Fine and Dandy

Bob Hudson is honorary professor of partnership studies
at the Health Services Management Centre, University of Birmingham.
He has written and researched on partnership issues for the past 20
years, and is a specialist adviser to the House of Commons
education and skills select committee on issues relating to
partnership and integration.

Co-authors – Maureen Allan is director, and Alix Crawford is
manager, at the Integrated Care Network.

Health secretary John Reid has been enthusiastically proclaiming
the improved figures for delayed discharge. In May, he was able to
report a drop of 4,000 compared with the position in late 2001 –
the equivalent, he estimated, of adding eight more hospitals to the
NHS. He was keen to point out the link between this and the policy
on reimbursement that took effect earlier this year. But has this
really been the key to the improvements? More than 200 delegates
gathered at the most recent Integrated Care Network (ICN) national
event to explore the issue.

The Community Care (Delayed Discharges) Act 2003 introduced a
system of reimbursement by social services to the relevant NHS body
for discharge delays that are caused solely by the failure of the
social services authority to provide timely assessment and social
care services (“What’s the deal?”, Community Care, 22
January 2004).

Despite fierce initial opposition, delegates at this event believed
that reimbursement had created a largely positive effect, but the
reasons are important. The shift from viewing reimbursement as a
“policy bogeyman” to a “partnership catalyst” has been largely the
consequence of the approach to implementation from the centre, once
the thrust of initial strategy had been determined. This was
brought out by Melanie Henwood’s briefing paper to the seminar, and
contains wider messages for thinking about policy effectiveness and
implementation in other fields.

Five key messages for policy implementation were identified:

• Ensure implementation is phased. During the passage of the
  bill, the implementation schedule was relaxed to allow an
  additional nine months for preparation -Êa vital window that
  gave local authorities an opportunity to make alternative
  arrangements.
• Use carrots as well as sticks. Although much of the public
  focus has been on reimbursement as a “penalty” on local
  authorities, there has also been a substantial increase in funding
  for the development of community services – £300m under the
  cash for change scheme and £100m a year under the delayed
  discharge grant. A strategy of incentives and penalties is more
  likely to succeed than one solely rooted in sanctions.
• Support for local implementation. The creation of a
  reimbursement group within the change agent team at the Department
  of Healthhas helped to enhance the acceptability of reimbursement.
  The group’s aim has been to support rather than judge, and the
  production of a range of products (such as templates and protocols)
  was reinforced by a series of roadshows.
• A balanced view of the nature of the problem. Delayed discharge
  can have many causes, and one of the early difficulties was that
  the reimbursement strategy seemed to pin the entire blame on social
  care. But the act also placed obligations on the NHS to notify
  social services of any patients likely to need community care
  services and of their proposed discharge date – a recognition that
  poor communication has been a two-way affair in the past. Indeed,
  the responsibilities on the NHS have been increased further, with
  the obligation to make an assessment for funded NHS continuing care
  before triggering the reimbursement procedures.
• A focus on benefits for individuals rather than blame between
  agencies. The implementation guidance eschewed the language of
  blame, fines and penalties. The use of more measured language has
  been helpful in changing perceptions of the legislation – as one
  delegate put it, “reimbursement has been successful because it
  focuses on the individual”.
• Securing local commitment. The initial lack of detail was
  unhelpful in securing commitment.

It appears that a combination of these factors has resulted in
reimbursement becoming more a catalyst for change than a focus for
discontent. One of the regional seminar discussions accepted that a
successful approach to delayed discharge required greater
structuring of good informal relationships, and that reimbursement
had provided a sharper focus for action. Moreover, there appears to
be an acknowledgement that reimbursement has had an effect in other
areas by strengthening the links between kindred strategies, such
as discharge planning, single assessment process, NHS continuing
care and the development of new models of community-based
services.

However, there is no pretence that all is suddenly rosy in the
delayed transfer garden. The reimbursement strategy does not turn
poor relationships into good partnerships – one regional group at
the seminar reported on some acute trusts “who just want to collect
the fines”. Others reported that engaging clinicians in a teamwork
approach continues to be a problem in some places, with consultants
still making individual decisions regarding discharge outside any
agreed framework. Some GPs still too readily view hospital
admission as an easier option than maintaining their clinical
responsibility in the community. And there was a feeling that we
still do not understand why the number of delayed discharges rises
or falls, and so end up addressing the symptom rather than the
cause.

Notwithstanding these concerns, the thrust of discussion was not
about turning back the legislative clock, but about moving the
debate on to a deeper level. In part this is about the scope for
extending the reimbursement strategy beyond acute care into other
areas such as mental health and palliative care, otherwise the
danger arises of a two-tier system emerging. Support was also
evident for including community hospital beds in reimbursement
arrangements to avoid the danger of these being used
inappropriately as a safety valve for the acute sector.

However, the broader agenda is about extending the notion of “whole
systems” working beyond a focus on the acute hospital bed, and into
the wider services and networks that support vulnerable
individuals. The impetus to move in this direction will come from
the new focus on chronic disease management as evidenced by the
government’s interest in the approaches of US health companies
Evercare and Kaiser Permanente. Here the emphasis is as much on the
prevention of unnecessary admission into hospital or nursing home
as it is on effective discharge arrangements.

Once the needs of individuals to stay in their homes and
communities become the focal point of the intervention, the number
of partners widens well beyond health and social care to embrace
services such as housing, transport, welfare rights and community
safety, among others. This is at the heart of the model proposed at
the ICN seminar by Chris Paley – one in which older people are seen
as citizens rather than consumers of health and social care. She
sees this as inverting the “triangle of care” that has acute care
sitting at the apex and any community engagement strategy flapping
loosely in the policy breeze.

Echoing the changes now being proposed for children’s services,
Paley calls for:

• National well-being outcomes across agencies.
• Local older people outcomes.
• Cross-agency information systems.
• Joint health and well-being delivery plans.
• Local older people’s partnership boards.
• A multi-skilled workforce and whole systems workforce
  plan.
• Leadership programmes for local communities.

This is the right time to have such a dialogue. Opening the ICN
event, health minister Stephen Ladyman laid out his broad vision
for the future of adult social care. His three key principles of
person-centred, proactive and seamless services matched well with
the mood of delegates and he clearly wants to hear what people want
(see Care Consultation, panel, below). It is important that the
wider vision coming out of the conference feeds into government
thinking.

Abstract

This article reports on the proceedings and papers discussed at
an event on reimbursement and delayed discharges held under the
auspices of the Integrated Care Network. It reports that the ways
in which the legislation has been implemented have done much to
counterbalance earlier criticism, but that much remains to be done.
The challenge for the future is to take a much broader view of the
issue and feed into the rethink on the future of adult social
care.

Structure of event

The Integrated Care Network event started with a briefing paper
by Melanie Henwood, plenary sessions from health minister Stephen
Ladyman, and Chris Paley, representing the Association of Directors
of Social Services’ older people committee. There was a range of
project-based workshops and regional table discussions. Copies of
the briefing paper, all presentations, and notes of workshops and
discussions can be obtained from the ICN website at www.integratedcarenetwork.gov.uk

Further information   

Details of the work and products of the reimbursement group can
be found on the website of the Health and Social Care Change Agent
Team: www.changeagentteam.org.uk.

Care Consultation

Comments on the government’s consultation on adult care should
be e-mailed to the Social Care Institute for Excellence at vision@scie.org.uk.

Contact the author

The author can be contacted on bob@bobhudsonconsulting.com