Another fine mess…

The government’s plan to punish local authorities in
England for bed-blocking are under fire from health-care
professionals and local government alike. Drew Clode
examines the proposals.

From the tone of the Department of Health press release issued
late last month, you’d have thought all the NHS’s bed-blocking
problems were solved. “More older people able to leave hospital on
time,” it boasted, along with an impressive array of figures from
health minister Jacqui Smith.

Targets for reducing delayed discharge numbers set last month
are well on the way to being met. The £300m building capacity
money given to local authorities to achieve the reductions was
clearly and evidently being well spent.

And by March this year the 4,691 beds “blocked” by older people
of 75 years or more were nearly 20 per cent down from the 5,938
recorded in March 2002. There was a simultaneous fall in the length
of time people waited to be discharged. The number of people
waiting more than 28 days, for example, tumbled by 800 in the past
nine months.

No wonder Smith was able to boast that the fall “demonstrates
that the £300m investment has helped local authorities to
provide the care and services needed by older people when they are
discharged from hospital”. The target to reduce delays by a further
20 per cent by March next year seems easily attainable.

So, in the midst of all this success, it has to be wondered why
the government suddenly threw into the melting pot a policy of
penalising social services if they don’t do better. Is this policy
the pound of flesh demanded by the Treasury in return for extra
resources in the comprehensive spending review? An irrelevant
spanner in the works? Or a carefully thought through addendum to
the NHS Plan?

In Delivering the NHS Plan, the Department of Health says that
much of the recent progress on reducing delayed hospital discharge
“has been driven by top-down targeting of resources, central
intervention and close monitoring of progress”. It states: “In the
longer term, this approach is not sustainable in a climate where
the philosophy of devolution and earned autonomy is applied both in
local government services and in health services.”

Delivering the NHS Plan crucially refers to how impressed the
government is by the success of the system in Sweden and Denmark in
reducing delayed discharges from hospitals, adding: “We intend to
legislate therefore to introduce a similar system of
cross-charging.”

The document goes on: “The new social services cash announced in
the Budget includes resources to cover the cost of beds needlessly
blocked in hospitals through delayed discharges… Councils
will need to use these extra resources to expand care at home and
to ensure that all older people are able to leave hospital once
their treatment is completed and it is safe for them to do so. If
councils reduce the number of blocked beds, they will have freedom
to use these resources to invest in alternative social care
services. If they cannot meet the agreed time limit they will be
charged by the local hospital for the costs it incurs in keeping
older people in hospital unnecessarily.”

Generously, the document allows that there will be matching
incentive charges on NHS hospitals to make them responsible for the
costs of emergency hospital readmissions, so as to ensure patients
are not discharged prematurely.

But there are increasingly bitter arguments among politicians
about the extent to which the chancellor’s Budget statement
represented “new money”, as well as widespread fears that such
emphasis on adult services will take resources from already
over-pressed children’s services.

With an impasse on both these fronts, it has become increasingly
important to tease out some of the implications of the so-called
Scandinavian Model – and to remember that it has surfaced within
one of the most fiercely fought political contexts that health and
social services have seen for some time. There is by no means
unanimity over the plans, either at the Treasury or in the
Department of Health.

At the very least, implementation will demand answers to
questions including:

– How will the decisions about whether or not an elderly person
is fit for discharge be monitored and fully endorsed by all the
parties concerned?

– Who decides whether or not an emergency readmission was
prompted by premature discharge?

– Who will arbitrate over disputes – especially when a local
authority believes that leaving hospital has been held up by a
fault within the NHS’s own community or hospital services?

– Who will be responsible if the market itself isn’t able to
provide the number of beds required to effect a punctual discharge
from hospital?

– Will the system discourage, rather than encourage, closer
integration between health and social care services?

– Is the current mechanism for identifying where delays are
taking place, and who is responsible, sufficiently robust to
predicate a “fining” system onto it? Information about which
authority was responsible for which older person has always been a
little shaky. Some insiders now fear that changes in the way
figures are collected and verified, along with changes in NHS
boundaries, mean that the task of assembling accurate figures has
become considerably more, not less, difficult.

– Will it lead to undue pressures being brought to bear on
elderly people and run contrary to their statutory right to
choose?

– Similarly, will it encourage the view that elderly users of
services are simply bringers or losers of money, rather than whole
people deserving of professional care, concern and respect?

– Do hospitals have long enough to solve these issues, given
that the government intends this to come on stream by April next
year?

– Will the amount of time given to local authorities to arrange
discharge following a declaration that somebody is fit to leave
hospital be nationally determined or locally negotiated?

These and similar questions will have been discussed in the two
meetings held so far by the Department of Health’s Cross-Charging
Stakeholder Group. But it will surprise no one to know that hardly
anyone in the wider health and social care policy and management
world believes that the proposals are workable. Even if they were
workable in theory, they could only be implemented if there was
substantially more cash in the system than is currently the
case.

