Responsibility discharged

Delayed discharge erodes older
people’s quality of life and sense of independence. It also
costs a lot and has threatened to derail the government’s
waiting time targets. So will the latest remedies announced by Alan
Milburn build on progress already made in England and Scotland,
asks Ruth Winchester.

So much for bringing down the
barriers between social care and health. Chancellor Gordon
Brown’s budget announcement of significant new investment in
social services was followed less than 24 hours later by a much
less welcome  development –
the decision to force local authorities to use this money to
reimburse hospitals for the cost of delayed discharges.

According to health secretary Alan
Milburn: “If councils reduce the current level of
bed-blocking so that older people are able to leave hospital
safely, they will have freedom to use these resources to invest in
extra services. If bed-blocking goes up, councils will incur the
costs of keeping older people in hospital
unnecessarily.”

Local authorities have reacted to
Milburn’s announcement with predictable hostility. Jeremy
Beecham, chairperson of the Local Government Association, has
described the move as “perverse and unhelpful”. But it
was not entirely unexpected – Milburn is known to have been
impressed with the Scandinavian system of financial penalties for
bed-blocking, and the long-awaited Wanless report on the NHS,
released last week, also recommended such a system. The issue has
been inexorably rising toward the top of the government’s
agenda over the past 12 months, spurred on by intractable NHS
waiting lists.

So how did we get here? Late
discharges have always happened, but since the implementation of
part of the National Health Service and Community Care Act in 1993,
they have been getting more common. What the act did was to bring
an end to a demand-led system whereby the social security budget
picked up the tab for anyone going into residential care who could
not afford to pay for themselves.

The new system threw the
responsibility for paying for residential care onto local
authorities – and the budget allocated by the government for the
task has simply not kept up with increasing demand. As a result
older people have been waiting months or years in hospital while
the various agencies fought over who should pay for
services.

Being stuck on a ward can be
disastrous for older people whose independence is eroded by life in
an institution. And as they languish in hospital, they are
occupying beds needed for other patients. As New Labour has swung
the spotlight onto the acute side of the health service, pressure
has built up on a bottleneck where healthy older people are stuck
at the exit, while queues of sick people form at the
entrance.

Clearly alarmed by the situation,
in October 2001 the government dished out nearly £100m to
councils in a bid to head off a winter crisis at the pass. Another
£200m Cash for Change money has been dished out for the
current financial year.

Of the 150 councils in England with
social services responsibility, 55 authorities were targeted for
special levels of funding because of the severity of their problem,
although all received some funding. The cash is to be spent
building capacity in the nursing and residential care home sector
and developing intermediate care services.

So has it worked? Ironically, given
the latest announcement, a progress report from the Department of
Health¹ launched earlier this month suggests that the
money is doing the trick. “Delayed transfers of care”
were falling and by March this year  the government’s target of
reducing the number of people awaiting transfer by 1,000 had been
met. There was also praise for the partnerships being developed
between the NHS and social care agencies.

This “success” has now
been somewhat overtaken by events. The concept of linking
performance with resources is not new, but Milburn has clearly been
under pressure from the Treasury to demonstrate that the settlement
for social services is going to produce demonstrable results –
despite the abject failure of such investment in the
NHS.

But with the average bed on an
acute ward costing around £120,000 per year and thousands of
older people stuck in hospitals at any one time, the £300m
increase for social services starts to look less generous. And it
is difficult to judge how Milburn’s actions will affect the
situation.

First, there are questions about
whether the additional funding will be available to invest in
services for older people. Social services departments are already
spending £1bn on top of the standard spending assessment each
year, so this increase could simply be swallowed up by social
care’s enormous overdraft. More significantly, the LGA has
argued that the hike in employers’ national insurance
contributions, announced in the budget, will consume most, if not
all, of the additional resources.

Second, the announcement has been
made with precious little in way of detail, leading some to
speculate that DoH civil servants were up all night last Wednesday,
making it up as they went along. No one knows when financial
penalties will be incurred, how much they will be, and what tactics
for avoiding them may be considered acceptable. Could, for
instance, a social care ward be set up inside a hospital? If so,
could wheeling someone down the corridor from one ward to another
exempt the local authority from charges? And while this seems
designed to ensure timely care for older people, it could backfire.
For instance, how many councils will hold out for the
patient’s first choice of care when the delay is costing them
£300 per day?

Third, it may create a vicious
circle from which councils are powerless to escape. Areas which
have few problems with delayed discharge are likely to have more to
spend building up capacity in older people’s services,
resulting in a further decrease in delayed discharges. Perversely,
areas with significant bed-blocking problems will have even less to
spend on their services, resulting in increasing delays. There is
also a possibility that the financial incentive to spend on older
people’s services could be a disincentive to spend on other
services which do not carry such penalties.

