Published: 08/01/2004, Volume II4, No. 5886 Page 12 13
Under the terms of the Community Care (Delayed Discharges etc) Act, from this week acute trusts are able to charge local authority social services departments£100 per night (£120 in London) for each patient who should be discharged from the acute sector, but for whom no alternative care package exists. Department of Health figures show there were 4,267 delayed discharges at the end of September 2003; its stated aim is to reduce the figure to 2,000-2,500 by the close of 2005. In a four-page report on the new legislation, Graham Clews, Helen Mooney and Mary-Louise Harding assess its likely impact
The introduction of fines for social services departments that cannot provide care for dischargeable patients has heralded a 'quiet revolution' in the way that the health and social care sectors work together, according to those implementing the scheme.
Under the reimbursement guidance issued to trusts and social services departments, there is no compulsion for acute trusts to make social services pay their fines, and in most cases they will not be enforced. But the inducement for trusts and social services to work more closely together to improve the standard of intermediate care is clear, and it seems that the 'lever' of reimbursement has paid off.
London borough of Barking and Dagenham council social services director Julia Ross says the policy has given a marked impetus to joint working: 'There has been a quiet revolution happening in appointments and a blurring of boundaries so there are more joint appointments with primary care trusts and acute trusts and between PCTs and community services. There are a lot more people in joint appointments'.
Ms Ross formerly also held the post of chief executive of Barking and Dagenham PCT, but her move back to a social services appointment leaves just two joint PCT chief executive/social services directors in the country despite an increase in joint appointments at a more junior level.
One of them is in Knowsley on Merseyside, formerly a hotspot for delayed discharges according to metropolitan borough council deputy director of health and social care Jan Coulter. Some 18 months ago the borough had 60 delayed discharges, but since senior management has been shared across the social services department and the PCT, that figure has been cut to just two.
Ms Coulter says there is now a 'lot of transparency' between budgets and the joint working arrangements 'make it hard to hide behind the barriers that can sometimes come up between health and social care'.
Ms Ross agrees that the new clarity has been key: 'In some areas there has been a tendency to hide behind delayed discharge by the acute sector, [while] some in the acute sector have not been as efficient or effective as they should have been.'
The PCT and social services department in Knowsley commission beds from three acute trusts. While Ms Coulter believes the arrangement has been very successful in her area, she admits the model might not work everywhere.
'We think it works for us, but it is not one size fits all.
Commissioning arrangements might be more complicated in other areas.'
Chris Bull, chief executive of Southwark PCT and director of social services for the borough council, is the only other person in England to hold these twin roles. He says that having an overview of both sides of the coin has made it easier to pool resources, avoid delaying discharge, and where possible avoid unnecessary admissions in the first place.
Hillingdon PCT chief executive and the borough's former director of social services Graeme Betts The other side of the coin: social services directors'views A survey of social services directors'views on the delayed discharge reimbursement policy by HSJ sister magazine Local Government Chronicle reveals a mixed picture of joint working across agencies.
One director in the anonymised survey said that they had witnessed 'either a complete lack of awareness in acute trusts or their perception that it is something social services has to do'and a 'worsening communication rather than improvement'.
Another said that the policy 'has put a massive administrative burden on both systems and has not speeded things up at all'.
However, some social services directors welcomed the policy.'To date [the system] has caused us to work very closely together to make this complex new policy work, ' said one.
Another said that 'the best way to manage delayed discharge would be full integration of health and social services with targets that are achievable within budget across the whole system'.
'Great care should be taken that targets for one part of the health and social care system do not conflict with targets for another part of it'. says an entire rethink of alternative care pathways to prevent unnecessary admissions is required if delayed discharge is to be dealt with in the long term.
His borough was one of the worst in London for delayed discharges, with 49 cases this time last year.
Now the figure is 20, and although he estimates that this could still cost the local authority£256,000 in fines in the first six months of this year, the money will not simply pour into the acute trusts' coffers.
He says it is important to ensure that staff 'work in new ways' across both healthcare and social services bodies, and he is realistic enough to admit that this is not always an option: 'You can't always have a range of professionals on hand to do the work.'
NHS Alliance chair Dr Michael Dixon says PCTs are in the perfect position to take an overview of commissioning for intermediate care, and he believes delayed discharge reimbursement might be the catalyst. He adds: 'You need a few things to push the system and it seems that this may be the thing. I suspect most people will not be fined and everyone will say the system is not working, but [that will mean] actually things will have changed.'
