OVER THE WALL

Published: 22/08/2002, Volume II2, No. 5819 Page 18

The 'blocked bed' seems to have replaced the 'health or social bath' dilemma as the metaphor for inter-agency failure.

A pledge was made in the NHS plan to 'end widespread bedblocking by 2004', and huge policy energy is being poured into addressing the problem.

However, the latest report from the Commons health select committee on this issue is a useful reminder that things are often more complex than they seem to be at first sight.

1The Department of Health has been looking decidedly Janusfaced, simultaneously boasting of the success of local partnerships in exceeding targets on reducing delayed discharge while threatening local authorities with penalties for blocking beds.

The health select committee is distinctly unimpressed, and takes issue with the DoH on some fundamentals, including definition, incidence and causation.

An official definition of delayed discharge has only been in place for just over a year, making any comparison with previous years problematic. But the committee finds fault with current usage on the grounds that it ignores those blocking beds in community hospitals, focuses unduly on those aged 75-plus, and includes delays of less than eight days, which might be regarded as a legitimate period for ensuring proper arrangements are in place.

The assumption behind the cross-charging proposal is that local authorities are at fault where beds are blocked.However, an interesting memorandum supplied to the committee by the DoH itself shows that delayed discharge to be a multi-causal phenomenon, much of which is down to delays in the NHS and individual behaviour and choice.

Moreover, once the committee was drawn into exploring the dimensions of 'the patient journey', it became clear that delayed discharge could not simply be viewed as a discrete intervention around an acute bed.

The real nature of delayed discharge is hugely complex - a perspective incorporating the prevention of acute admissions, discharge planning on admission in the case of unplanned admissions, the wastefulness of some hospital procedures, the impact of premature discharge on readmission, and the neglect of people with high dependency levels who do not have the 'passport' of an acute episode to trigger support.

In the light of the committee's analysis, current government policies appear narrow and limited. There are no quick fixes for dealing with 'wicked issues' - a whole-systems problem needs a complex and whole-systems response.

But despite the absence of any significant evidence to support the view, the committee opts for integrated structures across health and social care as the answer to fragmentation.

However, committee chair David Hinchliffe is far too canny to back care trusts, and the report is subtly agnostic about the precise nature of any such structural integration.

The way targets are currently structured and monitored encourages a preoccupation with short-term objectives (reducing delayed discharges).

Judging by the results of the recent star-rating exercise, this narrowly conceived monitoring understandably tells only part of the story.There is, for example, no apparent relationship between levels of blocked beds and readmission rates - the basis of the cross-charging proposal. It is as common for acute trusts with high levels of bed-blocking to have high readmission rates as it is for those with low levels of bed-blocking to have high readmission rates. Indeed, some localities singled out for praise by the committee have come out of the star-ratings rather badly.

Whole-systems working is difficult.As the Audit Commission points out in its evidence to the select committee, it simultaneously requires reducing demand by actively supporting people in the community, smoothing discharge by streamlining procedures, re-balancing services by putting in place alternatives to hospital, and co-ordinating care at both operational and strategic levels.

There will be little local incentive to face up to such a demanding remit as long as judgement is made on more narrowly conceived grounds.

REFERENCE 1Health Select Committee. Third report. Delayed discharge.HC 617-I.

The Stationery Office, 2002.

Bob Hudson is principal research fellow, Nuffield Institute for Health, Leeds University