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Bob Hudson is honorary professor of partnership studies at the Health Services Management Centre, University of Birmingham. He has written and researched on partnership issues for the past 20 years, and is a specialist adviser to the House of Commons education and skills select committee on issues relating to partnership and integration.

Co-authors - Maureen Allan is director, and Alix Crawford is manager, at the Integrated Care Network.

Health secretary John Reid has been enthusiastically proclaiming the improved figures for delayed discharge. In May, he was able to report a drop of 4,000 compared with the position in late 2001 - the equivalent, he estimated, of adding eight more hospitals to the NHS. He was keen to point out the link between this and the policy on reimbursement that took effect earlier this year. But has this really been the key to the improvements? More than 200 delegates gathered at the most recent Integrated Care Network (ICN) national event to explore the issue.

The Community Care (Delayed Discharges) Act 2003 introduced a system of reimbursement by social services to the relevant NHS body for discharge delays that are caused solely by the failure of the social services authority to provide timely assessment and social care services ("What's the deal?", Community Care, 22 January 2004).

Despite fierce initial opposition, delegates at this event believed that reimbursement had created a largely positive effect, but the reasons are important. The shift from viewing reimbursement as a "policy bogeyman" to a "partnership catalyst" has been largely the consequence of the approach to implementation from the centre, once the thrust of initial strategy had been determined. This was brought out by Melanie Henwood's briefing paper to the seminar, and contains wider messages for thinking about policy effectiveness and implementation in other fields.

Five key messages for policy implementation were identified:

• Ensure implementation is phased. During the passage of the bill, the implementation schedule was relaxed to allow an additional nine months for preparation -Êa vital window that gave local authorities an opportunity to make alternative arrangements.
• Use carrots as well as sticks. Although much of the public focus has been on reimbursement as a "penalty" on local authorities, there has also been a substantial increase in funding for the development of community services - £300m under the cash for change scheme and £100m a year under the delayed discharge grant. A strategy of incentives and penalties is more likely to succeed than one solely rooted in sanctions.
• Support for local implementation. The creation of a reimbursement group within the change agent team at the Department of Healthhas helped to enhance the acceptability of reimbursement. The group's aim has been to support rather than judge, and the production of a range of products (such as templates and protocols) was reinforced by a series of roadshows.
• A balanced view of the nature of the problem. Delayed discharge can have many causes, and one of the early difficulties was that the reimbursement strategy seemed to pin the entire blame on social care. But the act also placed obligations on the NHS to notify social services of any patients likely to need community care services and of their proposed discharge date - a recognition that poor communication has been a two-way affair in the past. Indeed, the responsibilities on the NHS have been increased further, with the obligation to make an assessment for funded NHS continuing care before triggering the reimbursement procedures.
• A focus on benefits for individuals rather than blame between agencies. The implementation guidance eschewed the language of blame, fines and penalties. The use of more measured language has been helpful in changing perceptions of the legislation - as one delegate put it, "reimbursement has been successful because it focuses on the individual".
• Securing local commitment. The initial lack of detail was unhelpful in securing commitment.

It appears that a combination of these factors has resulted in reimbursement becoming more a catalyst for change than a focus for discontent. One of the regional seminar discussions accepted that a successful approach to delayed discharge required greater structuring of good informal relationships, and that reimbursement had provided a sharper focus for action. Moreover, there appears to be an acknowledgement that reimbursement has had an effect in other areas by strengthening the links between kindred strategies, such as discharge planning, single assessment process, NHS continuing care and the development of new models of community-based services.

However, there is no pretence that all is suddenly rosy in the delayed transfer garden. The reimbursement strategy does not turn poor relationships into good partnerships - one regional group at the seminar reported on some acute trusts "who just want to collect the fines". Others reported that engaging clinicians in a teamwork approach continues to be a problem in some places, with consultants still making individual decisions regarding discharge outside any agreed framework. Some GPs still too readily view hospital admission as an easier option than maintaining their clinical responsibility in the community. And there was a feeling that we still do not understand why the number of delayed discharges rises or falls, and so end up addressing the symptom rather than the cause.

Notwithstanding these concerns, the thrust of discussion was not about turning back the legislative clock, but about moving the debate on to a deeper level. In part this is about the scope for extending the reimbursement strategy beyond acute care into other areas such as mental health and palliative care, otherwise the danger arises of a two-tier system emerging. Support was also evident for including community hospital beds in reimbursement arrangements to avoid the danger of these being used inappropriately as a safety valve for the acute sector.

However, the broader agenda is about extending the notion of "whole systems" working beyond a focus on the acute hospital bed, and into the wider services and networks that support vulnerable individuals. The impetus to move in this direction will come from the new focus on chronic disease management as evidenced by the government's interest in the approaches of US health companies Evercare and Kaiser Permanente. Here the emphasis is as much on the prevention of unnecessary admission into hospital or nursing home as it is on effective discharge arrangements.

Once the needs of individuals to stay in their homes and communities become the focal point of the intervention, the number of partners widens well beyond health and social care to embrace services such as housing, transport, welfare rights and community safety, among others. This is at the heart of the model proposed at the ICN seminar by Chris Paley - one in which older people are seen as citizens rather than consumers of health and social care. She sees this as inverting the "triangle of care" that has acute care sitting at the apex and any community engagement strategy flapping loosely in the policy breeze.

Echoing the changes now being proposed for children's services, Paley calls for:

• National well-being outcomes across agencies.
• Local older people outcomes.
• Cross-agency information systems.
• Joint health and well-being delivery plans.
• Local older people's partnership boards.
• A multi-skilled workforce and whole systems workforce plan.
• Leadership programmes for local communities.

This is the right time to have such a dialogue. Opening the ICN event, health minister Stephen Ladyman laid out his broad vision for the future of adult social care. His three key principles of person-centred, proactive and seamless services matched well with the mood of delegates and he clearly wants to hear what people want (see Care Consultation, panel, below). It is important that the wider vision coming out of the conference feeds into government thinking.

Abstract

This article reports on the proceedings and papers discussed at an event on reimbursement and delayed discharges held under the auspices of the Integrated Care Network. It reports that the ways in which the legislation has been implemented have done much to counterbalance earlier criticism, but that much remains to be done. The challenge for the future is to take a much broader view of the issue and feed into the rethink on the future of adult social care.

Structure of event

The Integrated Care Network event started with a briefing paper by Melanie Henwood, plenary sessions from health minister Stephen Ladyman, and Chris Paley, representing the Association of Directors of Social Services' older people committee. There was a range of project-based workshops and regional table discussions. Copies of the briefing paper, all presentations, and notes of workshops and discussions can be obtained from the ICN website at www.integratedcarenetwork.gov.uk

Further information   

Details of the work and products of the reimbursement group can be found on the website of the Health and Social Care Change Agent Team: www.changeagentteam.org.uk.

Care Consultation

Comments on the government's consultation on adult care should be e-mailed to the Social Care Institute for Excellence at vision@scie.org.uk.

Contact the author

The author can be contacted on bob@bobhudsonconsulting.com