Lastly, there is a real danger that
these charges will drive a larger wedge between social care and
health. While there are going to be disincentives for acute wards
to discharge patients too early – possibly as judged by emergency
readmission rates – what will happen when a discharge is delayed
because community health services are unable to cope, or a
specialist neuro-rehabilitation bed is not available? Will local
authorities pay then, too?

Richard Humphries is head of the
Change Agent team at the Department of Health which is charged with
pushing through the government’s agenda on delayed
discharges. He has some words of comfort for panic-stricken social
services departments, saying: “My line would be for people
not to get all worked up about this until the detail comes out.
Suspend judgement about it for the time being, and use the
consultation process to examine what it is really going to
mean.

“There will be financial
incentives for the NHS to look at the delays caused by health
services – social care isn’t being singled out,” he
adds.

Mike Leadbetter is director of
social services for Essex and president of the Association of
Directors of Social Services. He is also reluctant to jump on the
alarmist bandwagon before the real details of the
government’s plans come out, and says the ADSS is
“fully committed” to the government’s
bed-blocking agenda.

“It would be churlish to say
that the 6 per cent real terms increase is not extremely welcome.
But we have a lot of questions about the way this is going to work
in practice. To start with we would like to know what will happen
when there are residential care beds available, but we can’t
recruit home carers, or if someone’s house needs extensive
adaptations before they can go home.” He is also concerned
about the implications for rows between consultants, hospitals and
social care agencies over who has caused a delay, and about how
much clout social services will have in decisions that could be
viewed as purely medical.

Ultimately, if the improvements
local authorities have already made with bed blocking are
sustained, the threat of financial penalties will recede,
potentially leaving social care with a welcome increase in
resources. But thrashing out the details is likely to take time,
and in the meantime, those really paying for the delays are older
people.

¹
Department of Health, NSF for Older
People, DoH, 2001, www.doh.gov.uk/nsf/olderpeople.htm

²Department of Health,
Emergency Care Report, 2001-2002, DoH, April
2002.
www.doh.gov.uk/capacity
planning/emergencycarereport.htm

If delayed discharge is an issue
that affects you, visit Community Care Live at the
Business Design Centre in Islington on 22-23 May. Our headline
debate Housing Futures: Where to Care for Older People? takes place
on 22 May. For free tickets ring 020 8652 4455/4861 or see www.community-care.co.uk

Blocked Scots

Scotland may have taken the moral
high ground when it comes to free personal care, due to be
introduced on the 1 July, but its delayed discharge problem is on a
par with the rest of the UK and may be worse.

While delayed discharges in England
have been steadily decreasing, levels in Scotland rose again this
winter, prompting an emergency aid package of £20m from the
Scottish executive.

Scotland’s problems are
spawned partly by an increasingly elderly population. But
differences in the way the Scottish care system operates also have
an impact. Alexis Jay is director of social services and housing
for West Dunbartonshire Council, and is convenor of the community
care committee for the Association of Directors of Social
Work.

She says: “The situation in
Scotland is very variable and the problems tend to be different. We
shouldn’t have the same problems with funding residential
care because we have a national framework with providers under
which their fees are set at an agreed level – £390 for a
nursing home and about £340 for a residential care home.
We’re at the mid-point of a two-year process of introducing
them and we’re still discussing how that £390 is going
to be reached, but it’s an important difference with
England.

“Also we have directions on
choice – as part of the Community Care Act [1990] councils must
offer choice in residential services. It’s becoming a huge
issue in Scotland – a lot of cases of difficulty are around this
issue, because people dig in for their first choice,” Jay
says. “The problem is that one person’s choice is
another person’s six-month wait for a hip replacement. The
Scottish executive is revising the guidelines on choice, but as you
can imagine, it is not going to be popular.”

Edinburgh has one of the most
serious delayed discharge problems, a situation which director of
social services Les McEwan says is partly down to the city’s
demographics. “Edinburgh’s seen a rapid expansion
followed by an equally rapid decline in the number of care home
places – in our area we now have real difficulties with finding
places for people.”

He says Edinburgh’s high
property and land prices mean anyone wanting to set up new care
homes has to look elsewhere, while a relatively wealthy population
means that self-funders can afford to snap up whatever provision
there is, leaving those funded by councils out in the
cold.

McEwan agrees with Jay that
Scotland’s problems tend to be diverse: “In some areas
you’ve got the money, but you can’t find the bed – in
others you’ve got the beds but can’t find the money.
The Scottish executive recognises that there is no single
solution.”