The re-emergence of bed-blocking as an issue, due to the pressures of the Christmas cold snap and the winter ‘flu outbreak, has inevitably started a blame game between health and social care.
A survey for the Guardian by professional network Doctors.net.uk found that hospital doctors thought the situation was worse than a year ago and blamed cuts in social care in recent years.
Its findings echo a widespread feeling within the medical world.
“[Bed blocking] seems to have built up again, but I do have sympathy for councils,” said Dr Helena McKeown, chair of the British Medical Association’s community care committee.
This sentiment is shared by some social workers who also report a picture of rising rates, partly due to a progressive tightening of eligibility criteria.
However, Richard Jones, president of the Association of Directors of Adult Social Services, said figures for August to October 2010 showed 24% of delayed transfers were attributed to social care, 7% were jointly the responsibility of health and social care and 69% were the responsibility of health services.
In response, health secretary Andrew Lansley pumped in an extra £162m for the rest of 2010-11 to help people leave hospital more quickly through increased funding for home care, reablement services and short-term residential care places.
However, snapshot figures show the number of patients whose discharge from English acute hospitals was delayed is going down, from 2,652 as of the end of September last year to 2,011 as of the end of December.
The picture is confusing because some areas are performing well, while others, such as Birmingham, have high rates of delayed discharges, costing the NHS and councils millions.
Directors of adult social services have been angered by the accusations that they are at fault for delayed discharges, arguing that most are due to problems that can be laid at the door of the NHS through, for instance, the reduced numbers of hospital beds.
One director said: “My staff have worked solidly clearing beds over the Christmas and New Year periods. Our hospital social workers are on 8am-8pm seven-day-a week contracts, coming in at weekends and working every evening to clear beds.
“We are doing everything possible to discharge people, divert money to support health and not block beds. I don’t want us to get back into these winter pressures games because the NHS can’t manage its own pressures.”
But the long-term prognosis is not promising, with many fearing the worst when the cuts heralded by the government’s comprehensive spending review begin to bite from April when the new financial year starts, potentially signalling a further round of the blame game.
The panacea could be for more joint-working initiatives, as outlined by Lansley, who said the £162m would be given to primary care trusts to pass to councils to spend, according to local agreements.
Further funding worth about £1bn a year would follow the £162m for reablement and post-discharge support from 2011 to 2015.
This means councils will look at improving their rapid response capacity, while others will look at buying more beds in care homes for reablement and improving their general reablement offer.
Others are examining home improvement schemes, such as the successful Healthy Homes Programme in Liverpool, which is funded entirely by Liverpool PCT but run by the council’s public protection business unit.
The unit will visit 15,000 privately-rented homes over three years and use environmental health powers to tackle unhealthy and unsafe housing conditions.
This has been running for less than a year, but anecdotal evidence suggests it is helping to reduce delayed discharges and save the NHS money.
The revised NHS operating framework also states that hospitals will be responsible for patients in the 30 days after discharge, which means they will not receive payment for treatments if people are readmitted within a month.
Professor Ian Philp, the former national clinical director for older people at the Department of Health, was optimistic that the extra money and the 30-day rule would help.
“The NHS will do more because of the 30-day penalty, so the hospitals will want to ensure that when people are discharged they are discharged into a reablement service,” said Philp, who works at Sheffield University.
McKeown agreed that the NHS could do more by paying for services or adaptations now funded by social care and could also involve more community staff in hospital discharge planning.
Clearly, extra money when funds are tight will help alleviate delayed discharge problems.
But for the money to be effective it needs to be targeted in jointly developed projects.
Richard Humphries, senior fellow in social care at the King’s Fund, pointed out that, for these joint-working projects to work, personal relationship-building will be important. “That’s a slow burner,” he said.
When money is tight and when the health world is in turmoil through the proposed reforms, building these effective relationships could be difficult.
At the same time, it may also be difficult to persuade commissioners of the merits of providing upfront funds for long-term savings, particularly when the NHS could see itself coming under more pressure through cuts to council programmes intended to support vulnerable people.
Case study: Birmingham
Birmingham had 49 patients whose discharge from acute hospitals was delayed as of the end of November 2010.
This is not the worst rate in England, but it is high and last year the council was threatened with fines over delayed discharges by acute trusts in the city.
In a recent review, the authority’s health overview and scrutiny committee found the biggest single cause was the availability of nursing home placements. This was responsible for 19% of delayed discharges in the 28 months until the end of July last year.
The review was accompanied by a 12-point plan for improving the situation.
Among the recommendations was the creation of a “city-wide, community-based budget” approach to create pooled budgets for intermediate care.
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