Time to put the chisel away

NHS managers say it is just a case of balancing the books and helping managers to adjust to reform.

They argue that the deficits experienced by some health trusts in both primary and secondary care represent only a small percentage of the overall budget and are not a serious problem.

Health secretary Patricia Hewitt announced earlier this month that the latest unaudited figure for the overall deficit was 512m, up from 221m a year earlier, but down from 620m six months ago.

She says only one in 10 NHS organisations are contributing to two-thirds of the overspend, and that out of 65 trusts in financial trouble 23 will balance their books by the end of this financial year.

But the Royal College of Nursing claims that 15,000 jobs have now been lost in the NHS as a result of the deficits. In evidence on NHS deficits submitted to the House of Commons health select committee earlier this month, the RCN said it was also concerned that a dwindling number of district nurses could undermine the government’s drive for more home-based care.

Many questions are being asked about what has happened to the record amount of money invested in the NHS by the Labour government. But how is it relevant to social care? At first glance it may not be obvious how the financial malaise in the NHS will affect social services.

Ray Jones resigned from his role as director of adult and community services at Wiltshire Council in April because he did not want to make cuts to services he had spent 14 years helping to build. He blamed the NHS for passing on costs to his department. The council had built a close relationship with primary care trusts, jointly commissioning services, but had to try and absorb cuts through a “cost shunt” when the health side of the partnership withdrew 3m.

The cuts, announced just hours before the end of the financial year, hit respite care and day care for disabled children and adults, and people with learning difficulties. Residential and nursing care places were also affected.
It is clear from the evidence so far that Wiltshire is the most severe example of health deficits having a serious knock-on effect on social care. Elsewhere, the picture appears to be patchy, reflecting the fact that only a minority of health trusts are in financial trouble.

Anne Williams, who is co-chair of the Association of Directors of Social Services resources committee, says: “There is no consistent picture. It would be wrong to say the NHS is withdrawing money all over the country. In most areas, PCTs and social care services are working well together.”

She believes there may be difficulties with early discharges from hospitals, where the health service is looking at ways of cutting costs. She also believes health services may be tightening the criteria used to determine whether people qualify for continuing care services.

Hospitals may be using the system of fines for delayed discharges to boost their income, warns Penny Banks, senior fellow leading on social care at the King’s Fund.

She says there are “problems with the NHS having to cost shunt” and using the system to levy more fines while some local authorities are being fined for not being ready to deal with discharges.

In Wiltshire, a community hospital which was picked out in the white paper Our Health, Our Care, Our Say as a model of good practice on delayed discharge is to close. Trowbridge Hospital has, said the white paper, “successfully developed a project to improve patient discharge planning and promote independence”.

By setting a discharge date within 24 hours of a patient’s admission, and by putting the emphasis on more social work time on the wards, Trowbridge Hospital achieved shorter patient stays and lower readmission rates. This also meant a significant reduction in local authority funded placements, the white paper claimed.

But West Wiltshire and Kennet and North Wiltshire Primary Care Trusts have had to find savings after a 20m overspend in the area last year. They have come up with three options for reshaping local services to reflect the government’s emphasis on more GP and home-based care, and save money. Each option includes the closure of Trowbridge Hospital, which is too costly to maintain, and its replacement with a primary care centre.

Banks is particularly worried that older people may be “shunted around” because of the uncertainties about whether the intermediate services are in place to support them when they are discharged.

Services for older people are almost considered “a luxury” by health authorities, according to Help The Aged’s policy manager Jonathan Ellis.

He says older people tend to be a low priority, and so services for them are often the first to be cut. “With this sort of belt tightening the situation can only get worse rather than better.” He uses the example of foot care services, which are crucial to helping older people remain mobile and independent, and are being cut back.

Another area under particular strain is mental health. Charity Rethink has already estimated that 30m in cuts have been made in up to 30 areas. Rethink’s director of public affairs Paul Corry says it is difficult to work out whether these cuts are due to cash restrictions in social care or in health.

But there is evidence that PCTs are moving cash earmarked for mental health services to deal with shortages elsewhere. Conservative health spokesperson Andrew Lansley recently told MPs in the House of Commons that there had been “a lot of cuts in mental health services”.

The ADSS has said that Southampton is an area where the financial pressures have become serious. Dr John Beer, executive director of health and social care at Southampton Council, says that the authority has a “robust but friendly” working relationship with the local PCT. “We have a well-developed partnership with the NHS in Southampton, despite the horrendous pressure they are under.” But he warns that the prospect of scaling down services was “getting close”.

A serious overspend at strategic health authority level was the catalyst for the problems, he says. This led to increased pressure on the social services budget for nursing home and domiciliary care, as 200 beds were closed at the city’s general hospital, including some for older people. Despite this the city has managed to avoid delayed discharge problems so far. However, public health initiatives set up under the government’s health and well-being agenda are under threat, he adds.

For Jeni Bremner, programme director at the Local Government Association, the full extent of the impact of the health cuts will not be evident for some time.

She warns that the fall-out from cutbacks in the acute health sector will hit social care services over time as patients are discharged sooner from hospital. There is a particular need for well thought-out decision-making by hospitals at this time, she says, with consideration given to the long-term effects of their actions.

Patricia Hewitt has staked her job on the NHS’s ability to rein in the expenditure and achieve a sound balance sheet. The success of the government’s “patient-led” reforms is also an important part of prime minister Tony Blair’s legacy. Both recognise that the change agenda will not succeed without financial stability.

For many social services users the consequences of failure could be very serious indeed. They could be left without many of the services they require to achieve any kind of quality of life, the sort of services that are often not given credit for helping people but quietly make a crucial difference to their lives.

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