Fines for social services departments brought early success in reducing bed-blocking, but the numbers are creeping up again as more difficult problems - which may be a result of targets and choice - rise to the surface. Alison Moore investigates.

Bed-blocking - or delayed transfer of care - is meant to have become a thing of the past with the introduction of both fines and financial help for local authorities to transfer patients quickly.

But for many trusts the problem has never gone away - and there are signs that it may be on the increase again.

Figures released by the Department of Health show that the number of patients affected in England dropped from 3,220 in December 2003 (just before fining was introduced) to 2,190 last December - a 32 per cent decrease.

However, almost all of this reduction was achieved in the first year of fining and the figures have declined only slightly since December 2004. The last three quarters' figures are all higher than in the same period the year before.

Anecdotally, some trusts have been seeing a rise in the number of delayed discharges since last summer - although that is by no means consistent across the country.

Brighton and Sussex University Hospitals trust has seen a significant rise since last summer and has about 65 beds occupied by patients who do not need acute care, potentially costing the trust£1.5m a year. United Lincoln Hospitals trust had 90 beds blocked in December, compared with 76 a year before, but the number of bed-days lost increased from 630 to 1,138.

This trend has also been spotted in Scotland and Wales, where fining has never been introduced. In Cardiff and Vale trust, around 200 beds, or 10 per cent of the total, are currently blocked. Chief executive Hugh Ross says: 'We did get the numbers down to 150 in April last year but it has risen since then. We have had to create additional capacity - up to 50 or 60 beds - which cost us£2m over the last year.'

And the NHS in the Lothian district of Scotland recently reported a two-year high in the number of discharges delayed for more than six weeks.

There are a number of reasons why delayed transfers of care should be hitting the NHS particularly hard at the moment:

  • rising numbers of people coming into accident and emergency are putting extra pressure on the whole system and emphasising the need to get patients out of hospital once they are well enough to be discharged;
  • trusts have to meet A&E targets and are increasingly turning their minds to the 18-week target. Discharging patients promptly is vital for both of these;
  • bed-blocking costs money which is often not fully reflected in the payment by results system - and acute trusts are under increased pressure to break even. They are also working at very high bed-occupancy rates so there is no 'spare' capacity if a bed is occupied unnecessarily;
  • reconfiguration plans often involve fewer beds in acute settings, and these are hard to support when beds are full and the lack of social and community support for discharged patients is so evident.

The focus four or five years ago was on reducing the delays because of social services issues, such as delays in assessing and agreeing to fund patients who needed to be in a care home. Uncomfortably, there is some evidence that the 'easy wins' from sorting out social care delays may have been delivered fairly quickly and what is left is more problematic.

Some of the remaining delays are down to social services needing to assess or place patients but the majority may now be due to other factors - a combination of NHS delays and ones related to personal choice and decisions made by patients and carers.

The Department of Health cannot produce a breakdown of the reasons for delayed discharges.

The Local Government Association says that delays due to social services fell by 12 per cent last year. While 60 per cent of delays were social services linked when fining was introduced, the LGA says more recent figures suggest that around two-thirds of delays are now for NHS reasons - such as patients not being able to move out of an acute bed.

LGA adviser Tim Hind says that a lot of work has been done on social care-linked delays and many have been eliminated.

'There may have people who were in hospital inappropriately,' he says. 'It appears that now that is not the case. They stay in hospital for a long time because they are extremely unwell or they are waiting for an NHS resource. The linkage with the community hospital issue may be important.'

In East and North Hertfordshire trust, for example, the main problem has been the tightening of available beds in the community.

'At any one time, the equivalent of a ward to a ward and a half of patients remain in our hospitals when their acute health needs have been met,' says a spokesman. 'We have struggled in recent weeks and months with the A&E target - that is the measurable impact on us.'

Norfolk and Norwich University Hospital trust has seen delayed transfer of care rise from 2 per cent of beds in February 2006 to nearly 5 per cent in February 2007. That month 'patients were awaiting further non-acute NHS care'.

