Measuring and costing delayed discharges: conceptual and methodological challenges

Western societies are experiencing challenging economic times and in the UK the NHS is faced with budget reductions for the first time in decades. In the last few years, media reports of people staying in acute care for too long have proliferated. ‘Bed-blocking’ is the loaded term used to describe patients whose discharge from hospital is not timed with the speed desired by the institution. Synonymous expressions used in different countries and across time have similar meanings despite the contextual differences. ‘Delayed discharges’ is the recommended politically correct expression in the UK at the time of writing. In the 1990s, when the drive for efficiency embedded healthcare institutions, economists established that to maximise productivity in hospitals, patients had to flow through acute care at an average speed. Any deviance from this average is considered a decrease in efficiency and a misuse of public resources. Four interrelated issues challenge this economic theory and research studies such as the one carried out by Hendy et al1 and published in this month's issue of Clinical Medicine illustrates most of them

A realistic evaluation of fines for hospital discharges: Incorporating the history of programme evaluations in the analysis

Programmes and policies transform over time and locations. Evaluation projects can apprehend only temporal and contextualized sections of the social world. This article uses a realist evaluation of financial incentives in English hospital discharge policy to illustrate how previous evaluations of the same programme theory were inspected for evidence to construct context, mechanisms and outcomes. Following the discharges of a reduced number of patients with a case study approach, the preliminary programme theory ('fines reduce delays') was modified into a redefined theory on how fines operate locally in practice. This identified other mechanisms contemporaneous to the fines which are more or as likely to reduce delays. This article aims to contribute to the development of the realist evaluation strategy by introducing programme's transformations as key evidence when trying to understand how complex interventions work in particular contexts

Disentangling the impact of multiple innovations to reduce delayed hospital discharges

Delayed hospital discharges are often blamed for interrupting the smooth operation of hospitals. In England, the Community Care Act in 2003 introduced fines to social services departments to resolve this issue. Evaluations of this policy reported success in the reduction of delays. However, this policy was an amalgam of several innovations, not just the introduction of fines. This simultaneity makes attribution of impact of fines a difficult task because of the potential impact of those other measures. All the other designed organizational changes contain as much mechanisms of change as the more advertised fines. The exploration of how all these elements are connected unravels the inner workings of the programme as a whole, and by default, of the fines. This theoretical analysis also demonstrates how the reduction of some delays is based on the re-definition of key concepts for delayed discharges such as 'safe to transfer', team decision-making and causes for delays

Payment by results and delayed discharges

Delayed discharges caused by social services could potentially pose a financial risk for hospitals. In 2003, the English Government introduced a controversial policy based on fines for social services departments unable to discharge patients from hospital within set timescales. This article analyses the implicit relationship between Payment by Results (PbR) and the Delayed Discharges Act (DDA), and highlights some of its most relevant features

Delayed discharges in mental health beds

he Department of Health (DoH) has identified a high number of hospital delayed discharges in patients diagnosed with a mental illness. Since 2006, the weekly monitoring of these delays is required for all non-acute and mental health trusts. This article explores the limitations of standardized definitions of 'safe to transfer' for mentally ill patients; the conundrum created by co-morbidity and legal requirements; and the constraints of current categories for delay established by this performance system are exposed. Establishing when and why hospital discharges are delayed is not an easy task. It is embedded with subjectivity and complexity, which increases in the context of the intricacy of mental illness and discharge-pathways. Considering the constructed nature of delayed discharges, the limitations and over reliance on quantitative data collection must be taken into consideration in the case of quantitative itemization of mental health needs for Payment by Results tariffs, or when using audit data to construct evidence-based systems of care for people diagnosed with mental illnesses