CIH Cymru response to inquiry on the role of local authorities in supporting hospital discharges

Introduction

A chronic lack in the supply of suitable, safe and affordable homes in Wales is not just causing rising levels of homelessness and temporary accommodation use; a lack of suitable housing is also impacting discharges from hospital settings. This includes older people with mobility issues, those with mental health issues who need supported accommodation, together with those who were homeless on admission to hospital and remain homeless on discharge[1]. A delay in discharge can have a significant impact on the individual, as well as limiting bed spaces for others who need them. A sufficient level of secure and affordable housing coupled with the right level of community support are key to not only facilitating hospital discharge in a timely manner, but also aids an individual’s recovery[2].

Yet, whilst reducing delayed discharge from hospital is needed, we also need to look at preventing individuals from being admitted or readmitted to hospital in the first place. It is vital that we not only undertake work to reduce time spent in hospital but ensure that more people can reside in their own home for as long as possible. Investing in healthy ageing is vital, and prevention of falls can save the NHS money. By avoiding a fall resulting in a fracture, we can save on average £5,744 per patient[3] monies that can be used to further reduce the length of time an individual spends in hospital. The draft mental health strategy outlines the role and impact ill health prevention can have[4]. To do this we need to create the conditions that help people look after themselves whilst ensuring that the right health and social care services are in place to help people stay well[5].

Yet, whilst the inquiry considers the role of local authorities in delayed transfers of care, there is no consideration of the role registered social landlords can, and do, play in ensuring swift and effective discharges from hospital. Just half of all local authorities in Wales currently have housing stock, and as such rely on partnerships with registered social landlords to provide homes for those individuals coming out of hospital often with little-to-no notice. Registered social landlords will also ensure that an individual’s existing home is suitable, and will work with agencies to prevent admissions into hospital as much as possible.

Whilst we appreciate that a lack of social care provision by local authorities can delay a hospital discharge, we would like to see a wider view of hospital discharges to include the key role registered social landlords can, and do, play in preventing an admission or readmission coupled with helping to facilitate timely hospital discharges. We also need to consider the wider structural issues impacting housing as these are impacting the timescales for adaptations and the number that can be completed with the monies that are available. An effective adaptations service across Wales coupled with a wider view of the structural challenges to the housing sector is key if we are to ensure timely discharges from hospital settings.

Preventing admission and readmission to hospital

The health and wellbeing of people is shaped by foundational building blocks including warm and safe homes[6]. We all know that prevention is better than responding to a crisis and the same applies to health and hospital admissions. Many hospital admissions related to long term health conditions could be avoided with timely and effective community care[7]. Working to prevent hospital admissions and the worsening of health conditions can also provide significant savings with every £1 spent on public health interventions offering a financial return of £14[6].

Falls in the home are common for older people with 30 per cent of people aged 65+, and 50 per cent of people 80+ falling at least once a year[8]. Put into numbers around 278,000 older people will fall in their own home, of these falls around 8,100 will result in serious injury and around 1,500 older people will not recover their independence following a fall[9]. Yet by carrying out small, targeted works in a home aimed at assisting with mobility problems it can help support older people to live independently for longer and prevent admissions into hospital[10].

Yet this prevention should not just be focussed on older people. There are issues with delayed discharge from hospital across the whole life course, so it is vital that we consider key preventative measures for all ages[11].

In Wales, 32 per cent of adults have poor mental wellbeing. Social and structural factors such as poverty and wider inequalities can increase the risk of poor mental health[12]. The Health and Social Care Committee’s report on tackling mental health inequalities highlighted that whilst for some medication will help solve a mental health issue, too often it is used as a sticking plaster with little done to address underlying social issues such as problems with housing, unemployment or abusive relationships[13]. Yet Welsh governments draft mental health and wellbeing strategy failed to specify housing as a key part of the connected system needed to help people improve their mental health and wellbeing[14].

Whilst tackling social and structural factors will not solve all mental health and wellbeing issues, housing is a vital preventative measure.

Registered social landlords, other landlords and housing support providers are often in a privileged position and are able to see when an individual’s mental health is deteriorating. Yet our Tyfu Tai research on private renting and mental health found that 45 per cent of landlords felt that there is never enough support and information for landlords to support tenants with mental health problems[15]. Further research shows that even when a landlord or support provider knows where to go for help when someone’s mental health issues are worsening there is often a long waiting time. Freedom of information requests from Mind Cymru show around 2,000 people a month in Wales with moderate and severe mental health conditions are waiting more than six months to receive therapies[16]. Peoples’ mental health can worsen whilst waiting, and this increases the risk of a hospital admission[17].

There is a wider piece of work to be undertaken to look at ways we can actively move towards preventing a hospital admission, be it for older people or for individuals with poor mental health. Prevention and its focus on enabling someone to reman in their home for longer could help ease some of the pressure on health services. We need to look at hospital discharge as a two-pronged approach reducing the number of admission or readmissions whilst ensuring those in hospital can return home in as short a time frame as possible. A safe, suitable and affordable home is key to this. Good health should start at home.

