a cocktail of problems means it is now that they have reached a tipping point.

There are two principal barriers to vulnerable, often elderly patients – who make up the overwhelming proportion of “bed-blockers” – leaving hospital. The first, is assembling the many different doctors who might be involved in their care at the hospital to sign off that they are well enough to go. This internal NHS bureaucratic problem accounts for about one in eight delayed discharges. The second and largest difficulty is in arranging care to ensure they are looked after once they leave. This “external” problem accounts for about 61 per cent of delays. Around a quarter of all delayed patients are waiting for home care packages, a fifth need short-term rehab and 15 per cent require a care-home place.

But social care has faced its own crisis in the last year, as the sector has been hit by a wave of people leaving their jobs as carers, often for better-paid opportunities in less stressful sectors: supermarkets shelf stacking, hospitality or warehouse work. Underpaid and undervalued, carers are heading elsewhere. Half of new carers leave before a year is out. Why would they not? An experienced carer earns just 7p more per hour than a new entrant.

The sector is still a giant employer, offering some 1.79 million jobs. The problem is that only 1.62 million of them are filled, with the number of vacancies – 165,000 – up by 55 per cent in just 12 months. And just as that huge contraction has occurred in the number of carers able to take patients off hospitals’ hands, those hospitals have been hit by a post-Covid explosion in numbers seeking treatment, as patients who selflessly hid away during lockdowns emerge to get help for lumps and dodgy knees. The result is today’s log-jam, with 7.1 million and rising on waiting lists and NHS efficiency plummeting.

What is the solution? In the autumn statement, Chancellor Jeremy Hunt managed to find £2.8 billion extra to fund social care next year, promising 200,000 extra “care packages” for vulnerable patients over the next two years.

The question is whether the Government can keep relying on cash to defuse a demographic time bomb, as ever more baby boomers need treatment and fewer youthful workers provide the taxes to pay for it. Judging by the urgency with which the NHS is demanding hospital trusts rethink the way they deliver care, the answer is no.

There is pressure, for example, to create “virtual wards” of patients remotely monitored at home rather than languishing on wards. NHS England wants to free up 7,000 extra hospital beds in this way this winter. “Only critical services should be done in hospitals,” says Dr Maruthappu. “Everything else should be done at home.” Via our smartphone screens other huge industries – from banking to grocery shopping – have moved to the home. “Healthcare has to travel in the same direction.”

The Government could also offer more help for unpaid carers – usually family members. Despite repeated promises of aid, in the last five years analysis shows that support has significantly diminished. “You have more people relying on unpaid carers, but those carers aren’t receiving sufficient support,” says Scobie. “That has a knock-on effect on the carer’s health. And then you often end up with two people needing care.”

The private sector insists it can do better than the state. After struggling to find care for his mother, Dr Maruthappu founded his own care provider, Cera, which now provides 50,000 home visits a day. “Some people criticise the NHS for being backwards and not using technology,” he says. “Well, social care is about 20 years behind the NHS. It is extremely archaic. Over 90 per cent of social care providers operate on pen and paper… it is a very inefficient system. Staff get caught up in administrative work when they could be focusing on quality.”

He claims his staff, who are paid between £10-£12 per hour, are spared endless form filling by modern software. The data they do collect, he says, is analysed by artificial intelligence which, Cera claims, predicts with 80 per cent accuracy when someone is likely to be readmitted to hospital. “Let’s say someone has started to become drowsy. A carer may just think that they haven’t had a nap. But actually, for some older people being drowsy is a symptom of them having an infection and based on previous visits we’ll be able to identify that and flag that person as high risk compared to how they normally are.” Administering drugs quickly in such cases, he says, allows Cera to reduce hospitalisation rates by over 50 per cent – “which is massive given how vulnerable they are. It takes significant pressure off the NHS”.

In Wales, AI specialists Faculty, which helped the Government respond to the Covid outbreak, has teamed up with Hywel Dda University Health Board to help streamline the process of readying patients for discharge from hospital. “Tech has to be the path. We have to do better with less,” say Faculty chief executive Marc Warner. “For relatively small sums of money, you can utilise the enormous capital assets of the NHS much more effectively. If you can help the NHS staff to use beds more effectively, you can get very rapid gains in a relatively short amount of time.”

Faculty has created software called Frontier, which allows nurses and hospital managers to see through a blizzard of data captured by many different doctors from many different departments, much of it still on paper, to identify which patients will be ready for discharge and when. “Very often nurses have to do some detective work to piece together a story,” says Huw Thomas, director of finance at Hywel Dda. Frontier aims to do it for them.

Moreover, artificial intelligence allows Frontier to predict discharge dates from the moment patients arrive at a hospital, allowing the planning process for their departure to begin as soon as they walk in rather than only when they are fit for discharge.

“Delayed discharge is a very significant problem across the system,” says Thomas. “It has deteriorated very notably over the last year. Care homes are closing to new patients. Home care providers are exiting the market.”

The software, says Anthony Tracey, the health board’s digital director, “gives the insight to help very busy people understand what might be behind a very long discharge date, and put in place actions to mitigate that.”

It might be as simple as flagging that a patient has been admitted several times in the last couple of years, which often points to a longer stay. And flagging such long stays allows hospitals to get in touch with social care providers who will otherwise cancel a patient’s existing care provision – effectively trapping the patient in hospital.

A year ago, it was just such a cancellation of existing care that condemned the 90-year-old blind and deaf widow to her involuntary month-long stay at Salford Royal Hospital, prompting her family to wonder if the NHS was “just waiting for her to die”. This winter, after 12 months of unrelieved pressure, there are sure to be many more like her. “The previously established pattern is that things are worse in winter and then get better,” says Scobie. “This year that has just not happened. Waits in A&E and waiting lists have been getting worse through summer. The system hasn’t been able to recover between peaks in demand.”

Those many thousands trapped on wards may yet have longer to wait to escape.

Additional reporting by Ben Butcher.