The implementation of the Community Care (Delayed Discharges) Act has not only affected social services departments; it has also meant a concentrated administration and training exercise by acute trusts in order to implement the new policy.
The onus is on front-line acute staff to put into practice the new system, which from 5 January will enable acute trusts to invoice their local social services departments for any delayed discharge that falls under the reimbursement criteria (see box, above).
This has meant that many hospitals have had to use resources to train both ward and administrative staff on the new notification system that requires acute trusts to alert social services deparments to imminent discharges.
Hospitals have also had to inform clerical and finance staff on new procedures for issuing invoices to social services departments.
According to Hinchingbrooke Healthcare trust directorate manager for medicine Christine Wroe, the policy has had the effect of increasing bureaucracy, however it has also been a catalyst for addressing the problem.
'Reducing delayed discharge has been talked about a lot within the trust; we just haven't had the driver to do anything and this policy has provided that'.
University Hospital Birmingham trust emergency and elderly people's services general manager Kevin Bolger says the hospital is introducing a new IT system to deal with the extra administrative work generated by the new policy.
'We have developed our own IT system which is being rolled out across the trust, and we have had to train staff how use it on the wards.'
Mr Bolger says the hospital had also put in procedures to see where incomplete or inaccurate information on bed occupancy was being submitted and to address problems.
East and North Hertfordshire trust director of nursing Noel Scanlon believes that although the new system has created a lot of work, it has been helpful in bringing together the acute trust with social services and PCTs.
'We have tried to avoid the bureaucracy and concentrate on the philosophy of the system.'
Private care homes
At first glance, the introduction of fines for delayed discharge is a gift to the independent care and nursing home sector. They have long complained that social services abuse their position as the dominant purchaser of beds to keep prices at unrealistically low levels. These providers can now impose higher prices, knowing that the option for social services is a stark one: pay their price or pay the fine.
'Care and nursing home providers feel that prices have been kept too low for too long, ' says Bromley social services assistant director for older people Terry Rich: 'I agree, but the fact is we haven't had the money.
There is no doubt the private sector will try to use this [fining system] to jack up prices - they know We have got extra funding and will want to get a slice of it.'
This view is - unsurprisingly - disputed by providers who not only contest this premise, but are also claiming they have received few inquiries from social services departments looking to create 'more efficient systems of transfer to care' in the new year.
'There will be allegations that the nasty fat cat capitalist owners will put their fees up, but I haven't seen any indication this is remotely happening, ' says Nursing Homes Association chief executive Frank Ursell. 'The going rate for a nursing home is£100 more a week than local authority owned homes - so the real test of whether the independent sector is profiteering is if any nursing home is charging more than the going rate - which I doubt.'
He adds: 'So far, I haven't had a single member ring in about negotiations with local authorities about plans for January. I would have expected some contact to make planning arrangements - I think they're just hoping it will all happen in the same old way.'
Meanwhile, London and the South East private care home provider Westminister Healthcare says it has launched a new shortterm bed placement service which can be booked online and is specifically targeted at providing extra intermediate care capacity.
Dubbed Bed Bureau, the 'offer' consists of an en suite private bed for two weeks at£100 a night in any of the company's existing facilities. 'We have contacted every trust chief executive and social services director in the South East and have not had one enquiry, let alone a booking, in the four months since it launched, ' says a Westminster Healthcare spokesman.
Fingers on the trigger: who pays fines for what
As social services departments are quick to point out, hospital discharges can be held up for a variety of reasons - over half of which can be laid at the door of either the hospital or the patient and their next of kin.
The situation report (sitrep) categories listed below define the official agreed reasons for delayed discharge - those highlighted in blue type would trigger a fine notification to social services.
A - Awaiting completion of assessment: generally - but not necessarily - social care-related delay concerning a patient's ongoing care needs.
B - Awaiting public funding: patients awaiting confirmation of how their care post-discharge will be funded.
C - Awaiting further non-acute NHS care.
D - Awaiting residential home placement.
E - Awaiting domiciliary package: patients awaiting a social services package of care in order to return home.
F - Awaiting community equipment and adaptations: usually modifications to the patient's home.
G - Awaiting patient or family choice: patients who refuse - for their own reasons, family reasons or both - to accept discharge options made available.
H - Disputes: usually relating to G.
I - Housing: the patient is waiting to be housed.