News: The scale of the problem in 'hot spot' Birmingham, where about 350 people are waiting for discharge from hospital, has hit the headlines repeatedly.

Chief inspector of social services Denise Platt says: 'Some of that was [due to] some of the decisions the council took without talking to health. They were hitting budget deficits in the council, and they took a decision to reduce the number of placements they pay for. But councils facing deficits. . . must talk to health partners. Very often, health can help in these circumstances.' Ignoring the NHS was 'not a very adult strategy', she adds. 'Local authorities complain when wards are shut down.' Amid rumours of rationing strategies such as 'two-for-one', where just one care home placement is funded for every two that become vacant around the country, Ms Platt says she does not know how widespread this is. 'Some people may be operating less explicitly.

There has to be discussion.

It doesn't help if people play high noon. It doesn't help if health authorities posture or if local authorities posture.'

Birmingham councillor and 'cabinet member' for social services and health Susanna McCorry defends her council:

'We have got a finite budget. If people are staying in the system longer, they use more resources, which means throughput goes down. If we have a surge in winter, we will continue to have difficulties.'

She says the£3.2m that Birmingham has received from Mr Milburn's handout 'equates to£8m over a whole year' - money that Birmingham will need to maintain elderly people's placements. Ms McCorry is positive: 'I welcome the money for change.' But the difficulty is trying to change the nature of provision while maintaining services at the same time. She continues:

'The health service locally is going through a complete reorganisation. That sort of organisational change going through health is a reason why some of the speed of [service] change is being delayed.'

the 50 hot spots - strategic director for social services Lyn Burns says the council and the NHS locally are 'mapping out' the reasons why people end up in hospital, in order to see where people could be diverted to healthcare elsewhere: 'We have got to help people see they can receive healthcare - clinical services - in other ways than in hospital.'

She adds: 'We are fortunate in having a residential and independent healthcare sector with whom we are able to have a dialogue. Underpinning that is the tension between the independent sector and the local authority about the level of fees. We have to not let that get in the way of thinking laterally about services.'

Councillor Gareth Barnard, Bracknell Forrest executive member for social services and housing, points to a particular local strain on care home capacity: 'The issue in the Thames Valley is very clear cut.' Of 1,600 care home beds locally, 1,000 are filled by 'relatively affluent' full-fee payers who have chosen to be there. 'It is a fact of life. It is Berkshire, is not it?' He adds:

'Bed-blocking is a problem.

Our authority operates one-in, one-out at the moment. The finances of all social services departments in this area are under extreme pressure. With a gross budget of£22m, We have got a£1.2m overspend.' Pressure on the children and families budget is having a 'knock-on effect' on elderly people's services, he says.

A happier man is north east Lincolnshire council's community care director Peter Hay: 'We have only 13 delayed discharges. We are well above national performance.' Describing the situation as 'pretty funky', he nevertheless adds: 'We want to continue intermediate care development. We want to eliminate delayed discharge.

At one point last winter, we had no delayed discharges.'

Mr Hay says his department and the NHS have worked very hard for the past two years to develop alternatives to hospitalisation, such as rehabilitation services. 'The key to our success has been the engagement of practice staff. Rehabilitation services were driven by the practitioners. We have a firstwave primary care trust and That is been a major help. It is a big factor, ' he says.