Delayed reaction

The Community Care (Delayed Discharges) Act 2003 will introduce
fines for social services departments that fail to discharge
patients from hospital within set timescales. Described by the
government as a form of “reimbursement” for delayed hospital
discharges, the new system will begin in October 2003 (in shadow
form), with money due to change hands from January 2004.

Under the reimbursement policy, hospitals will have to notify
social services departments of patients who may require social care
on discharge. Social services will then have a specified period of
time to carry out a community care assessment and arrange a care
package. Where the prescribed timescales are exceeded due to delays
by the social services department, a fine of £100 a day will
be payable to the hospital (£120 in London and the South
East). To ease the implementation of reimbursement, the government
has since delayed the introduction of the policy (it was originally
intended to come into force in April 2003) and provided extra
resources for social services departments over the next three
years.

To date, this measure has attracted significant criticism from many
commentators, including the House of Commons health select
committee. In a previous article in Community Care, for example, a
series of senior health and social services managers attending a
national seminar on delayed discharges were asked about their
reactions to reimbursement.¹ Almost all described
themselves as “opponents” of the policy and were concerned that
fines would increase bureaucracy, damage local partnerships and be
difficult and expensive to implement and monitor. As one respondent
put it, reimbursement could “put partnership working back by five
years”, undermining the very relationships that local health and
social care agencies had been working so hard to develop.

In May 2003, the University of Birmingham’s Health Services
Management Centre ran a second seminar on delayed discharges and
took the opportunity to issue the same questionnaire to delegates.
Once again, those present tended to be senior health and social
services managers. Although the number of people choosing to
complete the questionnaire was much smaller than in 2002 (18 as
opposed to 34), responses demonstrated a significant shift in
opinion since the original research.

In October 2002, 76 per cent of participants felt that
reimbursement would not reduce delayed discharges at all, but would
merely recycle scarce public resources around the system without
improving patient care in the slightest.

By May, however, the mood had begun to change, with most
participants (55 per cent) suggesting that reimbursement was
already helping to reduce delays by focusing the mind of social
services departments on this issue and making it a priority. As one
respondent said: “Already we are experiencing change that I believe
would not be brought about without such proposals. These include a
clearer understanding of the data, additional investment in social
services and primary care services, and real effort in partnership
working to resolve joint issues.”

However, this interpretation was not universal, with a significant
minority of people still questioning the efficacy of reimbursement.
One said: “We’re all already committed to ensuring a timely
discharge and I resent it that the government thinks we’re not… I
have no problem with performance indicators…[or] nationally set
discharge targets, [but] I resent it that the government considers
the only way we’ll achieve this is through threats. It’s a populist
response to a complex problem.”

Although a greater number of people in May felt that reimbursement
might have a positive impact on delays than in October 2002, the
overwhelming number of people in both studies thought that
reimbursement would raise complex and expensive implementation
issues. Particularly significant was the need to agree joint
definitions of the phrase “medically fit for discharge”, set up
notification and financial systems, train front-line staff, monitor
the new system and arbitrate in cases of disagreement. As one
participant observed: “I will be managing the
implementationÉbut it already looks as though the money from
reimbursement will not cover the additional cost of collecting the
data.”

In addition to implementation difficulties, respondents in both
studies were adamant that reimbursement ran the risk of damaging
local relationships. For 72 per cent of participants in May, this
policy will undermine existing partnerships, encourage a blame
culture and prompt some NHS organisations to see delayed hospital
discharge solely as a social care issue. For one person, the
government’s approach was “gimmicky, bureaucratic and divisive”,
while another said reimbursement threatened to open a “can of
worms” that many local services had been working hard to keep
closed for many years. The potential dangers were perhaps best
illustrated by a respondent who described how local hospital staff
were already pointing to individual patients and commenting “you’ll
be charged £100 a day for that one”.

Interestingly, perhaps the biggest difference between October 2002
and May was in whether participants described themselves as
supporters or opponents of reimbursement. In 2002, 85 per cent
opposed this policy. By 2003, however, only 28 per cent saw
themselves as outright opponents of reimbursement, with 39 per cent
stating that they were undecided.

For many, this seemed a matter of weighing up the positives of
reimbursement (concentrating the mind on delayed discharge), with
the implementation problems and the threat to partnership working
described above. In particular, some people welcomed recent
government measures such as an extended lead-in time and additional
funding for social care to ease the transition to this new way of
working. However, the overall impression was very much that only
time would tell, with front-line services waiting to see whether
any of the positives promised by the government materialised, and
whether these outweighed the widely recognised limitations of the
policy.

In terms of future policies to tackle delayed discharge,
participants were keen to see more investment in community-based
alternatives to hospital and greater education for patients and for
professionals about the options available. In particular, many
people described the need for a much wider spectrum of services to
include support before hospital admission and after discharge,
health and social care and public and independent sector
provision.

Such a spectrum of services should include specialist mental health
input and a range of housing options to provide a needs-led
response as older people’s situations begin to change with the
onset of ill-health. Expanding intermediate care was also a
priority for many respondents, and several emphasised the value of
government bodies such as the Department of Health change agent
team spreading good practice and facilitating change at a local
level.

Overall, the results of this questionnaire offer a snapshot of the
many and varied views which seem to exist about reimbursement. The
outright hostility of our previous research appears to have given
way to a mood of “wait and see” and a cautious welcome for any
policy that focuses attention on delayed hospital discharges.

However, senior health and social services managers seem to be all
too aware of the potential limitations of reimbursement and
concerned about what the future may hold. Although recent measures
to ease the implementation of reimbursement may have been a step in
the right direction, the jury is still out.

Jon Glasby is a lecturer at the University of
Birmingham’s Health Services Management Centre

 References

1 J Glasby, “The wrong remedy”, Community Care, 5 December,
2002

Background Reading

J Glasby, Hospital discharge: integrating health and social
care, Radcliffe Medical Press, 2003