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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