Incentive to change
By: Unknown Author
NHS magazine, July 16, 2002
The NHS and social services have wrestled with the
problems associated with delayed transfers for decades. Now new incentives
are being built into the care system. Is this the solution? Greg Moulds
reports.
Imagine an NHS with so much spare capacity that the
equivalent of two major teaching hospitals were allowed to stand empty. It
is difficult to conceive of a time when the NHS would have such extra
resources at its disposal.
Yet in June 2001, 12 per cent of hospital patients
over the age of 75 - a total of 5,670 people - were occupying beds despite
being medically fit for discharge.
"Delayed transfers are a problem for the NHS
but, more importantly, they are a problem for older people," says
Craig Muir, head of older people's services at the Department of Health.
"The vast majority of these patients would much
rather be at home but they remain in hospital because neither the NHS nor
social care services can provide the support they need. Being in hospital
when there are more appropriate settings is extremely disruptive. It can
be bad both for a person's health and their social well-being."
So-called 'bed-blocking' is not a new phenomenon. The
knock-on effects - long waits for admission through accident and emergency
(A&E) departments, planned operations cancelled because of a lack of
beds for post-surgical recovery - have led to some of the most damaging
headlines about the NHS in recent years. Until now it has proved
impossible to overcome the problem.
Much of this can be attributed to poor joint working
between health and social care services. For decades, hospital trusts and
social services departments have been too inward-looking, concentrating
their energies and resources on carrying out their own roles instead of
focusing on the needs of the patient.
Muir explains: "Historically, people have tended
to work within their organisations rather than starting with the patient
and devising a single system of care that meets their needs.
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"There have also been differences in terms of
funding. In some cases health and social care have wanted to work together
but haven't had the money to do it."
Recent developments, however - such as the National
Service Framework (NSF) for Older People, the huge investment in older
people's services outlined in the Budget this year and the proposed
overhaul of health and social care services set out in Delivering the
NHS Plan - point to light at the end of the tunnel.
Good progress has already been made. A ё100
million allocation to local authorities in October 2001 has seen the
number of delayed transfers fall by more than 1,000 in the six months
leading up to April 2002. A further ё200m has been allocated for
2002-2003.
The next step is to look at ways of breaking down the
'Berlin Wall' between health and social care for good, by developing
permanent, performance-managed relationships between local partners
involved in the care of older people.
Ian Philp, national director for older people's
services, says that fundamental to the successful management of delayed
transfers under these new, more localised arrangements is an approach
which covers six key areas: good health prevention; timely intervention
and diagnosis; effective rehabilitation; support for family and carers;
speedy environmental adaptations and the availability of appropriate care
settings.
"The biggest breakthrough in the care of older
people over the next few years will not be a new drug, but smarter
organisation of a complex system," says Philp.
The Budget promised an annual real-terms increase in
NHS spending of 7.4 per cent per year for the next five years. Social
services budgets have been bolstered by an annual average of six per cent
for three years.
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But this money comes with strings attached. NHS
trusts and local authorities have had the power to pool budgets and form
partnerships for the delivery of certain services since the Health Act was
passed in 1999.
The limited use of this legislation to tackle delayed
transfers - either because of the tradition of looking inwards at their
own organisation or a shortage of funds to pool - has led to the
Government's intention to introduce a financial incentive system.
Delivering the NHS Plan makes it clear
that local authorities will be expected to use some of their additional
money to reduce the number of people remaining in hospital after they are
fit to leave.
"Additional funding cannot simply be used to
perpetuate existing services," says Muir. "At the same time as
working on things like stabilising the care home market, the NHS and
social care need to be looking at different solutions."
Failure to make appropriate alternatives available to
patients will result in hospitals charging social services departments for
the costs they incur by keeping older people in hospital unnecessarily.
Incentives will also apply to NHS trusts. They will
be held accountable for the cost of emergency hospital re-admissions in
order to ensure patients are not transferred prematurely. However,
provided NHS trusts work in close partnership with social care providers,
cross-charging will not happen in practice, says Muir.
"The intention is that councils should have both
the cash and the incentive to work with the NHS and others to build the
capacity to give older people the support they need to live as
independently as possible - including those coming out of hospital. If
they do this there will be no need for charges.
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"The majority of older patients want to return
to their homes or to an environment that most closely resembles their
homes. We, therefore, see a significant amount of investment going towards
things like quicker home adaptations, extra care housing and more
effective methods of assessment."
For those organisations trying to develop new ways of
reducing delayed transfers, help is on hand in the form of a national team
of change agents.
Set up under the umbrella of the Department of
Health's NHS Modernisation Agency in November 2001, the team is made up of
experienced health and social care professionals. Its role will be to work
with trusts and local authorities to share good practice and identify
local opportunities for joint working.
These measures are widely welcomed but the move to
introduce cash incentives is more controversial. It is universally
acknowledged that a solution is needed to encourage closer working
arrangements but some are not sure financial penalties are the way
forward.
Richard Hunt, policy advisor for social services at
the Local Government Association (LGA), says: "The penalty framework
for local councils that accompanied the additional funding was seen as a
retrograde step, pushing back progress made in health and social care
relationships.
"The LGA, with partners, has agreed the need to
positively address alternative incentives or leverage as a means of
delivering on delayed transfers. We would be looking to local partnership
solutions to meet local goals rather than imposed penalties."
For local intermediate care partnerships to be
effective, primary and secondary care must work hand in hand with the
private and voluntary sectors.
Local partnerships are being encouraged to use the
older people's NSF as their yardstick for the development of intermediate
care services.
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Philp explains: "It is very difficult to tackle
problems like delayed transfers because they are part of a whole system
that doesn't just cut across health and social care but also across
primary and secondary care. The private sector, families and carers are
also integral to the process.
"The NSF gives a detailed description of how
services for older people should be provided, around which there is a real
consensus."
Residential care home owners have a pivotal role to
play in the creation of a comprehensive intermediate care system. The
number of long-term residential beds in the UK has fallen by an estimated
15,000 a year for the last three years, according to the National Care
Homes Association. Chief executive Sheila Scott explains: "This has
led to real instability which the Government is finally beginning to
appreciate and address."
Muir believes the funding for social services - which
amounts to around double the funds allocated in recent years - will be
enough to alleviate the strain on care home owners. "Considerable
resources are required to stabilise the care home market and build the
capacity across the system, and indeed give people the choice to live at
home if that's what they want," says Muir. "That's why the
social care settlement is quite exceptional in historical terms."
Already today, six out of 10 acute hospital beds are
occupied by older patients.
With more people living into their 80s and 90s than
ever before, the NHS has to be prepared to respond to the growing demands
of an ageing population and make sure that this group of patients gets the
right care, in the right place at the right time
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