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The government's plan to punish local authorities in England for bed-blocking are under fire from health-care professionals and local government alike. Drew Clode examines the proposals.

From the tone of the Department of Health press release issued late last month, you'd have thought all the NHS's bed-blocking problems were solved. "More older people able to leave hospital on time," it boasted, along with an impressive array of figures from health minister Jacqui Smith.

Targets for reducing delayed discharge numbers set last month are well on the way to being met. The £300m building capacity money given to local authorities to achieve the reductions was clearly and evidently being well spent.

And by March this year the 4,691 beds "blocked" by older people of 75 years or more were nearly 20 per cent down from the 5,938 recorded in March 2002. There was a simultaneous fall in the length of time people waited to be discharged. The number of people waiting more than 28 days, for example, tumbled by 800 in the past nine months.

No wonder Smith was able to boast that the fall "demonstrates that the £300m investment has helped local authorities to provide the care and services needed by older people when they are discharged from hospital". The target to reduce delays by a further 20 per cent by March next year seems easily attainable.

So, in the midst of all this success, it has to be wondered why the government suddenly threw into the melting pot a policy of penalising social services if they don't do better. Is this policy the pound of flesh demanded by the Treasury in return for extra resources in the comprehensive spending review? An irrelevant spanner in the works? Or a carefully thought through addendum to the NHS Plan?

In Delivering the NHS Plan, the Department of Health says that much of the recent progress on reducing delayed hospital discharge "has been driven by top-down targeting of resources, central intervention and close monitoring of progress". It states: "In the longer term, this approach is not sustainable in a climate where the philosophy of devolution and earned autonomy is applied both in local government services and in health services."

Delivering the NHS Plan crucially refers to how impressed the government is by the success of the system in Sweden and Denmark in reducing delayed discharges from hospitals, adding: "We intend to legislate therefore to introduce a similar system of cross-charging."

The document goes on: "The new social services cash announced in the Budget includes resources to cover the cost of beds needlessly blocked in hospitals through delayed discharges… Councils will need to use these extra resources to expand care at home and to ensure that all older people are able to leave hospital once their treatment is completed and it is safe for them to do so. If councils reduce the number of blocked beds, they will have freedom to use these resources to invest in alternative social care services. If they cannot meet the agreed time limit they will be charged by the local hospital for the costs it incurs in keeping older people in hospital unnecessarily."

Generously, the document allows that there will be matching incentive charges on NHS hospitals to make them responsible for the costs of emergency hospital readmissions, so as to ensure patients are not discharged prematurely.

But there are increasingly bitter arguments among politicians about the extent to which the chancellor's Budget statement represented "new money", as well as widespread fears that such emphasis on adult services will take resources from already over-pressed children's services.

With an impasse on both these fronts, it has become increasingly important to tease out some of the implications of the so-called Scandinavian Model - and to remember that it has surfaced within one of the most fiercely fought political contexts that health and social services have seen for some time. There is by no means unanimity over the plans, either at the Treasury or in the Department of Health.

At the very least, implementation will demand answers to questions including:

- How will the decisions about whether or not an elderly person is fit for discharge be monitored and fully endorsed by all the parties concerned?

- Who decides whether or not an emergency readmission was prompted by premature discharge?

- Who will arbitrate over disputes - especially when a local authority believes that leaving hospital has been held up by a fault within the NHS's own community or hospital services?

- Who will be responsible if the market itself isn't able to provide the number of beds required to effect a punctual discharge from hospital?

- Will the system discourage, rather than encourage, closer integration between health and social care services?

- Is the current mechanism for identifying where delays are taking place, and who is responsible, sufficiently robust to predicate a "fining" system onto it? Information about which authority was responsible for which older person has always been a little shaky. Some insiders now fear that changes in the way figures are collected and verified, along with changes in NHS boundaries, mean that the task of assembling accurate figures has become considerably more, not less, difficult.

- Will it lead to undue pressures being brought to bear on elderly people and run contrary to their statutory right to choose?

- Similarly, will it encourage the view that elderly users of services are simply bringers or losers of money, rather than whole people deserving of professional care, concern and respect?

- Do hospitals have long enough to solve these issues, given that the government intends this to come on stream by April next year?

- Will the amount of time given to local authorities to arrange discharge following a declaration that somebody is fit to leave hospital be nationally determined or locally negotiated?

These and similar questions will have been discussed in the two meetings held so far by the Department of Health's Cross-Charging Stakeholder Group. But it will surprise no one to know that hardly anyone in the wider health and social care policy and management world believes that the proposals are workable. Even if they were workable in theory, they could only be implemented if there was substantially more cash in the system than is currently the case.

