What’s the deal?

Laurel and Hardy could teach health and social care a thing or
two about partnerships. How to stick together through thick and
thin, for example, even when one partner is blaming the other for
getting them both into hot water.

By its very nature, a blame culture automatically threatens a
partnership. So NHS bodies’ new power to impose heavy fines on
social services for their part in delayed hospital discharges could
undermine the progress already made in establishing sound
relationships between the two.

Although it was refreshing to see a radical new government policy
given a three-month shadow period to allow authorities to become
familiar with new structures, many are still worried about the
scheme. Establishing a system that operates on a basis of blame and
punishment, rather than on trusting, co-operative relationships,
hardly seems constructive.

The House of Commons health committee was thinking along the same
lines when it published its report on the policy in 2002. This
suggested the reimbursement scheme might lead to “an unproductive
culture of buckpassing and mutual blame between health and social
care”.

Jonathan Ellis is head of health and social care at Help the Aged.
He believes that, rather than creating a system that may squeeze
the problem somewhere else, a more constructive way forward is
through “better partnerships, better joint working arrangements,
and local councils and the NHS understanding each other more rather
than trying to apportion blame”.

He points out that, even without the reimbursement scheme in place,
there has been some quite dramatic progress in reducing delayed
discharges in the last few years. He questions whether the new
scheme will add anything except new barriers to partnership. “Our
principle concern is that at first glance it looks like it’s
working for the benefit of patients but it’s unclear whether this
will guarantee the right care in the right place at the right time,
or whether they will be passed around additional bits of the
system.”

Without a formal evaluation, it’s hard to know what the lessons of
the shadow period are. Ellis hopes it has encouraged more creative
ways of thinking about capacity, whether it be community health
provision or local authorities developing that capacity in a way
that’s responsive to the patients’ needs, “rather than just
creating a new warehouse to put them in while they wait”.

Whether the reimbursement scheme will actually improve care for
older people remains to be seen, amid widespread concern that it
could develop into a demarcation dispute between health and social
care. Whatever the outcome, there’s no disputing that delayed
discharge has been a problem since the beginning of the NHS. It’s
bad for the hospitals because it’s a waste of scarce public
resources. And it’s bad for older people because life in an
institution can mean they lose confidence, strength and
independence.

Over the years, countless pieces of research have shown recurring
factors that contribute to bed-blocking. These include:

• Poor communication between hospitals and the community.
• Lack of assessment and proper planning of discharges.
• Inadequate notice of discharge to older people.
• Inadequate consultation with older people and their carers in
  the planning process.
• Over reliance on family carers and an assumption that the carer
  will carry on.

These have all been historically problematic, says Jon Glasby,
head of health and social care partnerships at the University of
Birmingham’s health services management centre. “I don’t think
reimbursement does anything to help them.”

And we may end up with older people being discharged too quickly in
a bid by social services to evade fines. For his part, Glasby would
argue that premature or poorly co-ordinated discharges are just as
significant problems as delayed discharges.

It is likely that more older people will move to an interim
placement in a nursing or residential home until there is a place
available in the home they wish to go to. But the more moves an
older person makes, the more risk there is to their health.

Many of those who will return home after a stay in hospital will
need rehabilitation programmes at intermediate care services. But
there is concern that, because intermediate care beds don’t attract
fines, they could become “dumping grounds” for hospitals, says
Glasby.

“Older people should only be in intermediate care for up to six
weeks. But there is anecdotal evidence that some hospitals are
making blanket placements to intermediate care and older people
could just languish there. The danger is that we are shifting the
problem of delayed discharges from hospitals into a different
setting.”

Given these issues, it is not surprising that some health and
social care authorities are making informal agreements in their
areas to avoid fines and protect their joint-working relationships.
According to Norman Taylor, adult services manager at Sunderland
social services department, both sides decided before the shadow
period that there would be no exchange of money. Instead, any cash
available from the reimbursement policy would be reinvested in
Sunderland’s services.

“We were all anxious that the reimbursement policy could be
divisive where so much effort had gone into partnerships working,”
says Taylor. “So it wasn’t welcomed. Maybe in areas where there is
a significant problem it would be.”

