Extent of bed-blocking fines system surprises health and care sectors

You could almost hear the jaws dropping at the Local Government
Association last week following the arrival of the Department of
Health’s consultation paper on a system of reimbursements to tackle
delayed discharges.

It had been expecting further details on proposals for social
services to reimburse the NHS for the cost of caring for older
people waiting for social care, as announced by health secretary
Alan Milburn in April.

But the consultation proposals that arrived are far more
wide-ranging than originally suggested, with the scheme potentially
encompassing mental health patients and those leaving community
hospitals and intermediate care. It could also draw in housing
departments and other public sector services.

The paper also indicates the level of reimbursements and how
decisions will be made (see panel, facing page), but fails to
estimate the administrative cost of the system or how social
services departments would be compensated for early discharges.

The message is clear. The government is clearly fed up with
using the carrot approach, and disappointed that last year’s
£300m grant to tackle delayed discharges among people aged
over 75 resulted in only a 20 per cent reduction.

So now it is planning to take a big stick to those agencies it
blames for the continuing delays.

Social services departments are its first target, as they are
responsible for the majority of the 5,000 delayed discharges a day
(see below).

Delayed discharges of older people, who account for about 90 per
cent of cases, are the initial priority. But the consultation says
there is an “expectation” that the reimbursements will be
extended.

Housing departments are likely to be the next agencies to be
targeted, with primary care trusts and community mental health
trusts to follow in the future.

The consultation admits: “The legislation will be framed in such
a way that regulations can be used to gradually extend the
reimbursement scheme through the whole system where it would be
appropriate and beneficial to do so.”

Gemma Smith, policy officer with the mental health charity Mind,
says: “Although we are concerned about taking funds away from
social services departments that are already cash-strapped, it may
be the only way to ensure that they provide sufficient resources
for mental health.”

However, discharging patients too early or into inappropriate
settings with insufficient care will lead to them being readmitted
to hospital with more severe problems.

There is concern that, under the proposed scheme, social workers
will feel pressured to give people inappropriate care packages
simply to avoid the reimbursements.

The consultation emphasises the importance of joint working, but
the system of fines being introduced into partnerships risks
damaging the goodwill being developed between sectors.

David Fotheringham, head of policy for the Chartered Institute
of Housing, says: “This kind of scheme could be good to encourage
joint working but the trouble is if it’s done in too formulaic a
way it could lead to inappropriate decisions.

“If a property requires some sort of adaptation there will be a
process of undertaking the work which can be quite lengthy and
resources will not necessarily always be there at that time.

“Instead, people could be put into properties which are not
suitable for them or in situations which are not appropriate.”

Social workers have similar concerns. In addition they are
experiencing a crisis in the private care home sector, with many
establishments closing because of financial losses or because they
cannot meet the government’s new care standards.

Milburn said last month that he expected a third of the
additional £6.3bn of funding for social services between
2003-4 and 2005-6 to be allocated to older people’s services. Some
of this is to be spent on raising the fees paid to care homes.

His recent hurried announcement that the proposed mandatory
environmental standards for care homes would be downgraded to good
practice guidelines is another attempt to halt the tide of
closures.

But head of social affairs, health and housing at the LGA John
Ransford is still far from convinced: “We are opposed to these
reimbursement proposals on principle.

“This is going to undermine partnership working because there
will be perverse incentives for people to make decisions simply to
avoid a charge.”

The LGA is also alarmed that any fines paid by local authorities
will not go into a general NHS pot but to the specific acute trust
that has issued the bill. It is concerned that this provides acute
trusts with a clear incentive to discharge patients too early.

The LGA is supposed to be warned of such announcements. The
Central Local Partnership, created in 1997 to develop closer links
between the government and the LGA, met two weeks before the
consultation was announced and discussed the reimbursement
proposals. Yet there was no mention of widening the scheme.

“We are greatly concerned about the lack of consultation from
the Department of Health,” Ransford explains. “We were very
surprised to receive this document. There is a great deal in there
that has not been discussed with us.”

The timing of the paper has also raised eyebrows, with the House
of Commons already in recess and most local authorities’ political
functions largely on hold.

Council staff will need to reschedule their holidays this year
if they are to have their say in this major change.

– Implementing Reimbursement Around Discharge from Hospital from

www.doh.gov.uk/jointunit/delayeddischarge/consult.htm

Why discharges from acute and geriatric beds are
delayed

– 25 per cent waiting for a care home place.

– 24.5 per cent awaiting completion of assessment of future care
needs and identification of appropriate care setting.

– 12 per cent waiting for other types of NHS care.

– 11 per cent waiting for care home of their choice.

– 9 per cent waiting for social services funding for residential
or care home, or for social services and health to agree funding
for future care.

– 8 per cent waiting for arrangements for care, equipment or
adaptations to allow them to return to their own home.

– 10 per cent other reasons.

How reimbursement will work

• Hospitals must notify social services and primary care trusts 
  immediately it is clear that a patient will require continuing care
  after discharge.
• The acute trust, primary care trust and social services
  department must be involved in developing the discharge plan under
  clear joint protocols.
• Delay is counted from the end of three days allocated to
  draw-up the discharge plan or from the day after the decision that
  the patient is ready for transfer, whichever is the later.
• Reimbursements of £120 a day in London and the South East
  and £100 elsewhere will be paid by social services departments
  for every day of a delayed discharge.
• Where a pooled budget is set up between health and social
  services partners, the partnership agreement must state whether the
  social services’ contribution reflects the cost of
  reimbursements.
• Disputes between agencies will be resolved by an independent
  panel appointed by the strategic health authority.
• During disputes, social services will be required to provide
  on-going care or pay a reimbursement. If it is agreed that the
  discharge date was too early, a repayment for the reimbursements
  will be made.
• Guidance and good practice on the discharge process will be
  issued in an attempt to ensure that discharge decisions are well
  made and not subject to perverse incentives.
• Acute trusts will receive the reimbursements, as they will not
  receive funding from primary care trusts for patients subject to
  delayed discharge.
• Reforms proposed under the NHS plan will remove
  hospitals’ incentives to discharge patients too early, as if
  they are readmitted within a defined number of days they will not
  be compensated for the extra costs. There is no mention of
  reimbursing social services.