Numbers game straining relations between health and social services

Social services directors fear the delayed discharge reimbursement
system could paint a disproportionately poor picture of their
performance because of the way it has been set up.

Changes in the way information is produced and published by the
government and pressure on doctors to discharge patients from
hospital more quickly are contributing to difficulties bedding in
the system.

Problems with what information is compiled were highlighted last
week when East Sussex Council reacted angrily to comments made by
community care minister Stephen Ladyman that it would spend more
than £500,000 in fines in the first three months of the scheme
alone (news, page 7, 19 February). Ladyman blamed this on the
council failing to invest its government grant in building capacity
in the care homes sector.

East Sussex called the comments “grossly inaccurate”. Its own
figures suggest fines of £10,700 in January, with similar sums
predicted for February and March.

Elsewhere, there are signs that a month into the system – money
started changing hands on 5 January after a “shadow” period between
October and December 2003 – fines for social services departments
are generally low.

Although the Department of Health will not publish official figures
on levels of delayed discharge until March, it feeds weekly
information to social services directors about the number of
patients delayed.

Under the reimbursement system, social services will be fined
£100 a day (£120 in London and the South East) by the
hospital trust unless beds are found within three days of clients
being assessed as needing one.

To cushion the blow, the government handed out hundreds of
thousands of pounds in grants to every council to invest in
preventive services. Others have drawn up local agreements with
trusts so that any money generated from fines is ploughed back into
developing interim care.

Some estimate the average social services department will face
annual fines of £350,000, but councils contacted by Community
Care show a huge variation in levels of fines.

For example, Norfolk Council paid £5,200 in January, while
Bournemouth has fluctuated between £2,000 and £7,000 a
week. Hampshire looks set to be one of the hardest hit with fines
averaging about £6,000 a week.

But the concerns are likely to persist over what information is
collected and how that affects the money social services
departments are paying and their star rating. The DoH sticks by
Ladyman’s comments about East Sussex Council and says he based them
on its own preliminary figures “which still need to go through
checks and balances” showing delays rising in the area. “If this
continues it will spend more in fines than it received in grant.”

Although the DoH is adamant this relates to social services delays
only, the disparity with the council’s assessment is so vast that
the validity of the system is now in question.

Fines change hands only when the delay is caused by social
services. However, the weekly figures published by the DoH cover
all delays, including those caused by internal moves in the NHS.

A case in point is in the week beginning 9 February when 115 people
were delayed in Kent hospitals, according to the figure released by
the DoH to all other social services directors in the South East.
However, what it does not say is that only 28 per cent of these
were classed as social services delays.

The situation has prompted the Association of Directors of Social
Services to question how fair the figures are and whether they
accurately reflect bottlenecks in the system.

“We believe that 60 to 70 per cent of discharge delays are caused
by NHS-to-NHS transfers and people exercising choice,” says ADSS
president Andrew Couzens. “The whole system figures are taken into
account when assessing the social services star ratings. It is
unfair that we are being judged on that.”

Peter Gilroy, director of social services at Kent Council, says
many delays were due to health services’s own problems such as
getting duty doctors to discharge a patient. The percentage of
delays caused by social services were already reduced to their 2006
target levels, he says.

“There needs to be a degree of transparency about when it’s
particularly social care and when it’s particularly health care
trying to sort out its own issues. It isn’t good enough any longer
in publicity terms to turn around and say it’s all down to local
authorities.”

The DoH says its quarterly figures will cover reasons for delays,
but adds the whole-system figure is one of a range of indicators
for older people’s services councils will be assessed on. Primary
care trusts and hospitals will also be judged on this, it added.

Couzens has written to Ladyman explaining why he believes the
current way of publishing data and measuring performance is unfair.
Although it is unlikely to change the system overnight, he hopes
that new performance indicators due in November will “more
accurately reflect the cause of the delays”.

But Couzens believes the main issue is the levels of admission and
readmission of patients to hospital due to inappropriate discharge,
especially as “activity levels in the acute sector are going up by
10 to 20 per cent”.

Last year, the DoH stopped collecting and publishing data on
emergency readmissions of over-75s – a key group in delayed
discharge – because “patient organisations, clinicians and service
managers suggested it was ageist”, a DoH spokesperson says. Now,
figures cover all ages.

Liberal Democrat health spokesperson Paul Burstow believes that by
no longer publishing such data it is more difficult to ascertain
whether the system is working effectively.

“They used to publish this data and now that the new system is in
place they have stopped,” he says. “The focus has been about the
sooner a person is discharged the better but what I want to
reassure myself of is that the pressure from reducing the number of
delays doesn’t lead in turn to a revolving door scenario where
people come back in 28 days as an emergency.”

A DoH spokesperson says the age-specific data for readmissions do
not distinguish whether a person is readmitted for the same
condition for which they originally entered hospital.

Although the DoH approach has been to develop a system where health
and social services supposedly take joint responsibility for
delayed discharge, Jon Glasby, a researcher at the University of
Birmingham who has looked at the viability of fines, says there is
a danger it could harm relationships between the two.

“The jury is still out. The risk is that by having such a
high-profile policy and identifying the faults of social services
you run the risk of developing a simplistic blame culture.” 

Behind the figures

“There are a lot of misconceptions about where these delays are
caused,” says Pam Donnellan, social services director at
Bournemouth Council. “You need to look at all the reasons behind
the delays.”

She says a lack of nursing homes in the area and high private home
fees have made it difficult for the council to meet the demand for
beds, so many clients have been placed in homes in other
authorities. The council is raising nursing care rates by more than
10 per cent from April to address this.

But Bournemouth has already spent its grant on increasing its
hospital social work team and investing in community rehabilitation
teams so that fines come out of its budget. 

Price of progress

Hampshire social services has employed 19 extra social workers in
its acute hospitals enabling it to assess patients quickly, but it
is still averaging about £6,000 in fines a week.

However, compared with the rest of the system it has made great
leaps in performance.

January 2003:

Whole-system delays: 217

Social services responsible for: 130

January 2004:

Whole-system delays: 148

Social services responsible for: 28