Wrong remedy?

New Labour has frequently emphasised its commitment to producing
joined-up solutions to joined-up problems. In the health and social
care field it has introduced several policies designed to promote
greater partnership working, such as intermediate care, pooled
budgets, the single assessment process and care trusts.

The latest joined-up problem to receive attention from central
government is that of delayed hospital discharges. According to the
House of Commons health committee,1 more than 7,000 people of all
ages were awaiting discharge from hospital in the second quarter of
2001-2, costing the NHS around £720m. In response, government
has announced its intention to legislate to charge social services
departments for hospital beds unnecessarily “blocked” by patients
who are medically fit for discharge – a system of “cross-charging”
or “reimbursement”. To prevent premature discharge, hospitals will
also incur financial penalties for emergency readmissions.

From the outset, cross-charging has generated considerable
hostility at a local level. However, the government is pressing
ahead, and the new system will be in place by April 2003.

Cross-charging was one of the issues debated in October at a
one-day seminar run by the University of Birmingham’s Health
Services Management Centre. Speakers came from central and local
government, the NHS and the voluntary sector, and many of the 65
delegates were senior managers from health and social care. To gain
an early insight into cross-charging, we asked delegates to
complete a questionnaire about the desirability and practicalities
of the new policy. This was voluntary, and 34 out of 65 people
agreed to take part.

Many delegates who responded were from a social services background
(see questionnaire respondents panel). This in itself may be
significant, as the centre is a university department that has
traditionally appealed more to an NHS audience. The large number of
social care delegates responding may suggest that delayed hospital
discharges are seen at ground level as a social care, rather than
as a health care, issue. Also, the small number of respondents from
the independent sector or from housing may indicate the need for
much greater work to involve these stakeholders in debates about
hospital discharge.

Of the 34 respondents, 76 per cent said that cross-charging would
not help to reduce the number of delayed discharges. In particular,
participants were concerned that cross-charging would not lead to
any extra funding for health and social care, but would simply
divert money away from other important priorities and create
pressures elsewhere in the system.

Some felt that cross-charging ran the risk of encouraging poor and
premature discharges, increased complaints from patients and more
emergency readmissions. Others saw cross-charging as unhelpful, at
a time when new initiatives such as intermediate care or the Single
Assessment Process were still in their infancy and had not had time
to prove whether they could help to resolve the problem.

Some also found it ironic that those social services departments
with insufficient resources to prioritise hospital discharge would
be fined, thereby causing even greater financial difficulties.
Others said that delayed discharges in their areas were caused by
factors over which they had little control – such as lack of
capacity in domiciliary and residential care, and longstanding
under-investment in primary care – and that they were already doing
all they could to respond to these issues without the need for
cross-charging.

When asked what impact cross-charging would have on existing
relationships between health and social care, all but one
respondent felt the result would be negative. Above all,
respondents emphasised that cross-charging was a short-term
response to a complex problem, and that fines would merely serve to
encourage a culture of mutual recrimination and blame.

For one participant, cross-charging threatened to “put partnership
working back by five years”, while other respondents stressed the
danger of “jealousy and open warfare” at a local level, of
financial tensions between partner agencies, and of problems
recruiting to hospital social work teams. In two cases,
participants suggested that a blame culture had already begun to
develop following the announcement of cross-charging, with hospital
staff threatening social care workers. One medical consultant was
reported as saying to a social worker: “You’ll have to get your
finger out once we’re fining you.”

There were also concerns about the practical difficulty of
implementing cross-charging. For many, the new policy would lead to
significant administrative costs and increased bureaucracy,
diverting money and time from front-line services. In particular,
respondents felt it would be problematic to develop agreed
definitions of delayed discharges, to monitor the new system, and
to develop arbitration mechanisms for occasions when disagreements
arose.

Several respondents also expressed concern over where the money
levied by charging would be spent, with some suggesting that fines
would simply help to compensate for overspends elsewhere in acute
care budgets. One person said that cross-charging would even
increase the number of delayed discharges, with disputes between
local agencies over who was responsible for particular patients and
when they were ready for discharge, causing even greater delays
than at present.

Altogether, 85 per cent of respondents described themselves as
opponents of cross-charging, with only two supporters and three
people who felt unsure. Instead, participants identified a range of
other policies and approaches they felt would be more helpful and
more sustainable. In particular, they asked for additional funding
to develop more preventive services in the community – to stop
people being admitted to hospital in the first place – and a
spectrum of services to facilitate swift discharge.

They also called for government action to tackle underlying issues
such as low pay for care workers, lack of capacity in care homes
and the need to educate the public at large about the role of acute
services. Above all, however, there was a real sense that there
were few easy answers to the problem of delayed hospital discharge,
and that agencies were already using all the powers at their
disposal to make progress in difficult circumstances. As a result,
many respondents felt that the “blame culture” associated with
cross-charging was unhelpful and wanted a more supportive approach
from government.

This study revealed considerable difficulties associated with the
government’s cross-charging policy. The sample was very small and
self-selected, and may not necessarily represent views in the wider
health and social care economy. Despite this, respondents were
drawn from all over the UK and the strength of feeling indicated in
their responses suggests an urgent need to reconsider
cross-charging before the system is introduced and it is too late.