Delayed transfers of care: county councils struggle as government targets loom

Over the past year, the proportion of days where people’s discharge from hospital is delayed because of issues with social care packages has been increasing.

More than half of delayed transfers of care (DToC) are still attributable to the NHS – for example, where people are simply not referred for discharge quickly enough.

But recently released figures for June 2017 show that 38% of hold-ups that month were the responsibility of social care – a record proportion, as was the previous period’s 37.9% figure. The overall number of monthly ‘delayed days’ attributed to social care services has risen by 20%, to almost 68,000 nationally, in the last year alone – with a third of that total resulting from patients awaiting a home care package being set up for them.

The national pressures on the adult social care system are well documented, with stories of care providers handing back ‘unviable’ local authority contracts hitting national headlines during the spring.

Earlier this year, the government announced it would provide an extra £2bn to local authorities to try to ease the strain. Yet it has also set councils targets – criticised this week as ‘undeliverable’ in research carried out by the County Councils Network (CCN) – for reducing their delayed discharges, which if not met could lead to a cut in future funding allocations.

With those targets due to come into force in September, we asked local government representatives about the pressures they are facing, and what action they are taking to try to mitigate the situation.

National problem, local nuances

Broadly speaking, the problems faced by councils are similar across England. People are living longer with more complex conditions, making caring for them more challenging. At the same time local authority budgets are being drastically cut, exerting a corresponding squeeze on care contracts.

Margaret Willcox, president of the Association of Directors of Adult Social Services (ADASS), says the complexity and seriousness of conditions among people ready for discharge has changed, at a time when home care providers are finding it difficult to recruit and retain staff.

“This is similar in residential and nursing homes, especially in respect of nurses in the latter as there are significant shortages,” Willcox adds. “Many areas are struggling to sustain a viable workforce, especially where there is low unemployment and people can earn more in other options, such as retail.”

One such area is Hertfordshire, which has regularly been one of the councils with most delays attributed to social care.

“This is an affluent place with a high cost of living,” Jamie Sutterby, Hertfordshire council’s assistant director for integrated health and adult care services, tells Community Care. “We are lucky to have close to full employment, with not many economically inactive people.

“But that effectively puts [social care] in direct competition with lots of other sectors.

Whenever Aldi or Sainsbury’s open or close a shop, there’s an influence on people coming in and out of the care market. It’s difficult when you don’t have a lot of workforce capacity.”

Most of the other authorities with the highest numbers of delayed days are, like Hertfordshire, county councils. Large counties with more rural areas can face additional challenges, especially around home care, which is harder to deliver cost-effectively across a more dispersed population.

Such councils, according to research commissioned by the CCN, also have lower levels of social care funding than London and metropolitan boroughs and unitary authorities, while they are also experiencing accelerated demand for services.

“We have one of the fastest-growing populations in the country, yet one of the lowest-funded social care services in the UK per head of population,” says Anna Earnshaw, managing director of Northamptonshire Adult Social Services, the arms-length company that took over running social care services for the East Midlands county earlier this year.

“We have taken record numbers of people – 1,800 people last year – out of hospital to recover in their own home, but another 600 customers went on to need an assessment and some kind of care package.”

‘Undeliverable’ targets

The picture has been further complicated by the government’s last-minute decision in July to set targets, linked to councils’ 2018-19 social care funding allocations, around reducing DToC numbers.

Earlier this week the Independent reported that a letter, sent by the Department of Health to all councils responsible for delivering social care, had warned that NHS England would hold authorities “to account” for delivering targets before the winter, and “take action” if they fail to meet them.

Councils with the highest rates of delayed discharges relative to their populations face the steepest targets. Some, including Herefordshire, Suffolk, Northamptonshire, Cornwall and Cumbria, have been told they must reduce their DToC numbers by almost 70% by September.

According to the CCN, the policy could lead to “perverse behaviours” whereby councils with little realistic chance of hitting the targets may have no choice but to reduce care packages, for fear of a proportion of funding being taken back off them in 2018/19.

“There was a clear rationale to the government making £2bn available for social care – it was nationally accepted services were at breaking point,” says Colin Noble, the CCN’s health and social care spokesman. Noble, who is also the leader of Suffolk council, adds:

These targets are a backwards step. It is perverse that this money – designed to ease pressures – could be taken away if we cannot hit virtually undeliverable and arbitrary targets within a very short time period.”

Izzi Seccombe, chair of the Local Government Association’s community wellbeing board, says that the targets “could leave councils facing the absurd situation of failing to meet an unattainable target, losing their funding, and on top of this, potentially being fined by hospitals [due to an existing practice via which NHS trusts can charge local authorities for delaying discharges]”.

In Hertfordshire, Sutterby says, the council and local NHS have already suspended the latter practice on the grounds that taking money from cash-strapped public bodies is counterproductive. He says Hertfordshire’s 63% DToC reduction target will be “extremely challenging” to hit.

“Whether it’s realistic, in such a short time frame, remains to be seen,” he says. “We know that prolonged stays in hospital are never in a patient’s best interests; our priority is always to get people discharged as soon as they are well enough.”

Rushing people through the system is in any case unlikely to help the wider picture, points out Iain Chorlton, the chair of NHS Kernow, the clinical commissioning group for Cornwall and the Scilly Isles.

“It’s essential we make sure people have the care and support they need in place before they’re discharged, otherwise they risk being readmitted to hospital and taking beds that could go to other people who need them,” says Chorlton, speaking on behalf of Cornwall’s health and social care partnership.

The Department of Health has declined to say exactly what penalties will be imposed on councils that miss their delayed transfers of care targets for September.

“In November, depending on performance, a review of 2018/19 allocations of the social care funding provided at Spring Budget 2017 for areas that are poorly performing will take place,” a spokesperson says. “This funding will all remain with local government, to be used for adult social care.”

No short-term fix

Regardless of what happens with the 2018-19 funding allocations, none of those who spoke to Community Care feel there are any obvious or short-term solutions to the rising delays. Several stress the importance of taking a ‘whole system’ approach to the problem, given that delays relating to health rather than social care still account for the majority of delayed transfers of care.

“Obviously the demand at the front door of the hospital is the start of the pressure – managing the flow of people who are unplanned admissions requires efficient and timely systems,” says ADASS’s Willcox.

“Good discharge planning is essential, as is understanding the difference between health, which is an entitlement service, and social care, which has eligibility criteria, so that people are not referred to be assessed by social services when they do not have needs that are critical and substantial, causing further delay.”

She adds that recent months’ data seemed to at least show “some levelling off” of the rising trend in social care delays.

In Northamptonshire, Earnshaw says her organisation will put one-third of its Better Care Fund allocation of almost £12m into “staff and hospital-facing services in order to speed up discharges in a safe and supportive manner”. A further third, she says, will go towards home care services.

In Hertfordshire, meanwhile, Sutterby says that the council, CCG and local care sector are investing in training schemes to upskill care workers so they are better equipped to deal with the more complex cases they face.

“They can better handle crises in people’s homes without having to call an ambulance, avoiding inappropriate admissions,” he says. “That’s better for service users, but we also know that when people go into hospital and then come out they invariably need more care – so in everyone’s interest.”

But, Sutterby adds, such measures can only go so far.

“Nationally, market fragility is underpinning the DToC situation from a social care point of view,” he says. “If you don’t have the ability to generate capacity, it’s hard to think about how to move beyond the immediate situation. Simply, investment hasn’t kept pace with the demand being placed upon care.”

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