Published: 30/01/2003, Volume II3, No. 5840 Page 24 25
Results of a simulation suggest the government's plans for cross-charging will cause more problems than they will solve.
Bob Hudson and Gill Herbert report
Keeping people in hospital longer than necessary is not acceptable, and all agencies - central and local - want to find solutions; the question is how?
The Department of Health seems bent on fining local authorities up to£120 a day for delayed discharges following the passage of the Community Care Bill, which should take effect from April. But what will the impact of this measure be? A simulation exercise held in November in north Yorkshire sought some answers.
1Some 80 representatives drawn from acute hospitals, primary care trusts, local authorities, district councils, private residential and nursing homes, Better Government for Older People (the agency aimed at improving public services for older people) and the DoH took part in the one-day event, facilitated by the Nuffield institute for health in November.
Small groups, representative of all the organisations that would be required to implement the new policy, participated in activities designed to explore opportunities and pitfalls. Brief case studies of 16 people delayed in hospital were used as a focus for dialogue, and groups explored the practical consequences of four different local authority responses to these cases (see box below). Each group was asked to act as an advisor to one of the key parties - local authority, acute trust, PCT and patient/carer groups.
Groups gave feedback to all participants and then returned to a further exercise to explore potential solutions.
Three key themes emerged:
confusion over definitions;
the creation of a blame culture;
poor and inequitable outcomes for service users.
The potential for argument over what actually constitutes a delayed discharge was readily identified. The official definition - only in existence since April 2001 - is that 'a delayed transfer occurs when a patient is ready for transfer from a general and acute hospital but is still occupying such a bed'.
2It is a formula which raises more questions than it answers, and the third of the four scenarios involves an explicit challenge by the local authority to a narrow clinical interpretation. Also, as the Commons health select committee has pointed out, this definition has other limitations: it ignores beds blocked in community hospitals, it unreasonably includes delays of less than eight days and it focuses unduly on people over 75.
Critics of discharge penalties have consistently argued that they will lead to disharmony and attempts by the parties to shift the blame onto each other. Such misgivings were borne out by the simulation exercise. Groups 'advising' the main parties often suggested taking up robust positions to maximise self interest.
The acute trust was advised to put pressure on the local authority to both maximise income and hasten the creation of care trust status, which was seen as likely to be advantageous to acute sector interests. The local authority, in turn, was advised to respond vigorously by placing pressure on the other parties:
Telling the acute trust that it was not willing to assess need for long-term care within an acute setting and then building in delay to the assessment process.
Putting pressure on the PCT to focus attention on why acute admissions were happening in the first place.
Arguing that district councils needed to do more to provide different types of accommodation.
Blaming the government for lack of resources when fines had been paid and community resources depleted.
Some voices counselled against short-termism on the part of the acute sector, arguing that fine maximisation was a 'suicide scenario' in which beds would continue to be filled, social services would have paid the fines, local authorities would refuse to accept responsibility for those with health needs and debates about NHS and social service responsibilities for continuing care would resurface.
But overall, acute colleagues seemed willing to sit tight and see what happened, rather than seek sustainable outcomes in the long term. Not only does this prevent the development of sound partnerships, but it actually corrodes previously good relationships. The main growth area will be procedures for complaint and disputation.
The exercise suggested that neither individual organisations nor service users would benefit from the proposals for charging. Delayed discharges are partly due to processes and inefficiencies within the acute sector itself, but the proposed fines were seen as disincentives to hospitals reviewing their practice. The policy was also seen as a threat to investment in community support services.
Participants believed charging was more likely to lead to routine use of private nursing home beds, not suited to rehabilitation, simply to get patients out of hospital and avoid a fine.
If fines were not used to invest in alternative community services, gains for acute hospitals extending capacity would be short lived, with beds filling up once again and the local authority facing a catastrophic financial deficit. In such circumstances, those already in the community were likely to be ignored and admission to hospital might become the only passport to some sort of postacute support - a recipe for a huge increase in delayed discharges.
It emerged that users and carers would become major casualties of turf wars and could do little other than become hostile and litigious.
Participants 'advising' the user/carer groups suggested the following measures: pressuring councillors, MPs and the health secretary; starting formal complaints; contacting the ombudsman; briefing the media; demanding the fines money and using this as direct payments; seeking legal advice.
This is hardly the stuff of modernised health and social care services.
What could be done to avoid this nightmare scenario? Participants proposed an effective middleman role for PCTs whereby they would use their commissioning power to redirect resources into community services and act as honest brokers between acute hospitals and local authorities. PCTs' potential for promoting effective use of acute hospitals and ensuring adequate intermediate and community services was seen as key to a possible solution. But the role envisaged for them is challenging for newer organisations.
Participants also proposed more emphasis on maintaining people at home, with services that would prevent health problems and support independent living.
Different views on appropriate levels of risk were a big barrier to change, with social services and community health services staff more comfortable about dealing with high levels of risk than was the case with GPs and consultants. But it was recognised that developing community services would be costly.
Participants also favoured more partnership working and whole-systems approaches.
They supported judicious use of pooled NHS/local government budgets to ensure that fines were used in a shared way. A comprehensive approach, involving the acute and community sector, was seen as more likely to succeed.
This would be more difficult than introducing fines, but the dividend would be immense. Such a model could reduce demand for beds by supporting people in the community, smoothing discharge and co-ordinating care at operational and strategic levels.
The levels of trust and mutual respect required to put this into practice will not be easily achieved - the health select committee notes the contrast between widespread support for a whole-systems approach and its absence on the ground - but it is evident that it will never flourish in an environment characterised by fines and penalties.
It is difficult to know what to make of the government's determination to push through this legislation.The proposal is universally unpopular - more than three-quarters of the 268 organisations and agencies responding to the September consultation document warned that it would damage relationships, and the health select committee investigation into delayed discharge condemned it as 'over zealous'.
Is it a case ofmisplaced zeal or one of cunning Machiavellianism? Does the health secretary really believe this policy will work? Or is the real purpose to drive forward whole-systems solutions?
Whichever way, the evidence from this exercise is that the potential for disaster is high and may wipe out the hard won partnership gains of recent years.
Bed bugs: local authority responses to delayed discharges nNo additional placements/packages are made and fines are fully paid.
Additional placements are found for some patients and fines are paid for the rest.
The local authority refuses to accept anyone as fit for discharge if they are unable to return to the domicile from which they were admitted, arguing they need either intermediate care or continuing healthcare.
Additional placements/packages are found for all patients fit for discharge and are fully funded by the local authority.
A simulation exercise on charging for delayed discharges revealed significant potential for conflict between organisations, and no benefit for service users.
Participants thought the charging system would work against the development of community services.
They favoured joint NHS/local authority approaches to the development of an effective system for preventing delayed discharges.
1Herbert G, Breen S.
Introducing reimbursement for delayed discharge: a simulation and search for ways forward, 2002.
www. nuffield. leeds. ac. uk 2Health Select Committee.
Third report. Delayed discharge.HC 617-1. The Stationery Office, 2002.
Bob Hudson is principal research fellow, and Gill Herbert is head of consultancy, Nuffield institute for health, Leeds University.