Published: 08/01/2004, Volume II4, No. 5886 Page 14 15
There will be different responses to the discharge fine go-ahead after 5 January.Some areas will be collecting fines; in others, acute trusts, social services departments and primary care trusts have struck agreements not to introduce any at all.
HSJ reporters examine the options
Some parts of the country have chosen not to 'fine' social services departments at all.
Instead, the extra money provided to ensure smooth discharge has been ringfenced locally to improve intermediate care, with the long-term goal of reducing the number of delayed discharges.
South Warwickshire primary care trust has teamed up with Warwickshire county council and South Warwickshire General Hospitals trust to organise a pooled budget to increase capacity in intermediate and long-term care outside the hospital.
The joint financial and administration function of the three groups has led to an agreement that from 5 January the acute trust will not fine the council's social services department for any delayed discharge which falls into the category for reimbursement.
The partnership means that between them, they have been able to set aside£4m to build intermediate and long-term care capacity for social services.
Warwickshire county council received£800,000 in a delayed discharge grant from the Department of Health to cover the cost of the reimbursement programme for the year. South Warwickshire PCT has been allocated£400,000 of this, which has been included in the pooled budget.
Kate Woolley, delayed discharge project manager for Warwickshire social services and joint PCT service commissioner, says: 'We want to get beyond punitive measures... we identified chunks of money on all sides which we earmarked as part of the pool.'
She says that although staff would be instructed to follow the reimbursement procedure, the acute trust would not be invoicing the social services department for the fines.
The system would be used as an audit tool, which would highlight where there were gaps in provision.
Ms Woolley believes it is too early to say whether the reimbursement system will work in practice, as it will be reliant on all acute trust ward staff knowing how to follow the notification structure.
She says the system of joint working had been introduced because though delays were small in number, they represented 'a significant potential cost if reimbursement applied'. One delayed patient had been identified as potentially costing the social services department£25,000 in fines.
Although not pooling budgets, Birmingham and the Black Country strategic health authority has worked with local authorities, PCTs and acute trusts to develop a joint best-practice guide on how to implement the delayed discharge charges when they come into force.
David Martin, executive director of health and social care at Walsall metropolitan borough council and chair of the steering group that drafted the joint protocol, says one of the biggest issues on implementing the new delayed discharge policy was to have 'a consistent approach across the different boundaries'.
'Money was made available for us to commission a number of projects to find out what was going on across the SHA in delayed discharge and what is seen as best practice, ' says Mr Martin.
He explains that the joint policy the SHA has drafted should be seen as a 'handbook to help people who are struggling with delayed discharge and use it as an audit tool'.
The protocol looks at how the different acute trusts, PCTs and social services departments are working to manage the notification process used when a patient is required to be moved from a hospital into the care of social services.
Mr Martin says that the protocol could not be used to instruct trusts on how to implement the delayed discharge system, but that the SHA needed some way 'to bring pressure to bear'.
The areas covered by the protocol include key definitions for delayed transfer of care, the system of notification of social services (known as a section 2 and 5 notification) and financial arrangements for reimbursement, including pooled budgets and resources.
Not everyone is happy with the reimbursement system.
In its 2002 report on the likely impact of a reimbursement policy, the Commons health select committee warned: 'Cross charging could lead to an unproductive culture of buck-passing and mutual blame.'
In Plymouth, the local authority, social services and primary care and acute trusts appear to have found that reaching agreement on how money raised from the fines should be spent is a challenging process.
None of the guidance on reimbursement says acute trusts need to receive approval from social services on what to do with money collected in fines. But councils in particular are keen to find joint solutions which invest cash in capacity.
'We think our record on delayed transfers is pretty good, but we still face potential fines of£137,000 over a full year, which would be quite seriously destabilising for us, ' says Plymouth city council social services sector manager Julian Grail.
'There is not enough impetus to reach an agreement at the moment. We should be focusing on a pooled budget arrangement so investment goes into building capacity, rather than passing fines across the system.'
