Can the seemingly intractable problem of delayed patient discharge from hospitals be solved by the creation of a single responsible body? Pharmacist Norman Niven, CEO at The Medication Support Company, investigates.
It is widely recognised that one of the biggest challenges facing the NHS is greater numbers of patients experiencing delayed discharge from hospital, meaning they are medically fit to leave but are unable to do so.
The impact of delays is especially acute when waiting lists are rising, emergency departments are overstretched, and the winter flu season is upon us.
On top of that, and because there are fewer available beds, planned procedures are also impacted.
Finally, there are many risks associated with longer stays: higher chances of hospital-acquired infections, blood clots, muscle weakening and pressure sores – to name a few.
While most will be discharged to their home, some patients will require more formal support, often requiring resources from the social care sector.
However, within the discharge system there is friction, with the NHS often citing lack of social care capacity as the primary reason for delayed discharge – but as we shall see, the problems run much deeper.
Streamlining discharge responsibility
It is a complex, disjointed process, made even more challenging by a lack of resources, poor communication, confusing financial channels and fragmented systems.
We know there are enormous pressures on the NHS, but pressures on social care services are well documented too. Growing demand, staff shortages and under investment have severely impacted the capacity available to deliver care.
On the plus side, there’s no shortage of data, analysis and proposed fixes. Everyone knows the extent of the problem, even if only through the lens of a febrile national media, so how come it persists?
Breaking down the various components of the system is required to see where responsibility lies, how funding works (or doesn’t) and to examine the roles of the many players in this tangled ecosystem.
Could the answer be simplification? And is it really that simple? Creating a single body with the sole responsibility for handling every aspect of the discharge process, and with a single source of funding that covers all the cost areas, could bring with it the accountability that is, today, tellingly missing.
But, first, it’s important to determine the scale and nature of the problem.
Assessing alternative avenues for discharge
According to the Nuffield Trust, the total number of patients in acute hospitals who were ready to leave but were delayed increased by 43% from an average of 8,545 patients per day in June 2021 to 9,933 patients per day in June 2025.
‘At its peak, in January 2024, there were 14,096 patients delayed in hospital,’ it said, adding that the impact of winter only compounds the number of delayed patients. ‘Every winter sees an increase in A&E admissions and a reduction of staff due to sickness absence that can hinder effective discharge processes within hospitals.’
When a patient is medically fit but cannot leave, the reasons are classified as:
- Hospital process: issues within the hospital’s control, such as awaiting medications, final tests or transport
- Wellbeing concerns: worries from the patient or their family about safety, or delays in assessing mental capacity
- Care transfer hub process: delays in identifying the appropriate destination or funding
- Interface process: delays in coordinating care with external services such as homecare or social care
- Capacity: shortages of available spots in community or long-term care beds, or a lack of staff to provide home-based support.
The King’s Fund has noted that apart from hospital process, all other categories include delays due to both the NHS and social care. Capacity delays are the most common reason for delayed discharge, but the majority of capacity delays cannot be attributed to social care alone.
Last December, responding to the most recent NHS winter data, the Royal College of Nursing said there was ‘barely a spare bed’ left in NHS hospitals due to a lack of capacity in social care.
Who’s in (dis)charge?
There are multiple parties involved at different stages of the patient discharge process, but it is, of course, the NHS and social care sectors that are the key players.
The NHS is vast and complex, and its multiple interactions with the social care sector are positively, and predictably, Byzantine. They are of course two distinct systems, funded differently, and often facing different demands.
Focusing on the relationship between the two sectors and digging a little deeper into the systems that most directly impact patient discharge, we firstly find integrated care systems (ICSs) and integrated care boards (ICBs).
Established by the Health and Care Act 2022, ICSs bring together NHS organisations to plan and deliver joined-up health and care services, while ICBs are the statutory NHS bodies responsible for managing the budget, commissioning services and coordinating care.
This means the body with overall responsibility for patient discharge is the ICB, working with local authorities to arrange the necessary community support to get patients home safely and quickly.
In essence, the ICB acts as the strategic lead, ensuring the whole system works together to discharge patients safely and effectively, and preventing delays.
But it’s not working, or at least not well enough, and that’s in part down to a lack of proper funding – or inefficient use of existing funding.
According to Dr Agnes Arnold-Forster, a policy fellow at The Health Foundation, ‘ICBs are facing cuts of 50% to their running costs’, and last summer ‘submitted plans setting out how they will live within their new financial means’.
