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Imagine you are old, frail, and stuck in hospital. The doctors and nurses don't say it, but you sense they would rather give your bed to "someone who really needs it".

In the meantime, social services are talking up a care home on the other side of town. You want to go home, but your ill-health makes this impossible. You want to go to a care home that is near your daughter but there are no vacancies. The clock is ticking and all the professionals dealing with you want to move you on.


Despite predictions that scenarios such as this could become commonplace, and notwithstanding attempts by the House of Lords to block the move, the government is to press ahead with fining social services for delayed discharge from hospitals. Although it has put back its plans until October to allow councils and the NHS time to put the necessary systems in place.

Last month, health minister Jacqui Smith confidently declared that the Community Care (Delayed Discharges) Bill would not only bring an end to delayed discharges but would ensure "older people get the services that they need when they need them".

Many MPs and peers remain less than convinced by her assertions, and they are not alone. In December, Community Care revealed how the government pressed ahead with the proposals despite being fully aware of the strong opposition from health and social care bodies (news, page 8, 5 December 2002).

More than three-quarters of the 268 organisations that responded to the government's consultation believe the fines could damage partnerships. In addition, more than half, which includes councils, primary care trusts and NHS trusts, claim it is unrealistic to put together a care plan for discharge in three days and include the views of patients, carers and families.

Most of the debate so far has focused on the implications of the fines for councils and their health partners. What appears to have taken more of a backseat however is the impact of the proposals on the 5,000 or so older people at the sharp end of the discharge process. With cash-strapped social services desperate to avoid fines, there are concerns that they may find themselves encouraged to accept care placements that are not necessarily to their liking.

Ian Johnston, director of the British Association of Social Workers, says there is a danger that this will happen: "They are vulnerable and should not be pressurised to accept placements on offer by local authorities or others under pain of penalty."

He questions whether the bill, which he describes as a blunt instrument, can really nurture the professional partnerships necessary to meet the needs of older people requiring a range of health and social care interventions.

Johnston agrees there is a risk that the pressure created by fining could result in higher numbers of older people placed in care homes, rather than cared for in their own homes, as setting up care packages can take longer to organise.

The DoH has done little to dispel fears that the bill will restrict patient choice. It has published a document setting out its answers to frequently asked questions, one of which asks whether patients are likely to be pressurised into accepting unsuitable care so that their local authority can avoid charges.¹ The answer, rather than a "No", is that "remaining in an acute hospital when acute treatment is no longer required itself constitutes unsuitable care".

Perhaps more worrying is the government's view that in certain instances patients should be persuaded to take interim care, or face the prospect of having to stump up the funds themselves.

Meanwhile, nursing staff have also voiced concerns over the effect that fining could have on patients. "There might be undue pressure to get older people out quicker than is necessary and take what is available rather than the patient's choice," says Lynn Young, primary health care adviser at the Royal College of Nursing. "It would be difficult if the family is not articulate. An elderly person who is isolated and without advocacy may be very vulnerable."


Young is outraged by the proposals to fine social services. She claims she has not come across a single organisation that supports the move. She hints that where there are already strong links between health and social care, the bill could serve to unite health and social services in taking steps to avoid implementing the fines. "Older people will get the services they need when there are resources in terms of people, equipment and money to provide them. Fining social services will do nothing in my view," she adds.

The Relatives and Residents Association recommends that older people resist pressure to accept a care package that they are not entirely happy with.

Association development worker Julia Burton-Jones says: "We know that where a person is pressured into accepting a place that isn't their preferred choice they are unhappy and don't settle as well."

The situation is likely to be worse for those with a condition that affects mental capacity, such as dementia.

Harry Cayton, chief executive of the Alzheimer's Society, says: "Our main concern is that people with dementia are often not in a position to make a real decision for themselves and are likely to be vulnerable to being moved without their consent."

He says that the real issues are reducing inappropriate admissions to hospital and achieving better co-ordination between social services and hospitals. Cayton, who is also the patients' tsar for the DoH, says that the pressure to get people out quickly will limit individuals' choice.

But local authorities will have to be careful to make sure they do not place people inappropriately. Last year, a disabled woman and her husband were awarded £10,000 damages under the Human Rights Act 1998 after being forced to live in unsuitable conditions. The judge ruled that because of the "corporate negligence" of Enfield Council in London the woman had been almost totally confined to her home and forced to sleep in the lounge because she was unable to go upstairs. He said the council had shown a "singular lack of respect" for the couple's private, family and home life in violation of article 8 of the European Convention on Human Rights.

In practice, the consequences of the bill are likely to affect not just patients and clients but also their carers. And it was this group that had been left out of the original draft. Government amendments have since made it necessary for local authorities to respond when a carer requests an assessment and to arrange services, whether for the patient or the carer, to ensure the patient is "safe for discharge". Services to carers are also to be free for a limited period after discharge.

At her most optimistic, Glenys Jones, chairperson of the Association of Directors of Social Services' older people's committee, predicts that if the bill is passed it could result in additional services to prevent hospital admission, as well as early referrals so that social services can ensure after care is organised in time. But she concedes that, realistically, grave concerns remain over whether these will actually be in place.

¹ See Department of Health, Community Care (Delayed Discharges) Bill Frequently Asked Questions on Reimbursement and other documents about the policy at www.doh.gov.uk/jointunit/delayeddischarge/