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Social services directors fear the delayed discharge reimbursement system could paint a disproportionately poor picture of their performance because of the way it has been set up.

Changes in the way information is produced and published by the government and pressure on doctors to discharge patients from hospital more quickly are contributing to difficulties bedding in the system.

Problems with what information is compiled were highlighted last week when East Sussex Council reacted angrily to comments made by community care minister Stephen Ladyman that it would spend more than £500,000 in fines in the first three months of the scheme alone (news, page 7, 19 February). Ladyman blamed this on the council failing to invest its government grant in building capacity in the care homes sector.


East Sussex called the comments "grossly inaccurate". Its own figures suggest fines of £10,700 in January, with similar sums predicted for February and March.

Elsewhere, there are signs that a month into the system - money started changing hands on 5 January after a "shadow" period between October and December 2003 - fines for social services departments are generally low.

Although the Department of Health will not publish official figures on levels of delayed discharge until March, it feeds weekly information to social services directors about the number of patients delayed.

Under the reimbursement system, social services will be fined £100 a day (£120 in London and the South East) by the hospital trust unless beds are found within three days of clients being assessed as needing one.

To cushion the blow, the government handed out hundreds of thousands of pounds in grants to every council to invest in preventive services. Others have drawn up local agreements with trusts so that any money generated from fines is ploughed back into developing interim care.

Some estimate the average social services department will face annual fines of £350,000, but councils contacted by Community Care show a huge variation in levels of fines.

For example, Norfolk Council paid £5,200 in January, while Bournemouth has fluctuated between £2,000 and £7,000 a week. Hampshire looks set to be one of the hardest hit with fines averaging about £6,000 a week.

But the concerns are likely to persist over what information is collected and how that affects the money social services departments are paying and their star rating. The DoH sticks by Ladyman's comments about East Sussex Council and says he based them on its own preliminary figures "which still need to go through checks and balances" showing delays rising in the area. "If this continues it will spend more in fines than it received in grant."

Although the DoH is adamant this relates to social services delays only, the disparity with the council's assessment is so vast that the validity of the system is now in question.

Fines change hands only when the delay is caused by social services. However, the weekly figures published by the DoH cover all delays, including those caused by internal moves in the NHS.

A case in point is in the week beginning 9 February when 115 people were delayed in Kent hospitals, according to the figure released by the DoH to all other social services directors in the South East. However, what it does not say is that only 28 per cent of these were classed as social services delays.

The situation has prompted the Association of Directors of Social Services to question how fair the figures are and whether they accurately reflect bottlenecks in the system.

"We believe that 60 to 70 per cent of discharge delays are caused by NHS-to-NHS transfers and people exercising choice," says ADSS president Andrew Couzens. "The whole system figures are taken into account when assessing the social services star ratings. It is unfair that we are being judged on that."

Peter Gilroy, director of social services at Kent Council, says many delays were due to health services's own problems such as getting duty doctors to discharge a patient. The percentage of delays caused by social services were already reduced to their 2006 target levels, he says.

"There needs to be a degree of transparency about when it's particularly social care and when it's particularly health care trying to sort out its own issues. It isn't good enough any longer in publicity terms to turn around and say it's all down to local authorities."


The DoH says its quarterly figures will cover reasons for delays, but adds the whole-system figure is one of a range of indicators for older people's services councils will be assessed on. Primary care trusts and hospitals will also be judged on this, it added.

Couzens has written to Ladyman explaining why he believes the current way of publishing data and measuring performance is unfair. Although it is unlikely to change the system overnight, he hopes that new performance indicators due in November will "more accurately reflect the cause of the delays".

But Couzens believes the main issue is the levels of admission and readmission of patients to hospital due to inappropriate discharge, especially as "activity levels in the acute sector are going up by 10 to 20 per cent".

Last year, the DoH stopped collecting and publishing data on emergency readmissions of over-75s - a key group in delayed discharge - because "patient organisations, clinicians and service managers suggested it was ageist", a DoH spokesperson says. Now, figures cover all ages.

Liberal Democrat health spokesperson Paul Burstow believes that by no longer publishing such data it is more difficult to ascertain whether the system is working effectively.

"They used to publish this data and now that the new system is in place they have stopped," he says. "The focus has been about the sooner a person is discharged the better but what I want to reassure myself of is that the pressure from reducing the number of delays doesn't lead in turn to a revolving door scenario where people come back in 28 days as an emergency."

A DoH spokesperson says the age-specific data for readmissions do not distinguish whether a person is readmitted for the same condition for which they originally entered hospital.

Although the DoH approach has been to develop a system where health and social services supposedly take joint responsibility for delayed discharge, Jon Glasby, a researcher at the University of Birmingham who has looked at the viability of fines, says there is a danger it could harm relationships between the two.

"The jury is still out. The risk is that by having such a high-profile policy and identifying the faults of social services you run the risk of developing a simplistic blame culture." 

Behind the figures

"There are a lot of misconceptions about where these delays are caused," says Pam Donnellan, social services director at Bournemouth Council. "You need to look at all the reasons behind the delays."

She says a lack of nursing homes in the area and high private home fees have made it difficult for the council to meet the demand for beds, so many clients have been placed in homes in other authorities. The council is raising nursing care rates by more than 10 per cent from April to address this.

But Bournemouth has already spent its grant on increasing its hospital social work team and investing in community rehabilitation teams so that fines come out of its budget. 

Price of progress

Hampshire social services has employed 19 extra social workers in its acute hospitals enabling it to assess patients quickly, but it is still averaging about £6,000 in fines a week.

However, compared with the rest of the system it has made great leaps in performance.

January 2003:

Whole-system delays: 217

Social services responsible for: 130

January 2004:

Whole-system delays: 148

Social services responsible for: 28