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Laurel and Hardy could teach health and social care a thing or two about partnerships. How to stick together through thick and thin, for example, even when one partner is blaming the other for getting them both into hot water.

By its very nature, a blame culture automatically threatens a partnership. So NHS bodies' new power to impose heavy fines on social services for their part in delayed hospital discharges could undermine the progress already made in establishing sound relationships between the two.

Although it was refreshing to see a radical new government policy given a three-month shadow period to allow authorities to become familiar with new structures, many are still worried about the scheme. Establishing a system that operates on a basis of blame and punishment, rather than on trusting, co-operative relationships, hardly seems constructive.

The House of Commons health committee was thinking along the same lines when it published its report on the policy in 2002. This suggested the reimbursement scheme might lead to "an unproductive culture of buckpassing and mutual blame between health and social care".

Jonathan Ellis is head of health and social care at Help the Aged. He believes that, rather than creating a system that may squeeze the problem somewhere else, a more constructive way forward is through "better partnerships, better joint working arrangements, and local councils and the NHS understanding each other more rather than trying to apportion blame".

He points out that, even without the reimbursement scheme in place, there has been some quite dramatic progress in reducing delayed discharges in the last few years. He questions whether the new scheme will add anything except new barriers to partnership. "Our principle concern is that at first glance it looks like it's working for the benefit of patients but it's unclear whether this will guarantee the right care in the right place at the right time, or whether they will be passed around additional bits of the system."

Without a formal evaluation, it's hard to know what the lessons of the shadow period are. Ellis hopes it has encouraged more creative ways of thinking about capacity, whether it be community health provision or local authorities developing that capacity in a way that's responsive to the patients' needs, "rather than just creating a new warehouse to put them in while they wait".

Whether the reimbursement scheme will actually improve care for older people remains to be seen, amid widespread concern that it could develop into a demarcation dispute between health and social care. Whatever the outcome, there's no disputing that delayed discharge has been a problem since the beginning of the NHS. It's bad for the hospitals because it's a waste of scarce public resources. And it's bad for older people because life in an institution can mean they lose confidence, strength and independence.

Over the years, countless pieces of research have shown recurring factors that contribute to bed-blocking. These include:

• Poor communication between hospitals and the community.
• Lack of assessment and proper planning of discharges.
• Inadequate notice of discharge to older people.
• Inadequate consultation with older people and their carers in the planning process.
• Over reliance on family carers and an assumption that the carer will carry on.

These have all been historically problematic, says Jon Glasby, head of health and social care partnerships at the University of Birmingham's health services management centre. "I don't think reimbursement does anything to help them."

And we may end up with older people being discharged too quickly in a bid by social services to evade fines. For his part, Glasby would argue that premature or poorly co-ordinated discharges are just as significant problems as delayed discharges.

It is likely that more older people will move to an interim placement in a nursing or residential home until there is a place available in the home they wish to go to. But the more moves an older person makes, the more risk there is to their health.

Many of those who will return home after a stay in hospital will need rehabilitation programmes at intermediate care services. But there is concern that, because intermediate care beds don't attract fines, they could become "dumping grounds" for hospitals, says Glasby.

"Older people should only be in intermediate care for up to six weeks. But there is anecdotal evidence that some hospitals are making blanket placements to intermediate care and older people could just languish there. The danger is that we are shifting the problem of delayed discharges from hospitals into a different setting."

Given these issues, it is not surprising that some health and social care authorities are making informal agreements in their areas to avoid fines and protect their joint-working relationships. According to Norman Taylor, adult services manager at Sunderland social services department, both sides decided before the shadow period that there would be no exchange of money. Instead, any cash available from the reimbursement policy would be reinvested in Sunderland's services.

"We were all anxious that the reimbursement policy could be divisive where so much effort had gone into partnerships working," says Taylor. "So it wasn't welcomed. Maybe in areas where there is a significant problem it would be."

Sunderland hasn't had a major problem with delayed discharges for a considerable time, says Taylor, because of partnership working with health and a £2m investment in intermediate care services from both sides. The investment has also meant that a specialist social work team works with the discharge nurses to see who would benefit from intermediate care. They work with clients through that care and then organise their care package to return home. Patients who may have initially wanted to go into care homes from hospital now feel able to go home because of the quality of intermediate care available, says Taylor.

During the shadow period, Sunderland social services would have been liable for about 130 days. In the first week of January, when the scheme went live, there were no reimbursable days.

There's no denying that the delayed discharge debate has focused people's minds on the issue. The prospect of hefty fines has also given social services directors some valuable ammunition when asking elected members for more money to invest in alternative services for older people.

Lynn Waight, strategic service manager at Hampshire social services department, agrees that the Community Care (Delayed Discharges) Act 2003 acted as a catalyst for focusing attention on discharge processes. The shadow period showed that "our initial leaning towards working very closely with health partners has been profitable, but we were doing that anyway".

The social services department has invested in interim placements, some intermediate care, rapid response teams and 19 care managers to help the discharge process work more effectively. The results speak for themselves. As a snapshot figure, this time last year, of 217 delayed discharge cases in acute beds for health and social care, 130 were down to social care. A year on, this figure is just 35 from a "whole systems delay" of 140. And not all of these will be reimbursable cases, as it's a moving figure.

"We are pleased that we have achieved a huge reduction in delays. If we were pressed for one thing that has come out of the shadow system, it is that with so much focus on processes we must continue to keep person-centred care at the forefront."

Hampshire has not signed up to the idea of an informal agreement with health to avoid fines. "Our aim is no fines anyway," says Waight. "If our figures continue the way they are we will meet our objective."

Like many, the county has been hit hard by the loss of nursing home capacity. Up to 60 per cent of the delays have been due to patients waiting for nursing home placements.

To address this, a nursing home project is coming on line soon in conjunction with the local primary care trusts and the Department of Health. It will provide nursing home beds through new builds and by altering current sites.

Waight is concerned that the concentration on discharge processes will take the focus away from other areas that need attention, including community services and prevention work. Delayed discharges are a whole systems issue, she adds. "We have to look at all delayed discharges if we are going to crack it, as well as social care discharges.

"The reimbursement scheme focuses on one point in the process and that's not necessarily healthy. A bottleneck further down the line might give us huge problems."

Glasby agrees: "Hospital discharge is a complicated whole systems problem and requires a whole systems response. This is too simplistic. If we haven't cracked it since 1948 is this going to crack it now?"

If it does not, social services and health might be left scratching their heads and blaming each other in the manner of Laurel and Hardy, for "another fine mess you've got me into".

Beds unblocked

The overall number of delayed discharges fell from 5,700 in July 2002 to just over 4,000 in May 2003. This beat the March 2003 target of 4,200. The number of over-75s delayed in hospital halved from 7,000 in March 1997 to 3,500 in December 2002.

It came from the north

• The idea is based on a Swedish model introduced 10 years ago where older people now spend 30 per cent less time in hospital. However, some question whether the comparison is fair because political responsibility for Swedish health care rests with local government. 
• The reimbursement scheme was first proposed in England and Wales in April 2002 and met immediate opposition from councils. The scheme was introduced under the Community Care (Delayed Discharges) Act which received royal assent in April 2003. 
• In May 2003, former health minister Jacqui Smith announced the details of how the £50m delayed discharge fund would be spent. Each local authority was allocated a share of the fund based on expected need. It was to be used to cover fines and put preventive measures in place. A further £100m will be allocated to councils in each of the following two years. 
• From January 2004, social services will be fined £100 a day (£120 in London and south east England) for failing to have a care package available within two days of notification from a hospital that a client is to be discharged.