A charge too far

The introduction of penalties for local authorities who
fail to prevent delayed discharges, and corresponding incentives
for hospitals, does not take account of the complexity of care
services on the ground, as experience in Sweden shows, writes
social policy academic Caroline Glendinning.

This year’s budget, and the subsequent policy document,
Delivering the NHS Plan¹ proposed the introduction of
“cross charges” between hospitals and local authorities, to tackle
problems of delayed and premature discharge from hospital. Local
authorities would be charged for people kept in hospital
unnecessarily because of a lack of community services. Matching
incentive charges will be imposed on hospitals for emergency
re-admissions, on the assumption that this indicates patients had
been discharged too soon.

These proposals originated in the pre-budget Wanless Report on
the future of NHS funding. They were prompted by the experience of
Sweden, which introduced similar charges in the early 1990s to
tackle the division of responsibility for the care of older people
between county councils (which provide hospitals and nursing homes)
and municipalities (which provide home nursing and home care). But
how successful will these new incentives be?

First, there are always risks in importing a discrete measure
from another country, divorced from its social and policy context.
The Swedish measures were part of a comprehensive package of
reforms aimed at shifting the balance of responsibility for
long-term care – not just from counties to municipalities, but also
from institutional to community-based care. They also included a
substantial shift of resources from county to municipal levels to
support these policy objectives.

Other differences between the two countries are also
significant:

– Swedish county councils and municipalities have far greater
independence from central government than in England – including
power to raise revenue from local income tax.

– Swedish municipalities still provide most of their own
residential and home care services – in contrast to England, where
most institutional care and half of home care services are
purchased from independent sector organisations. In about half of
the municipalities, home nursing services are also completely
integrated with personal care and home help services. It is
probably easier to organise quick, responsive services when these
are provided in-house, than to co-ordinate a number of different,
external provider organisations.

– As part of the 1990s reforms, Swedish municipalities made
major investments in sheltered housing – this is seen as an
integral element of community care. Swedish domiciliary services
are also extensive – not just personal care (as in England), but
also cleaning, shopping and errands to the chemist as well. Even
personal care in Sweden can include help with outings and
accompanying an older person to outpatient appointments.

The consequent reduction in delayed discharges in Sweden is
therefore likely to be the result of several factors, not simply
the introduction of financial penalties and incentives.

By contrast, trends in the UK during the past 30 years have
substantially increased pressures on local authorities. NHS
long-term care facilities have closed and length of stay in acute
hospitals is dramatically shorter. Responsibility for the
post-discharge care of older people has largely been transferred to
local authorities, but without a corresponding transfer of
resources.² Although the 6 per cent increase in local
authority funding announced in April is welcome, it will be shared
between children’s services and those for adults and older people.
Also, the increase is lower than that announced for the NHS, and no
redirection of existing patterns of expenditure between NHS and
local authority sectors is planned.

Moreover, given the serious problems that have arisen in the
independent residential and nursing home sector over the past few
years, social services’ first priority in spending their budget
increase is likely to be the stabilisation of local institutional
care markets. Investments in new domiciliary and day care services,
to provide long-term support for older people in their own homes,
will take lower priority.

Also, the proposal assumes that deciding when someone is
“medically fit for discharge” is clear and unambiguous. In
practice, it is likely that considerable discretion is involved.
Moreover, that discretion may be exercised differently by different
medical and other professionals. In any case, decisions about
fitness for discharge from NHS care and the transfer of
responsibility to local authorities also need to take account of
the Coughlan ruling, which restated the responsibilities of the NHS
in relation to substantial nursing care needs. In Sweden, the
municipalities and county councils have recently agreed that “ready
for discharge” means that a doctor has confirmed that hospital care
is no longer needed and that a care plan has been agreed, with
respective responsibilities for providing services clearly
defined.

Support following hospital discharge also involves primary and
community health, as well as social services. In Sweden, the
proposed care plan, to be drawn up before being deemed “ready for
discharge”, includes primary care as well as municipal health and
social services. Indeed, the municipalities and county councils
have agreed that the former should not be fined if a patient cannot
be discharged because the latter cannot provide the necessary
community-based health services.

English primary care trusts, which now hold unified budgets for
all hospital and community health and most primary care services
are, in principle, in an ideal position to ensure adequate primary
and community health services are available, if necessary by
redirecting resources away from hospital to community sectors.
Certainly, PCTs do report plans to redirect some resources away
from traditional patterns of expenditure. However, evidence to date
shows these resource shifts to be constrained by financial
pressures from hospitals and increased prescribing costs; and by
the interests of GPs wishing to invest in their practice-based
services.³

There are currently no incentives for PCTs to move more
resources into providing more, and better quality, community health
services. Indeed, the priority of improving hospital throughput is
likely seriously to limit their scope for new investments in
community and preventive health services. Along with social
services, PCTs may also need incentives to invest in more
community-based health services.