Mr Grail continues: 'We need to do more work on establishing priorities - as there are currently differing views between social services and the council and the PCT and hospital trust on where money needs to be spent.'
Mr Grail says he hopes an agreement will be reached in the new year.
A spokesperson for Plymouth Hospitals trust says a new ` planning and development officer, employed by the local authority, would help improve joint working.
'This way we can avoid reimbursements being about fines; instead it will be about effective joint investment.'
Hampshire and Isle of Wight
SHAs have been tasked with arbitrating where there are disputes between acute trusts and social services departments on reimbursement.
DoH guidance says recourse to a formal disputes procedure should be viewed as a 'failure', but the guidance also admits that 'it has to be recognised that this is a complex, high-risk area of activity for all the parties and that there may well be issues of disagreement and difference, particularly in the early days of implementation'.
Hampshire and Isle of Wight SHA has been held up as an example of implementing an innovative solution.
The scheme, currently in draft form, can be used to resolve disagreements about individual patient delays or issues of broader disagreement between organisations around reimbursement provisions.
It will ensure that reimbursement arrangements are reviewed every year and provides three stages of informal resolution before an arbitration panel would be reached.
The panel would include one NHS representative not employed by the trust involved, one representative from a different local authority and a chair who represents neither the NHS nor a social services body.
Cumbria SHA is setting up a panel to arbitrate not only on delayed discharge disagreements, but also on other issues around continuing care.
It is keen to stress that it sees the panel as a last resort, and a spokeswoman says the SHA 'would hope that difficulties can be sorted out locally'.
She adds: 'If trusts come to us, it would be viewed as being disappointing.' The arbitration panel will not be in place by 5 January.
In cities, the situation is complicated by the transfer of patients across many trusts and social services departments.North West London SHA is ensuring 'there is a consistent resolution process across the sector'.
So if a patient is moved from an acute trust in one borough to another's social services department, any dispute will be settled in the same way.
A spokesperson for the SHA says a process has been set up that will allow the SHA to pull together a formal panel, with a chair in place.
It will consist of a chief executive of an acute trust, a director of a social services department, and a chair, Michael Whelan, who is also chair of the SHA's continuing care review panel.
The human cost: 'all of a sudden there was a meeting and the PCT said it couldn't afford to fund it'
Among the protocols and official guidance, the human cost of delayed discharge should not be forgotten.
One patient, wheelchair bound after a stroke, was left on a general ward for nearly six months because his local primary care trust could not provide beds for younger stroke victims.
Last year, a Commission for Health Improvement clinical governance review criticised Tower Hamlets PCT for not providing specialist stroke care and rehabilitation to under-65s.The PCT promised to remedy the situation but that did not help Jeff Happe, admitted to a general surgical ward at Royal London Hospital in London on 11 July last year after a stroke.Although his case would not be 'fineable'under the reimbursement programme, he is considering taking legal action against the PCT.
Mr Happe, who is 47, was eventually discharged onto a private stroke unit just before Christmas.'I have been sitting on a general ward which should be used for someone who needs it. I have even had people saying 'what are you doing here?'as if I am some sort of malingerer when all I want is to be in the best place for my treatment.'
Royal London has a stroke rehabilitation unit at the nearby Mile End Hospital but Mr Happe has been rejected - the unit only accepts the over-65s.
Mr Happe also applied to Homerton Hospital, east London which accepted his transfer in October.But just days before the move, he was told there was no bed available and he would have to wait until January.
The PCT also invited him to view facilities at Blackheath Hospital, a private unit in southeast London.'The hospital said there was a chance of getting 90 per cent of the use of my arm and leg back.All of a sudden, there was a meeting and the PCT said it couldn't afford to fund it.'
Mr Happe was eventually treated at the unit after making a complaint.
A Tower Hamlets PCT spokesperson said plans have been approved to develop a specialist stroke unit for younger people at Mile End Hospital in the new year.