news analysis of delayed discharge fines

    The new system of fining councils for the delayed discharge of
    older people from hospital came into effect in shadow form last
    week, writes Natasha Salari.

    Hospitals must now notify social services departments of patients
    who may need social care on discharge. But no fines will be levied
    until the new year while hospitals and authorities adjust to the
    new paperwork.

    From 5 January, social services departments will be charged
    £100 a day (or £120 in London and the south east) if they
    fail to arrange care packages for patients assessed as needing one
    within two days of notification.

    When the system was first proposed in April 2002, it met immediate
    opposition from councils. But many have now found ways to reinvest
    fines in services and work in partnership with local health
    bodies.

    The government introduced the Community Care (Delayed Discharges)
    Act 2003 because it had found that, in about 60 per cent of cases
    of older people in hospital care, delays were due partly to social
    services departments “not fulfiling their responsibilities”.

    In early 2002, 6 per cent of acute beds were blocked at the cost of
    about £120,000 a bed every year.

    Life expectancy increases

    The idea is based on a Scandinavian model introduced 10 years
    ago. Since then, life expectancy for men and women in Sweden has
    increased by 2.3 and 1.5 per cent respectively. Older people now
    spend 30 per cent less time in hospital, and the number needing
    intensive supported housing has also reduced by a third – even
    though health spending in Sweden has fallen from 8.8 to 8.5 per
    cent of gross domestic product.

    But despite these impressive results, winning approval for the
    Community Care (Delayed Discharges) Act has not been easy. In
    February 2003, a survey of more than 1,700 readers by Community
    Care and Nursing Standard found that more than two-thirds of nurses
    and 88 per cent of social care staff opposed the fines.

    In March, there were wrangles in the House of Lords over plans to
    include Saturdays, Sundays and public holidays in the period that
    councils would have to arrange a care package, and over the
    inclusion of mental health patients in the policy.

    The outcome was that mental health patients will not be covered by
    the act and that Sundays and bank holidays – but not Saturdays –
    will be exempt from the period in which a care package must be
    arranged for the time being.

    More recently, a report by the House of Commons’ public accounts
    committee found that attempts to reduce delayed discharge levels
    could lead to older people with the most complex needs being left
    in hospital as social services departments focus on the cases that
    are easiest to resolve.

    Although the Department of Health says it has recently sent
    councils their share of the £50 million delayed discharges
    grant for the next six months to help cover fines and put
    preventive measures in place, none of the councils ‘Community Care’
    spoke to last week had received anything. The plan is for a further
    £100 million to be allocated to councils in each of the
    following two years.

    Profit can be made

    Last month, community care minister Stephen Ladyman said
    councils could even make a profit out of the delayed discharges
    system by paying less in fines than they would get in grant.

    But his comments have angered social services directors, who say
    they are pouring thousands of pounds out of their own budget into
    services for older people on top of their delayed discharge grants
    in order to avoid fines.

    Councils are also working with partners to make the fining system
    less punitive. Many are setting up pooled budgets with local
    primary care and acute hospital trusts which fines are paid into
    and then used to improve services such as intermediate care to
    prevent further fines.

    Suffolk council is one of those hoping to set up a pooled budget.
    Anthony Douglas, director of social care and health, believes it is
    wrong to see councils, care trusts and hospitals as “rivals and
    competitors”.

    “We have five primary care trusts and three acute hospitals so we
    have to reach agreements with each. It’s not a one-size-fits-all
    model,” he says.

    “We could get fines in January, but we are depending on the
    goodwill of the hospitals and we are trying to set up a pooled
    fund.

    “But the acute hospitals can see that the fines are money they can
    use for private hospitals or getting people out of hospital beds to
    free up their own space. We have to persuade them that we can
    deliver. I don’t think fines are helpful to agencies that need to
    collaborate. They don’t motivate people.”

    John Fisher, head of adult care services at Sunderland council, is
    confident that the department will be able to keep down the number
    of delayed discharges to four or five a week, but says there is “no
    room for profit” in the system.

    “We are still expecting to get some fines in January but we will
    pay these into an intermediate care pooled budget,” Fisher says.
    “The city hospital has agreed with us on this. That money could
    also be used for the winter pressure.”

    Newcastle council is not expecting to pay any fines for older
    people in local hospitals, but it does expect to face fines over
    some of its residents in hospitals in other parts of the country.
    The policy states that the council responsible for paying the fine
    is the one in which the patient normally lives.

    Newcastle’s health and social services directors are drawing up the
    details for a pooled budget, and they have also bought an extra 50
    care home places on the back of their delayed discharge grant
    allocation.

    Opposed on principle

    But Hampshire council is not considering setting up a pooled
    budget at this stage. It will receive the largest grant in England
    for 2003-4, at just over £1.2 million, but it remains opposed
    to the principle of fines.

    Although Hampshire has halved the number of delayed discharges in
    the past six months, it still expects some fines due to the
    turnover and volume of patients going in and out of hospital.

    It has allocated an extra £7 million to community-based
    initiatives, such as providing intensive support for patients on
    their return home from hospital, short-stay rehabilitation beds and
    services to support older people living at home.

    But the council’s executive member for social care Felicity
    Hindson, says: “We continue to oppose the underlying principle of
    fining, which flies in the face of already established
    partnership-working in the area, takes with one hand while giving
    with another, and continues to require enormous time, energy and
    resources to set up the new bureaucracy which does nothing to aid
    the patient.”

    The Witham, Braintree and Halstead Care Trust in Essex is more
    hopeful that pooling the delayed discharge money could help improve
    services for patients. Sally Sparrow, director of social care,
    says: “We have an agreement with the acute hospital trust that the
    money will be recycled for intermediate care. It wouldn’t be used
    to plug gaps or cover deficits. I think it’s the only thing to do.
    It’s just nonsense otherwise and you lose the money into the
    overall deficits.

    “It has to be used to reduce the delays otherwise it won’t
    help.”

    How councils will spend their delayed discharge
    grant:

    Suffolk: £656,000

    Putting social workers into GP practices

    Investing in services in people’s homes

    Intermediate care schemes

    Converting 50 residential beds in the council’s own homes into
    special needs beds

    Birmingham: £1.2m

    Additional intermediate care beds

    Interim care provision

    Increasing and improving rapid response care

    Creating respite and rehabilitation services

    Investing in hospital social work teams

    Newcastle: £330,000

    Buying 50 additional care home places

    Increasing and expanding domiciliary care capacity to create an
    intermediate care service with occupational health included

    Employing 27 extra home care workers

    Sunderland: £352,000

    Creating 60 intermediate care beds

    Investing in convalescence, support and therapeutic work

    Buying a nursing home

    Employing six new care managers for the assessment process

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