Sunderland hasn’t had a major problem with delayed discharges for a
considerable time, says Taylor, because of partnership working with
health and a £2m investment in intermediate care services from
both sides. The investment has also meant that a specialist social
work team works with the discharge nurses to see who would benefit
from intermediate care. They work with clients through that care
and then organise their care package to return home. Patients who
may have initially wanted to go into care homes from hospital now
feel able to go home because of the quality of intermediate care
available, says Taylor.

During the shadow period, Sunderland social services would have
been liable for about 130 days. In the first week of January, when
the scheme went live, there were no reimbursable days.

There’s no denying that the delayed discharge debate has focused
people’s minds on the issue. The prospect of hefty fines has also
given social services directors some valuable ammunition when
asking elected members for more money to invest in alternative
services for older people.

Lynn Waight, strategic service manager at Hampshire social services
department, agrees that the Community Care (Delayed Discharges) Act
2003 acted as a catalyst for focusing attention on discharge
processes. The shadow period showed that “our initial leaning
towards working very closely with health partners has been
profitable, but we were doing that anyway”.

The social services department has invested in interim placements,
some intermediate care, rapid response teams and 19 care managers
to help the discharge process work more effectively. The results
speak for themselves. As a snapshot figure, this time last year, of
217 delayed discharge cases in acute beds for health and social
care, 130 were down to social care. A year on, this figure is just
35 from a “whole systems delay” of 140. And not all of these will
be reimbursable cases, as it’s a moving figure.

“We are pleased that we have achieved a huge reduction in delays.
If we were pressed for one thing that has come out of the shadow
system, it is that with so much focus on processes we must continue
to keep person-centred care at the forefront.”

Hampshire has not signed up to the idea of an informal agreement
with health to avoid fines. “Our aim is no fines anyway,” says
Waight. “If our figures continue the way they are we will meet our
objective.”

Like many, the county has been hit hard by the loss of nursing home
capacity. Up to 60 per cent of the delays have been due to patients
waiting for nursing home placements.

To address this, a nursing home project is coming on line soon in
conjunction with the local primary care trusts and the Department
of Health. It will provide nursing home beds through new builds and
by altering current sites.

Waight is concerned that the concentration on discharge processes
will take the focus away from other areas that need attention,
including community services and prevention work. Delayed
discharges are a whole systems issue, she adds. “We have to look at
all delayed discharges if we are going to crack it, as well as
social care discharges.

“The reimbursement scheme focuses on one point in the process and
that’s not necessarily healthy. A bottleneck further down the line
might give us huge problems.”

Glasby agrees: “Hospital discharge is a complicated whole systems
problem and requires a whole systems response. This is too
simplistic. If we haven’t cracked it since 1948 is this going to
crack it now?”

If it does not, social services and health might be left scratching
their heads and blaming each other in the manner of Laurel and
Hardy, for “another fine mess you’ve got me into”.

Beds unblocked

The overall number of delayed discharges fell from 5,700 in July
2002 to just over 4,000 in May 2003. This beat the March 2003
target of 4,200. The number of over-75s delayed in hospital halved
from 7,000 in March 1997 to 3,500 in December 2002.

It came from the north

• The idea is based on a Swedish model introduced 10 years ago
  where older people now spend 30 per cent less time in hospital.
  However, some question whether the comparison is fair because
  political responsibility for Swedish health care rests with local
  government. 
• The reimbursement scheme was first proposed in England and
  Wales in April 2002 and met immediate opposition from councils. The
  scheme was introduced under the Community Care (Delayed Discharges)
  Act which received royal assent in April 2003. 
• In May 2003, former health minister Jacqui Smith announced the
  details of how the £50m delayed discharge fund would be spent.
  Each local authority was allocated a share of the fund based on
  expected need. It was to be used to cover fines and put preventive
  measures in place. A further £100m will be allocated to
  councils in each of the following two years. 
• From January 2004, social services will be fined £100 a
  day (£120 in London and south east England) for failing to
  have a care package available within two days of notification from
  a hospital that a client is to be discharged.