Help the Aged policy officer Gail Elkington, for example, notes
archly that “local authorities are not sitting on pots of money,
refusing to give people places in homes. They are rationing
services, sometime even waiting for people to die before
sanctioning another placement.”

In Sweden, responsibility was moved to local authorities 10
years ago, accompanied by huge amounts of money, she argues. The
agencies were given time – three years – to build up substantial
home care services, while they already controlled something like 90
per cent of the residential market.

This contrasts with the situation in the UK, where the public
provision of residential care has shrunk over the past 20 years,
leaving most places in the hands of the private sector, which is
clearly feeling the pinch.

According to Elkington, there’s not much doubt that penalties
will be introduced: the only hope is that before they are – she
would argue that next April is too soon – someone will have
discovered how it’s all going to work. Equally resigned to the fact
that some sort of system will eventually be introduced, Stuart
Marples of the Institute of Health Care Managers is sceptical about
many of the outcomes. For him, delayed discharge is a real problem
in many parts of the country, but he describes fines as “a very
heavy-handed way of ensuring it gets the attention it deserves. It
will lead to disputes, and it will require arbitration
procedures.”

There is a danger that bureaucracy will overtake the intent, he
says. A former acute trust chief executive, he is aware that
delayed discharge requires high-profile attention, and remains
convinced that next April is too soon to implement. He is clear
that “the practicalities of implementation are major stumbling
blocks.”

But the most emphatic rejection so far is from the Local
Government Association. Its social care and health committee
dismissed the proposals as threatening to:

– Create a perverse incentive for social and health care staff
to become “overly conscious with hastening transfers at the expense
of being professionally satisfied that the transfer is appropriate
and timely”.

– Skew the market so that social services concentrate too much
on the needs of older people awaiting transfer “at the expense of
those at home, awaiting preventive home care services”.

Perhaps lurking beneath these positions is a fear that in the
delicate local balances between council, primary care trust and
acute hospital trust, these proposals will give far too much clout
to the acute sector at the expense of the still fragile PCTs.

The LGA position is shared by the Association of Directors of
Social Services whose older persons committee chairperson Glenys
Jones argues that while no one challenges the need to eliminate
delays in discharge, the idea of “cherry picking a model from
Sweden when the Swedish context is not the same” should be treated
with caution. Most care provision in Sweden is publicly provided,
with local government responsible for community-based health care.
Nor is there the market volatility experienced in the UK.

Along with the LGA, directors also understand the need to
address issues across the whole system and not just the
acute/social care interface. Jones says: “We are very willing to
work with the Department of Health to develop a system. But we want
to see much more emphasis on incentivising the whole system to work
effectively and on realistic levels of investment – well beyond the
current building capacity grant.”

Sharing those anxieties is Age Concern England (it is
significant that the Welsh assembly has no plans to introduce fines
in Wales, and that Scotland, with free personal care, has gone down
a completely different avenue). According to policy worker Stephen
Lowe, the charity is against the proposal. He says: “It won’t
promote joint working; it will lead to increased pressure to
concentrate on older people in hospital, drawing attention away
from those at home who may be at more risk; it will increase
pressures to discharge prematurely. And it won’t work.”

On top of this, Lowe foresees an explosion in complaints via the
local authority complaints procedures, where older people or their
families believe that pressures to discharge have overridden
statutory directions on choice.

“Much of the problem with delayed discharge now is that, because
of resource pressures, local authorities are not offering services
to older people related to their assessed needs. It would be better
if local authorities were enabled to meet their current statutory
obligations rather than have new legislation placed on their
shoulders,” says Lowe.

If all these objections don’t provide pause for thought, there
is an implicit threat from the LGA that it might encourage councils
to sue local hospitals if acute beds are blocked because of
problems at the hospital. The absurdity of an acute hospital trust
threatening to fine the same local authority for failing to provide
a residential place or home care package for the same older person
should not be lost on Treasury and DoH policy makers.

Not only would these and similar disputes and potential farces
threaten the integration and collaboration built up between health
and social care over past years, but they could also have a
devastating effect on older people themselves.

As Marples puts it, financial penalties “will bring labelling to
people who ought not to be labelled; they will be labelled as
problems rather than older people who need support. And there’s a
danger that they will be seen only as bringers, or losers, of local
authority money.”

It might be that the logistical and practical problems can be
solved, and that the new systems can be imbued with an ethos that
doesn’t aggravate an ageism which, according to Age Concern,
already permeates many of the nooks and crannies of the NHS.

But nobody seems to be betting on whether April 2003 is too soon
for implementation – nor whether the planned outcomes will
inevitably be tainted by the perverse and complicated processes
that will have to be introduced in order to make the system
work.

Delivering the NHSPlan at www.doh.gov.uk/deliveringthenhsplan/

Drew Clode is press adviser at the Association of
Directors of Social Services but is writing here in a personal
capacity.