Step-Down Clinics: A Step In The Right Direction For The NHS

There have been 2 instances which have occurred within the 6 months which have affected family and friends. Both highlight an important (and much publicised) negative impact upon the NHS as well as an equally important (and just as well publicised) solution.

The first affected an octogenarian, who was hospitalised following a serious fall. The patient suffered broken bones which required surgery and stayed in hospital for a total of 6 months whilst a suitable care package was organised (his wife is of similar age and was unable to care for him without support).

His 6 months stay was not needed for clinical reasons and from a medical perspective as he was ready to be discharged within weeks. What kept him in hospital was the fact it was unsafe for him to return home until support was organised and there was (quite literally) nowhere else for him to go to.

As we know, this practice has been christened the somewhat unsympathetic name of bed-blocking.

On the side of this particular coin, a friend in her late twenties was admitted to hospital for a traumatic leg fracture, which required a serious of operations and monitoring. Unfortunately, her initial few hours in A&E were made even more traumatic by the fact there wasn’t an available bed on the ward.

To the dismay of the medical team, they were unable to provide her with the care they wanted to provide as there was another patient in the bed who was in an identical position as the octogenarian patient referred to at the start of this blog.

Our twenty-something friend had become a victim of bed-blocking. By way of reassurance, no blame was attached to the other elderly patient or her family (or the medical staff treating her) but rather the system that has allowed this issue to develop.

It is not my intention to start evaluating the causes behind bed-blocking. The solution, however, needs serious considerations: step-down clinics, which is as much a mindset as it is budgetary; our European neighbours have embraced the solution much quicker than the UK has as they have more flexibility to implement innovation than the prevailing dogma within the NHS.

There has, of course, been large scale investment in step-down clinics in the last few years and they provide an important service to the approx. 125,000 patients who pass them every month (between 750,000 to 1.5 million patients are said to be supported in someway by step-downs every year). However, the UK is still significantly far behind the EU.

For example, the UK is said to have 2.5 step-down spaces per 1,000 patients. The average EU spaces are 4.6 per 1,000 patients (with Germany, France, Italy, Denmark, Sweden and the Netherlands leading the way with significantly more (Germany has the highest with 7.8 spaces per 1,000 patients)).

Not only do these countries set aside a greater proportion of budget to a step-down model, they have a different culture; European countries have not accepted the UK model that a central hospital is the best place for care. Their model is based more upon a higher bed density model across the rehabilitation network, which mitigates against delayed patient discharge.

The solution does not need to be greater spending, which is always the public sector’s preferred action and does not always guarantee results. Rather, there can be a reallocation of funds away from hospital care towards a new system of step-down clinics. Furthermore, the NHS should work with private healthcare providers who own and manage step-downs, whilst utilising the private sector’s skills and expertise to help formulate a modern bed density system which is fit for the 21^st century.

It is ridiculous to suggest that either the octogenarian or the other elderly patient should have been discharged to make room for younger patients, but the question as to whether hospital was the most suitable place for them must be asked.

Firstly, are they receiving suitable care? In other words, is remaining on a trauma ward for months the best long-term care they require or should they be in a specialist rehabilitation unit pending the implementation of a long-term care package? I would suggest the latter.

Conversely, there are said to be between 13,000 and 14,000 cases of bed-blocking in the NHS at any one time. What is the wider impact on healthcare provision?

The easy answer is that it prevents up to another 13,000 to 14,000 patients from receiving adequate care, such as our friend with the fractured leg. However, this is assuming that the Patient A who requires the blocked bed needs treatment for the same length of time as Patient B who is unable to be discharged. As we all know, length of treatment varies from patient to patient and true number is compounded almost week on week.

Further, requiring medical and facilities to provide care they are unsuitable in providing creates stress, inefficiency and demands, all of which negatively impacts upon service provision and other important considerations such as staff retention and burnout.

The related issues of bed-blocking and inadequate provision of step-down clinics is an issue which, on the face of it, affects only a relatively small number of patients but has tremendous wider implications. It is important that policymakers realised the issue and the solution, thereby looking to bring the UK into a more European model.