news analysis of delayed discharge fines

The new system of fining councils for the delayed discharge of
older people from hospital came into effect in shadow form last
week, writes Natasha Salari.

Hospitals must now notify social services departments of patients
who may need social care on discharge. But no fines will be levied
until the new year while hospitals and authorities adjust to the
new paperwork.

From 5 January, social services departments will be charged
£100 a day (or £120 in London and the south east) if they
fail to arrange care packages for patients assessed as needing one
within two days of notification.

When the system was first proposed in April 2002, it met immediate
opposition from councils. But many have now found ways to reinvest
fines in services and work in partnership with local health
bodies.

The government introduced the Community Care (Delayed Discharges)
Act 2003 because it had found that, in about 60 per cent of cases
of older people in hospital care, delays were due partly to social
services departments “not fulfiling their responsibilities”.

In early 2002, 6 per cent of acute beds were blocked at the cost of
about £120,000 a bed every year.

Life expectancy increases

The idea is based on a Scandinavian model introduced 10 years
ago. Since then, life expectancy for men and women in Sweden has
increased by 2.3 and 1.5 per cent respectively. Older people now
spend 30 per cent less time in hospital, and the number needing
intensive supported housing has also reduced by a third – even
though health spending in Sweden has fallen from 8.8 to 8.5 per
cent of gross domestic product.

But despite these impressive results, winning approval for the
Community Care (Delayed Discharges) Act has not been easy. In
February 2003, a survey of more than 1,700 readers by Community
Care and Nursing Standard found that more than two-thirds of nurses
and 88 per cent of social care staff opposed the fines.

In March, there were wrangles in the House of Lords over plans to
include Saturdays, Sundays and public holidays in the period that
councils would have to arrange a care package, and over the
inclusion of mental health patients in the policy.

The outcome was that mental health patients will not be covered by
the act and that Sundays and bank holidays – but not Saturdays –
will be exempt from the period in which a care package must be
arranged for the time being.

More recently, a report by the House of Commons’ public accounts
committee found that attempts to reduce delayed discharge levels
could lead to older people with the most complex needs being left
in hospital as social services departments focus on the cases that
are easiest to resolve.

Although the Department of Health says it has recently sent
councils their share of the £50 million delayed discharges
grant for the next six months to help cover fines and put
preventive measures in place, none of the councils ‘Community Care’
spoke to last week had received anything. The plan is for a further
£100 million to be allocated to councils in each of the
following two years.

Profit can be made

Last month, community care minister Stephen Ladyman said
councils could even make a profit out of the delayed discharges
system by paying less in fines than they would get in grant.

But his comments have angered social services directors, who say
they are pouring thousands of pounds out of their own budget into
services for older people on top of their delayed discharge grants
in order to avoid fines.

Councils are also working with partners to make the fining system
less punitive. Many are setting up pooled budgets with local
primary care and acute hospital trusts which fines are paid into
and then used to improve services such as intermediate care to
prevent further fines.

Suffolk council is one of those hoping to set up a pooled budget.
Anthony Douglas, director of social care and health, believes it is
wrong to see councils, care trusts and hospitals as “rivals and
competitors”.

“We have five primary care trusts and three acute hospitals so we
have to reach agreements with each. It’s not a one-size-fits-all
model,” he says.

“We could get fines in January, but we are depending on the
goodwill of the hospitals and we are trying to set up a pooled
fund.

“But the acute hospitals can see that the fines are money they can
use for private hospitals or getting people out of hospital beds to
free up their own space. We have to persuade them that we can
deliver. I don’t think fines are helpful to agencies that need to
collaborate. They don’t motivate people.”

John Fisher, head of adult care services at Sunderland council, is
confident that the department will be able to keep down the number
of delayed discharges to four or five a week, but says there is “no
room for profit” in the system.

“We are still expecting to get some fines in January but we will
pay these into an intermediate care pooled budget,” Fisher says.
“The city hospital has agreed with us on this. That money could
also be used for the winter pressure.”

Newcastle council is not expecting to pay any fines for older
people in local hospitals, but it does expect to face fines over
some of its residents in hospitals in other parts of the country.
The policy states that the council responsible for paying the fine
is the one in which the patient normally lives.

Newcastle’s health and social services directors are drawing up the
details for a pooled budget, and they have also bought an extra 50
care home places on the back of their delayed discharge grant
allocation.

Opposed on principle

But Hampshire council is not considering setting up a pooled
budget at this stage. It will receive the largest grant in England
for 2003-4, at just over £1.2 million, but it remains opposed
to the principle of fines.

Although Hampshire has halved the number of delayed discharges in
the past six months, it still expects some fines due to the
turnover and volume of patients going in and out of hospital.

It has allocated an extra £7 million to community-based
initiatives, such as providing intensive support for patients on
their return home from hospital, short-stay rehabilitation beds and
services to support older people living at home.

But the council’s executive member for social care Felicity
Hindson, says: “We continue to oppose the underlying principle of
fining, which flies in the face of already established
partnership-working in the area, takes with one hand while giving
with another, and continues to require enormous time, energy and
resources to set up the new bureaucracy which does nothing to aid
the patient.”

The Witham, Braintree and Halstead Care Trust in Essex is more
hopeful that pooling the delayed discharge money could help improve
services for patients. Sally Sparrow, director of social care,
says: “We have an agreement with the acute hospital trust that the
money will be recycled for intermediate care. It wouldn’t be used
to plug gaps or cover deficits. I think it’s the only thing to do.
It’s just nonsense otherwise and you lose the money into the
overall deficits.

“It has to be used to reduce the delays otherwise it won’t
help.”

How councils will spend their delayed discharge
grant:

Suffolk: £656,000

Putting social workers into GP practices

Investing in services in people’s homes

Intermediate care schemes

Converting 50 residential beds in the council’s own homes into
special needs beds

Birmingham: £1.2m

Additional intermediate care beds

Interim care provision

Increasing and improving rapid response care

Creating respite and rehabilitation services

Investing in hospital social work teams

Newcastle: £330,000

Buying 50 additional care home places

Increasing and expanding domiciliary care capacity to create an
intermediate care service with occupational health included

Employing 27 extra home care workers

Sunderland: £352,000

Creating 60 intermediate care beds

Investing in convalescence, support and therapeutic work

Buying a nursing home

Employing six new care managers for the assessment process