Royal Devon and Exeter foundation trust has seen problems with delayed discharge become more acute because more patients are coming in through A&E.

The LGA says there is also some evidence that, when delayed transfers of care go down, emergency readmissions go up, suggesting that some discharges may be premature or without a suitable package of care in place.

In Wales, 689 people were waiting to move on from hospital in the middle of January - slightly up on the previous year but below the level of December 2003 (988).

Of these, 20 per cent were waiting for healthcare to be arranged (either assessment or movement to other settings), and 31 per cent were delayed for social care reasons. Nearly half were delayed for 'other' reasons.

In East Sussex, the number of delayed discharges has plummeted from 107 to 31 in a year. The area has historically had the highest number of delayed discharges in the UK, reflecting its elderly population.

Juliet Mellish, who is employed by both the PCTs in the area as well as East Sussex county council, says when the problem is examined 'it is not quite as simple as being about social care'.

Much of the reduction has been brought about by quite simple steps, such as ensuring staff know about the pathways available for someone who is ready to leave hospital and high-level phone contact when numbers hit a threshold.

Now, only around eight to 10 of the delays are linked to social care and the main reason for delay tends to be more directly linked to the patient. Examples of delays linked to patients include their choice of home not being available or patients and carers taking time to decide what they want to do.

Hugh Ross says a majority of the beds blocked in Cardiff are because of patient-related reasons. He stresses he has great sympathy for the patients and relatives in these positions but there comes a point where they are inappropriately occupying an acute bed and staff have to address this. Leading clinicians and executive directors sometimes have to get involved in these cases.

'We help staff to walk this line, to be firm with patients and relatives...But what we think is a firm and fair line can be construed as harassment by some patients,' he says.

Patients and carers - who can be faced with 'dreadful dilemmas' such as selling the family home - may try to disengage with the process, he says, then may have genuine difficulty in finding a home they feel is suitable, be faced with having to top up the amount the local authority will pay for the place, and end up questioning the assessment made by healthcare staff and may even threaten to challenge decisions in the courts.

The Mental Capacity Act - which will give additional ammunition to carers determined to challenge the judgements - may add to problems.

The discharge process can take months. The trust has found the time 'delayers' stay in hospital has doubled in the last couple of years.

If patient choice is a significant factor nationally, reducing the figures for delayed discharge may be difficult. No NHS organisation is going to want to be seen to be pushing patients out of hospital against their will.

The Department of Health points out that bed blocking has fallen from over 7,000 to under 2,200 at the end of last year - down by 69 per cent. It also says the number of intermediate care places has increased rapidly.

That is a tremendous achievement which has undoubtedly helped the NHS and benefited patients - but getting the figures even lower may be an even greater challenge.

As Mr Ross points out, there may be an 'irreducible minimum' of delayed discharges.

Give or take? social services fines

Three years ago, the government introduced a system of 'fining' local authorities for delaying transfers of care.

The system was opposed by the Local Government Association, which argued it was simply recycling money around the system, and given a lukewarm welcome by many in the NHS, who were expected to impose fines with one hand while building up joint working with the other..

Some bed-blocking cases could not be easily categorised as being simply the fault of one organisation.

Extra money from the government to encourage good joint working was also used -£100m has been transferred from the NHS budget to social services each year, which was meant to more than compensate for 'fines' incurred.

Fines were set at£100-£120 a day and strict criteria applied.

Implementation was patchy. Some trusts concentrated instead on joint initiatives, where both sides put in money to improve procedures and services. Other trusts gave out fines.

Evidence from the National Audit Office showed that many delays when fining was introduced were due to social care reasons: 26 per cent of patients experiencing delays were waiting for nursing or residential home places; 17 per cent were awaiting assessment: 13 per cent were awaiting public funding; and 9 per cent were waiting for care in their home.

Against that, 14 per cent needed to be moved to other NHS settings and 10 per cent were waiting for a placement of their choice.