Delivering the NHS Plan also proposes to charge NHS hospitals
for emergency re-admissions, on the assumption that these will
involve people who have been discharged too early. The operational
criterion currently used to measure premature discharge is
re-admission within 28 days from the original discharge. However,
NHS-funded intermediate care services are already provided in many
areas, for up to six weeks. Consequently, anyone receiving a period
of intermediate care following discharge would be unlikely to be
readmitted to hospital within 28 days and so trigger the
cross-charge. The performance indicator also omits anyone who dies
within 28 days of hospital discharge (whether or not an early
discharge may have contributed to death). This performance
indicator therefore requires amendment if it is to provide a fair
basis for hospital charges for premature discharge.

One consequence of the introduction of fines in Sweden was that
municipalities quickly started developing sheltered housing and
residential homes, in order to accommodate older people quickly
once they were ready for discharge. In England, few local
authorities will be able to provide their own accommodation, but
will have to rely on independent residential and nursing homes –
already in very short supply in some parts of the country, and the
only source of spare capacity for new intermediate care services
elsewhere.

However, not all nursing and residential homes have access to
equitable, consistent, good quality NHS medical and nursing
services to care adequately for people discharged after illness or
treatment.⁴ Without active encouragement for PCTs to
review and improve levels of NHS services to homes in their areas,
the health care received by many older people following hospital
discharge will remain variable and inequitable.

Pressure on local health and social care services to support
prompt hospital discharge also diverts resources from developing
preventive services, such as chiropody, domestic help, health
promotion, social activities and equipment. These can maintain
physical and mental health, prevent accidents and avoid hospital
admissions altogether – as the Older People’s National Service
Framework⁵ recognises.

The cross-charging proposal risks recreating a blame culture
between NHS and local authority services, a culture which has
largely disappeared since 1997, as health and social services
organisations have worked hard to break down old barriers. In
contrast, these proposals emphasise narrow sectoral
responsibilities, threatening to undo the considerable progress
made in local health and social services partnerships.

The Health Act 1999 flexibilities are particularly helpful in
creating a whole systems focus on the needs of service users,
rather than the interests of providers.⁶ It is difficult
to see how cross-charging could operate within the context of the
pooled budgets and integrated provider organisations created by the
flexibilities, without very considerable damage to the wider
collaborative relationship.

In contrast, the recent discussions between the Swedish
Association of Local Authorities and the Federation of County
Councils have restated their joint responsibility for planning
together the medical care and other services required by individual
older people. Furthermore, the proposals developed by the two
federations are likely to be accepted by central government as an
alternative to new central regulations.

At the heart of the government’s modernisation agenda is the aim
of making services more responsive to the needs and circumstances
of users – designing services around users, not vice versa. The
prospect of increased pressures on older people to leave hospital
in order to avoid charges threatens the fundamental principles of
user choice, continuity and quality of care. It increases the
number of moves and the number of staff involved in the care of an
older person, both of which are likely to impact adversely on
physical recovery and increase mental confusion.

Above all, the proposal does not consider the circumstances,
wishes or needs of older people themselves.

Little is known about the desired or actual destinations of
older people deemed ready for hospital discharge, particularly if
accident or illness has called into question their capacity to
continue living independently. It is not clear how far delayed
discharges simply reflect older people making informed, but
difficult, choices about where and how to live, taking into account
the amount of help likely to be available from statutory services,
relatives and friends – and the changes those relatives and friends
may need to make to their own living and working arrangements.

Standard two of the Older People’s National Service Framework
requires that older people receive care that meets “their needs as
individuals”; the role of NHS and social services is to enable
older people to “make choices about their own care”. The
cross-charging proposal, and the resulting pressures to leave
hospital that are likely to accompany it, are not compatible with
the commitment to choice and user-centred care. At the very least,
proposals to expedite the discharge of older people from hospital
need to be based on clear evidence about the preferences and
decisions faced by older people in these circumstances, and the
barriers and difficulties they may experience in achieving those
choices.

Caroline Glendinning is professor of social policy,
National Primary Care Research and Development Centre, University
of Manchester. This article was written in a personal
capacity.

References

¹ Department of Health, Delivering the NHS Plan: Next
Steps on Investment, Next Steps on Reform, DoH, April 2002, from www.doh.gov.uk/deliveringthenhsplan/

² R Means, H Morbey, R Smith, From Community Care to
Market Care, The Policy Press, 2002

³ D Wilkin, S Gillam, A Coleman, The National Tracker
Survey of Primary Care Groups and Trusts: Modernising the NHS?,
National Primary Care Research and Development Centre (NPCRDC),
2000-1, from www.npcrdc.man.ac.uk

⁴ C Glendinning, et al, “A survey of access to
medical services in nursing and residential homes in England”,
British Journal of General Practice, (forthcoming)

⁵ Department of Health, National Service Framework
for Older People, DoH, 2001

⁶ B Hudson, et al, Evaluating the Section 31
Flexibilities in the 1999 Health Act: 2nd Interim Report, NPCRDC
and Nuffield Institute for Health, 2001