An overview of hospital discharge in Wales

Welsh government has published hospital discharge guidance. This guidance sets out the key tasks and expectations of relevant partner agencies. It also sets out that planning for discharge should take place at the earliest stage. Support that individuals need should be in place and ready for the day the individual is discharged[18]. The Health and Social Care Committee’s report on hospital discharge also highlighted that a whole system approach is needed to help with patient flow through the health system and help tackle the issue of delayed discharge. The report also recommended that a patient’s housing need must be given higher priority in the discharge process with housing organisations included in the multi-disciplinary teams as a matter of course[19]. Yet, the hospital discharge guidance does not include housing as a named partner agency. Rather the role of housing is generally considered in the context of homelessness on discharge or ensuring adaptations are in place following discharge[18].

Even though the hospital discharge guidance outlines that timely referrals should be undertaken when an individual is likely to be homeless on discharge, this is not always the case. We have heard from members working in homelessness settings that there are still occasions when a person is discharged as homeless late in the day with little background information to inform an appropriate placement. Other members have cited situations where a person admitted to hospital from a supported accommodation setting was discharged back to that setting with no prior warning, even though their support needs had changed in hospital and needed more support on discharge. Contrary to the guidance that has been published by Welsh government.

Our members recognise the importance of timely discharge from hospital and the positive impact this can have on individuals. Yet, even when our members have worked with health to secure funding for step down accommodation on discharge these units often lie empty. One member informed us that they had worked with the health board to provide two step down units within an extra care setting. After no referrals were received the health board was contacted. It was established that the health employee involved in the project had moved to another position and nobody knew about the project. When no referrals were still not forthcoming the units were put back into general use as demand for extra care properties is too high to leave them void for long periods of time.

Welsh government’s hospital discharge guidance outlined that housing adaptations can help reduce delayed discharges and ensure a home is suitable for an individual to return to[20]. Welsh government has provided different funding streams to facilitate these adaptations.

If the individual is living in a housing association property their landlord can access monies through the physical adaptations grant. The grant will cover large scale adaptations such as bathroom adaptations or installing hoists. It will also cover handrails and grab rails[21]. An annual limit on this funding has now been put in place which has reduced the level of monies available to housing associations to undertake adaptations. One member told us that their annual grant limit in 2024 is approximately 30 per cent lower that it was before the limit was brought in. Yet, despite this reduction, the number of requests has not diminished. There are also increased pressures on the grant due to inflationary increases in the cost of materials. The cost of timer, steel and concrete has risen 40 per cent since the pandemic[22] coupled with increased subcontractor and labour costs[23]. These increased costs coupled with a reduction in grant levels has reduced the number of funded works one member has completed, from 132 in 2021/22 to 96 in 2023/24.

For households living in a property, they own, or rent from a private landlord they can apply for financial support through ENABLE: support for living independently scheme or for a disabled facilities grant[24]. The ENABLE grant funding is a flexible resource which can be used to pay for small and medium adaptations. This money is provided to Care and Repair Cymru in some areas. The disabled facilities grant is means tested which is used to fund larger and more costly adaptations. The maximum grant that can be awarded is £36,000[25]. Owner occupiers living in homes that need to be adapted are also facing high costs.

Care and Repair Cymru in their research into older peoples housing highlighted the impact of rising costs for adaptations and repairs. Ongoing issues with supply chains means people need to wait longer for an adaptation, which can have negative health and wellbeing implications, as well as extending stays in hospital settings. The report also outlined some specific price rises that impacted undertaking adaptations:

• In 2020 a sheet of plaster board was £6-£7 it is now £18-19.
• The average steel price for grab rails is up 50 per cent.
• A bathroom adaptation costs £6,000-£6,500 it used to be £5,000.

The report also highlighted a shortage of contractors meaning there are longer lead in times for work to be completed[26].

The issue of a lack of contractors is a common theme within the housing sector. Research carried out in autumn 2024 outlined that at least 500,000 construction workers are set to leave the workforce in the next 10-15 years. Specialist trades are one of the most depleted construction workforces with 350,000 workers having been lost across the UK since 2019. Whilst there are healthy numbers of young people starting an apprenticeship, the current dropout rate is over 40 per cent, which will have a further negative impact on the construction industry[27].

Our members are committed to working with health boards and social care to ensure an individual can return home after a hospital stay. However, they must be seen as a key part of the process, and be provided with an appropriate level of funding to ensure the homes they provide are suitable for their tenants. We also need to ensure that those individuals who own their own home can access the right level of funding to adapt their home to enable them to return home and minimise the risk of readmission to hospital. Housing is a key building block to good health, but it needs to be adequately funded to ensure we can realise the cost benefits having a home can provide.

Right to adequate housing the solution

Legislating for a right to adequate housing will provide the whole housing system strategic approach to housing in Wales. The right will also provide the lens through which all other services need to be delivered. This includes health services and hospital discharge. The right will ensure that housing has to be considered as part of a timely hospital discharge process, and that the individual’s right to a safe, secure, and affordable home is protected. The right will also come with significant cost benefit savings as outlined in the #BacktheBill independent costs benefit analysis undertaken by Alma Economics. This found that for every £1 spent on the right to adequate housing, there will be £2.30 in benefits. It will:

• Save £5.5 billion in improved wellbeing
• Save £2 billion from local council budgets
• Save £1 billion for the NHS
• Save £1 billion for the criminal justice system
• Generate £1 billion in additional economic activity.

Savings that can re reinvested into our public services including adequately funding adaptations and our social care workforce. The right will ensure that everyone in Wales can access a safe, secure, and affordable home - a vital part of improving wider health outcomes, including preventing hospital admissions coupled with timely and effective hospital discharge process.