Help the Aged policy officer Gail Elkington, for example, notes archly that "local authorities are not sitting on pots of money, refusing to give people places in homes. They are rationing services, sometime even waiting for people to die before sanctioning another placement."

In Sweden, responsibility was moved to local authorities 10 years ago, accompanied by huge amounts of money, she argues. The agencies were given time - three years - to build up substantial home care services, while they already controlled something like 90 per cent of the residential market.

This contrasts with the situation in the UK, where the public provision of residential care has shrunk over the past 20 years, leaving most places in the hands of the private sector, which is clearly feeling the pinch.

According to Elkington, there's not much doubt that penalties will be introduced: the only hope is that before they are - she would argue that next April is too soon - someone will have discovered how it's all going to work. Equally resigned to the fact that some sort of system will eventually be introduced, Stuart Marples of the Institute of Health Care Managers is sceptical about many of the outcomes. For him, delayed discharge is a real problem in many parts of the country, but he describes fines as "a very heavy-handed way of ensuring it gets the attention it deserves. It will lead to disputes, and it will require arbitration procedures."

There is a danger that bureaucracy will overtake the intent, he says. A former acute trust chief executive, he is aware that delayed discharge requires high-profile attention, and remains convinced that next April is too soon to implement. He is clear that "the practicalities of implementation are major stumbling blocks."

But the most emphatic rejection so far is from the Local Government Association. Its social care and health committee dismissed the proposals as threatening to:

- Create a perverse incentive for social and health care staff to become "overly conscious with hastening transfers at the expense of being professionally satisfied that the transfer is appropriate and timely".

- Skew the market so that social services concentrate too much on the needs of older people awaiting transfer "at the expense of those at home, awaiting preventive home care services".

Perhaps lurking beneath these positions is a fear that in the delicate local balances between council, primary care trust and acute hospital trust, these proposals will give far too much clout to the acute sector at the expense of the still fragile PCTs.

The LGA position is shared by the Association of Directors of Social Services whose older persons committee chairperson Glenys Jones argues that while no one challenges the need to eliminate delays in discharge, the idea of "cherry picking a model from Sweden when the Swedish context is not the same" should be treated with caution. Most care provision in Sweden is publicly provided, with local government responsible for community-based health care. Nor is there the market volatility experienced in the UK.

Along with the LGA, directors also understand the need to address issues across the whole system and not just the acute/social care interface. Jones says: "We are very willing to work with the Department of Health to develop a system. But we want to see much more emphasis on incentivising the whole system to work effectively and on realistic levels of investment - well beyond the current building capacity grant."

Sharing those anxieties is Age Concern England (it is significant that the Welsh assembly has no plans to introduce fines in Wales, and that Scotland, with free personal care, has gone down a completely different avenue). According to policy worker Stephen Lowe, the charity is against the proposal. He says: "It won't promote joint working; it will lead to increased pressure to concentrate on older people in hospital, drawing attention away from those at home who may be at more risk; it will increase pressures to discharge prematurely. And it won't work."

On top of this, Lowe foresees an explosion in complaints via the local authority complaints procedures, where older people or their families believe that pressures to discharge have overridden statutory directions on choice.

"Much of the problem with delayed discharge now is that, because of resource pressures, local authorities are not offering services to older people related to their assessed needs. It would be better if local authorities were enabled to meet their current statutory obligations rather than have new legislation placed on their shoulders," says Lowe.

If all these objections don't provide pause for thought, there is an implicit threat from the LGA that it might encourage councils to sue local hospitals if acute beds are blocked because of problems at the hospital. The absurdity of an acute hospital trust threatening to fine the same local authority for failing to provide a residential place or home care package for the same older person should not be lost on Treasury and DoH policy makers.

Not only would these and similar disputes and potential farces threaten the integration and collaboration built up between health and social care over past years, but they could also have a devastating effect on older people themselves.

As Marples puts it, financial penalties "will bring labelling to people who ought not to be labelled; they will be labelled as problems rather than older people who need support. And there's a danger that they will be seen only as bringers, or losers, of local authority money."

It might be that the logistical and practical problems can be solved, and that the new systems can be imbued with an ethos that doesn't aggravate an ageism which, according to Age Concern, already permeates many of the nooks and crannies of the NHS.

But nobody seems to be betting on whether April 2003 is too soon for implementation - nor whether the planned outcomes will inevitably be tainted by the perverse and complicated processes that will have to be introduced in order to make the system work.

Delivering the NHSPlan at www.doh.gov.uk/deliveringthenhsplan/

Drew Clode is press adviser at the Association of Directors of Social Services but is writing here in a personal capacity.