On a day-to-day basis, responsibility for hospital discharge lies with a multidisciplinary team, including the patient’s named consultant who decides medical readiness; the discharge coordinator or case manager who coordinates logistics; and a pharmacist who reconciles their medicines, annotates the discharge letter and counsels the patient on changes to their medicines ahead of their transition back to the community.
Nurses, social workers and occupational therapists are also closely involved, as well as the patient themselves and their family or carer.
With so many parties involved, it is unsurprising to find friction, communication problems and financial challenges.
Show me the money
The coordination of funding is particularly challenging, with a plethora of individuals and multiple funding mechanisms involved.
The Better Care Fund (BCF) is the main pooled fund, combining mandatory contributions from ICBs and local authorities. It is used for joint health and social care initiatives, with a significant focus on hospital discharge to prevent delays elsewhere in the system.
The Hospital Discharge Fund comprises specific national funds that are allocated to ICBs and local authorities to pay for short-term care packages, helping people leave hospital quickly and safely. This funding is now consolidated within the BCF but remains a key shared priority.
Continuing Healthcare is available for individuals with a primary health need and the ICB funds their entire care package, including health and social care costs. This can include personal care and accommodation in a care home and ICBs fund a standard weekly rate for the nursing care component for eligible residents in nursing homes, separate from personal care costs.
With multiple funds coming from various sources and being channelled through different networks, the overall management adds a considerable overhead – and introduces complexity (for which read delays).
A new hope for hospital discharge
Is it possible for a new service, based on an equal partnership between the NHS and social care sector, with a direct, single source of funding, and with a clear mandate to implement best practice for patient discharge, to be the answer?
The good news is that it can be achieved within the current system and by assessing and improving existing mechanisms. It only takes the will and commitment from the Government, NHS and local authorities to make it happen.
Indeed, the problem of hospital discharge cannot be solved without fundamental reform, especially around funding. The structure of the current system inevitably results in friction between the NHS and local authorities and the ever-present issue of who pays for it.
In January, a BBC InDepth report on hospital discharge quoted Kerrie Allward, a policy lead for the Association of Directors of Social Services, as saying, ‘councils often lack the funds to invest in integrated services that would support more timely discharge’.
Adding that some NHS leaders blame social care for delayed discharges, she said: ‘This blame can strain relationships, especially as data reveals that social care is usually responsible for only a minority of delays.’
A report produced by the House of Commons Library in 2019, before the pandemic added exponential pressure, noted that ‘the UK is experiencing increased demand for NHS and social care services’ and that ‘an increasing number of people are living longer with multiple long-term health conditions, and require support from a wide range of services at home, in the community and in hospitals’.
Meanwhile, in July 2023, an Age UK report found that 2.6 million people in England aged over 50 are unable to get care, including ‘hundreds of thousands who are stuck on waiting lists for support or even just waiting to have their needs assessed’.
‘A unified service with a clear mandate’
We can fix this. The creation of a ‘Health and Care Unified Discharge Programme’ could take advantage of the position of ICBs to define and implement this new service, which would be funded directly by Government.
This new service would see the health and care sectors as equal partners in delivering safe, effective and efficient discharge service programme, no longer a piecemeal, fractured association of individual services that have been stitched together, but a unified service with a clear mandate to implement a programme that benefits the NHS, social care and – most importantly – patients.
You could be forgiven for thinking this all sounds very nice in theory, but some hospitals in the northwest of England are already demonstrating what can be achieved with such a unified approach. Patient discharge delays and hospital readmissions have been cut significantly.
In this case, the local ICB was not directly involved, but the opportunity is there to set out a standard service programme and provide funding alongside the councils, who are delivering the care element.
Conclusions
Making changes to a complex system is a major challenge, very often leading to unintended consequences.
The NHS is a textbook case: one after another, governments seem unable to resist tinkering, their interference based on short-term thinking and resulting in patched-up solutions. The results over the past 50 years have not been encouraging.
The problems with hospital discharge serve to expose and highlight structural, systemic issues within the service itself and the relationship it has with the social care sector.
Yet, simply by shining a light on these issues it is possible to see how existing structures, systems and processes could be better utilised to deliver more optimal patient discharge.
It looks like a tangled mess, but the exceptional talents in the NHS can be exploited to engineer a new way of working that is simpler, stripped back, made lean.
A new single body would ultimately be responsible for ensuring every patient is discharged in a timely manner, to an appropriate destination and with all the necessary support measures in place.
This is a longer-term solution; it takes time to turn a tanker. But as everyone knows, making the easy choice now only leads to greater pain later – and vice versa.
Author
Norman Niven
Entrepreneurial pharmacist, CEO at The Medication Support Company, and former director at BUPA
