Hospital discharge is one of the most pressing issues facing the NHS today. Every day around 15,000 people are delayed in hospitals in England after they are medically fit for discharge, accounting for over 17% of the NHS’s bed-base.¹ The cost to the NHS of these ‘excess bed days’ is nearly £2 billion each year, not to mention the knock-on effect on elective recovery, ED performance, ambulance handovers, as well as patient outcomes and experience.² 

Some improvement can be realised through the introduction of better discharge processes in-hospital (e.g. more patients receiving a same-day proportionate discharge assessment). However, data published by NHS England shows that around two thirds of discharge delays are caused by a lack of capacity in services designed to support people after they have been discharged from hospital. In other words, around 10,000 people are delayed in hospital every day while they wait for support to become available closer to home.³  

So, care outside a hospital is key to fixing challenges within it. 

Post-discharge support can take many forms, ranging from short spells of rehab and reablement provided by councils or community trusts (often referred to as ‘intermediate care’), to longer term packages of domiciliary or residential care provided by independent providers.  

Whereas the latter is focused on providing the care and support needed to live safely, intermediate care is all about supporting a person to recover to the greatest of their potential and live more independently. Evidence shows that nearly everyone requiring support after discharge from hospital – either at home or in another community setting – would benefit from some form of intermediate care.⁴  

In many cases, insufficient capacity in intermediate care means patients end-up delayed in hospital or discharged with a ‘sub-optimal’ package of care that limits their recovery potential. One healthcare system we worked with needed to double the size of its intermediate care workforce to meet current and future demand. Doing so would enable more people to access the support they need to recover their independence, and in the process free up hospital beds, improve patient flow, as well as reduce demand for packages of social care – in short, make life far better for patients as well as providers.   

Delivering more intermediate care capacity also aligns well with national health and care policy. Successive governments over the last thirty years have repeatedly emphasised the need to move the focus of health and care away from hospitals and into the community.⁵ Despite this, intermediate care is often poorly understood and underfunded, with problems exacerbated by the fact that it often straddles the health and social care divide – making it difficult to unpick who exactly is responsible for providing which services.   

The financial case is strong too. The PSC’s cost-benefit analysis in a large UK system demonstrated that for every £1 invested in intermediate homecare, £2 is saved through reduction in the need for hospital beds and packages of care. In-short, investing in intermediate care can pay for itself. 

So why isn’t it sorted already? There are two significant barriers to overcome:  

1. Funding additions to intermediate care capacity can be difficult, particularly within the context of strained NHS and local authority budgets. Although intermediate care may be a financially sustainable investment (as we have previously seen, it pays for itself), the organisations that provide intermediate care services – usually local authorities or community trusts – are not the ones who benefit most from it. Instead, it is acute trusts who will see the greatest benefit – a reduction in discharge delays will support elective recovery as well as improved patient flow. To make investing in intermediate care feasible, there may need to be a mechanism for transferring funding from beneficiaries (i.e. acutes) to providers (i.e. local authorities and community providers). This could prove contentious, particularly in areas where collaborative working across health and social care is less developed. 
2. Challenges with recruitment and retention pose a second major barrier to delivering increases to intermediate care capacity. Data from NHS England show that NHS vacancy rates in 2023 were around 10% (or 125,000 vacancies), with the social care sector running at a similar level.⁶ Vacancy rates can be even higher for specific intermediate care roles – The PSC worked with one local authority that had a vacancy rate of nearly 50% for occupational therapists at the start of 2024. This challenge is even more acute in areas where local authorities are competing for staff with NHS providers, who more often than not provide more favourable terms of employment.  

Collaboration between system partners is the key to overcoming these barriers. Pooled financial mechanisms like the Better Care Fund, introduced in 2015, are making it easier to transfer funding from the organisations that benefit from intermediate care to those who pay for it.  

Collaborative recruitment and shared workforce planning can help sustain and grow the intermediate care workforce, unlocking opportunities to improve staff terms and conditions or draw on new recruitment pools, including internationally.  

These barriers may feel challenging to overcome, but doing so will help deliver safer, higher quality and more cost-efficient services that help people live long, healthy and independent lives.

To learn more about our upcoming roundtable, Getting discharge right: making change happen in hospital discharge and intermediate care, read our recent overview or reach out to rachel.lewis@thepsc.co.uk or joseph.norbury@thepsc.co.uk

References:

¹ NHS, Bed Availability & Occupancy and Discharge Sitrep, 2023-24 

² NHS, Discharge Sitrep, 2023-24 

³ NHS, Discharge Sitrep, 2023-24 

⁴ Local Government Association, The Case for Homebased Intermediate Care, 2023 

⁵ Kings Fund, Making care closer to home a reality, February 2024 

⁶ Kings Fund, Social Care 360: workforce and carers, March 2024 & Nuffield Trust, The NHS workforce in numbers, February 2024