‘Councils pushing patients through hospitals’ revolving doors’

Fining councils for delayed discharges has almost halved the extra
time that older people spend in hospital, but up to half of those
patients are back in hospital within three months, a report by the
Commission for Social Care Inspection revealed last week..

The research, which looked at the effects of delayed discharge
reimbursement, also suggests that some councils are turning to
residential care as a quick fix to avoid fines – at the expense of
intensive home care and rehabilitation services.

Researchers looked at 151 case files at seven local authorities,
and interviewed 70 older people about their experiences of
discharge in the first three months of the reimbursement system’s
operation.

Although the CSCI was unable to find an instance of the threat of
fines leading to a patient being discharged prematurely or into
unacceptable care, it says that something is clearly going wrong
for patients.

“Reviewers did see some examples of people with chronic or complex
needs being ping-ponged around the system,” says the report.

One older person recalled being talked into leaving their sheltered
housing for a nursing home while in hospital. “They said it was for
me to decide, but with the drugs I was on I was in no fit state to
do so.”

The controversial policy, introduced in October 2003, allows NHS
trusts to levy fines of £100 (£120 in London) for every
extra day a patient spends in hospital due to delays in organising
social care.

On one level, it has been successful. Figures for England show that
in the first six months of the policy, the number of extra hospital
days that patients spent waiting for social services assessments
fell by two-thirds.

But it has prompted concerns that decisions made in haste to avoid
fines are driving up hospital readmission rates. The Healthcare
Commission reported earlier this year that the proportion of people
over 75 who needed emergency readmission to hospital within 28 days
had shot up from 7.1 per cent to 8.2 per cent during the period
when delayed discharges had fallen the fastest.

At one council examined by the CSCI, more than half of older
patients were readmitted to hospital within three months of their
discharge. In the best-performing authority this figure was 8 per
cent.

In a few cases, older people’s fear of NHS continuing care costs
may be responsible, the report suggests. Some people with a clear
need refused all further help once the six-week no-charge period
had elapsed.

“Most of these people worried about the cost and preferred to
struggle on alone,” says the report. “It is quite possible this
could accelerate the need for hospital readmission.”

There is also evidence that some councils are using residential
care homes as a quick fix to avoid fines.

In one authority one in three older people went directly into
residential care after hospital discharge, compared with one in 25
in the authority that made least use of them. In three of the seven
authorities studied, admissions to residential and nursing homes
increased by more than the amount forecast.

Worryingly, older people are often pressurised to make
life-changing decisions about their future care while still in
hospital – a time when they are most vulnerable. In some councils
one in three people needing social care after discharge reported
this experience.

David Behan, the CSCI’s chief inspector, warns of the dangers of
rushing people into life-defining decisions from their hospital
bed.

“We found a number of cases where people were being pushed into
long-term residential care when they could have been supported to
live in their own homes.”

But equally, the report cites cases where the new notification
system, where doctors inform social services within three days of a
patient’s discharge, enabled social workers to challenge these
decisions if the person was not mobile or lacking a mental health
or continuing care assessment.

Is an over-reliance on institutional care linked to the rise in
revolving door admissions? The CSCI does not address this question,
but has promised to revisit the issue next year, perhaps giving a
clearer picture.

Frank Ursell, chief executive of the Registered Nursing Home
Association, says that a correlation is unlikely as studies show
that residential and nursing homes have the lowest rate of hospital
readmission.

Ursell believes the difficulties of getting funded NHS continuing
care are a more likely explanation. “A big problem with
readmissions is that a large number of people who should go into
nursing homes are going into care homes.”

But the report does suggest that councils are more likely to use
residential care where community-based services are lacking.
“Councils with delayed discharge problems also had underdeveloped
community provision,” it says. “There is some evidence that these
councils may be turning to institutional options as a quick
solution to discharge pressures.”

The CSCI noted more “fragility” in intensive home care services in
many authorities it investigated. In four councils there was a
decline in people receiving intensive home care services, while use
of non-residential intermediate care declined at three authorities.
The proportion of people receiving rehabilitation services ranged
from none in one authority to a third in another.

Incomplete assessments were a particular problem in one area. In
the worst-performing authority, 12 out of 20 delayed discharge days
in one month were attributed to incomplete assessments.

Equally significant were the difficulties people encountered in
accessing community health provision, sheltered housing and
transport.

Glenys Jones, Sunderland’s social services director and co-chair of
the Association of Directors of Social Services older people’s
committee, says high readmission rates are “extremely
worrying”.

“In some areas intermediate care has seemed like an alternative to
community rehabilitation. It is not. It should be placed alongside.
We need much greater focus on risk identification and proactive
engagement,” she says.

Although delayed discharge fines superficially appear to be a
roaring success, the jury is still out on them. Discharge rates
were improving before the system was introduced anyway. The fines
policy may have accelerated that improvement, but it may have come
at the expense of care in the community solutions, such as rapid
response and 24-hour crisis teams.

“There is some risk that the spotlight on speed of discharge may
take effort away from extending community capacity to prevent
hospital admissions in the very councils where this development is
most fragile,” the CSCI report notes. “Localities with less
well-developed community provision know this is where investment is
needed but are pulled towards securing quick fixes to support
discharge.”

Instead of letting health and social care get on with developing
intermediate care and rehabilitation, has the system just
introduced conflict and a drain on resources?

Much of this investment has had benefits, and there are plenty of
examples of good practice. Authorities which invested in additional
managers to co-ordinate discharges – Cornwall, for instance – have
had the best results for patients. Better discharge liaison between
health and social care has also improved communications between the
NHS and social services rather than pulling them apart.

But Ray Jones, Wiltshire’s social services director, disagrees.
“The concept of fining wasn’t what has got us there but a
combination of performance indicators and earmarked funding to
invest in the system. I wouldn’t want to have to have those fining
discussions again.”

Many senior figures are now hostile to extending the fine system to
mental health and intermediate care patients.

“We have made dramatic improvements in spite of fines and it has
cost us £250,000 to administer the process,” says David Munro,
Surrey executive member for social services. “We have done it by
ourselves, with health, and I don’t want a fining system ever
again.”