19 May 2006
Bed-blocking numbers have increased dramatically in over 10% of England's local authorities with social service responsibilities, figures seen by Public Finance reveal.
Senior NHS and social services sources have told PF that the cause is a combination of under-funding, primary care trust cuts, and cash-struck hospitals attempting to move patients through their system at a faster pace.
By the middle of April, the number of acute beds still blocked by patents aged over 65 despite the NHS declaring them fit for discharge reached two-year highs in eleven areas across England. In each case, the increases began in September 2005 – the month the scale of the projected NHS deficits became clear.
Sarah Pickup, director of adult care services in Hertfordshire - where the average number of bed days lost to delayed discharge per week has grown 79%, from 331 in September 2005 to 591 in April 2006 - told PF the issue was no longer due just to a lack of capacity in social services.
'The financial pressure on the NHS means they are under acute pressure to discharge people quickly,' she said. 'There are less beds in hospitals so the pressure is even greater to get people through the system. If you lose rehabilitative beds, you don't have anywhere for people to go. The acute episode may be finished, but it's often not appropriate to discharge people straight to a care home.'
Substantial increases in bed days lost since September have also been recorded in Derbyshire (90 to 232), Brent (71 to 124), East Riding (88 to 113), Staffordshire (269 to 343), Wiltshire (188 to 323), Cornwall (211 to 360), Bristol (63 to 124), Manchester (129 to 165), Lancashire (125 to 224) and Oxfordshire (285 to 480). A further seven local authorities saw significant increases over 2005/6.
The Department of Health has described bed blocking as a 'priority area' and claims figures have fallen by over 65% since 2001.
But Pauline Thompson, head of care finance at Age Concern, told PF the new figures – obtained from the Commission for Social Care Inspection – were 'worrying, especially as you can pinpoint the increases to a particular date in these areas.'
At least five of the 11 areas have substantial NHS deficits. The deficits in those five total over £143m.
Social services and NHS consultant and CIPFA social services panel member Roger Mortimore told PF that the impetus to move patients through hospitals quicker came not just from deficits, but also the introduction of payment by results.
'Hospitals get paid for individual patients, not beds,' he said. 'It was always intended that this regime would be an incentive for more patient throughput… Not only is there pressure for faster discharge, since the payment is the same per patient however long they stay, but there are more patients passing through the one hospital bed. Both of these put pressure on out-of-hospital care.'
Anne Williams, co-chair of the Association of Directors of Social Services resources committee said the ADSS was investigating how the faster pace at which patients are being moved through hospitals is leading to greater demand for social services.
'We've begun to look into the increases in referrals for domiciliary care which quite a lot of areas are experiencing, some of which is linked to earlier discharges from hospital,' she said.
Patients have been declared ready for discharge but are stuck waiting for funding, a care or nursing home placement, a needs assessment or home help.
In Staffordshire, where delays have increased by 28%, the health economy has a projected deficit of over £18m. Whilst a spokesman for the University Hospital of North Staffordshire admitted the major share of delays in the area were due to patients waiting to be transferred to other hospital – rather than social care – beds, he said it was tempting for hospitals to solve the problem by declaring patients ready for discharge earlier.
'It'd be terribly easy for us to reduce length of stay which would help us enormously,' he said. 'But if we chucked patients out when there was no provision for them in social services that would just cause a problem elsewhere.'
A spokeswoman for the DoH said it was down to clinicians to decide when a patient was ready for discharge. 'If a person does not need the intensive care given in a hospital then they should be discharged and returned to their own home if possible, or to another setting, such as a care home,' she added.
Pauline Thompson said that Age Concern frequently heard from people concerned that they, or their relatives had been discharged too early. Some ended up back in accident and emergency the next day or were sent to nursing homes when really they should be in hospital, she said.
Hospitals are able to fine social services departments for each day a bed is blocked due to a lack of social service capacity. Between April 2005 and 2006 fines payable by Wiltshire social services almost quadrupled from £6900 to £26,700. In Hertfordshire they more then trebled from £11,000 to £36,000. In Staffordshire, Bristol and Oxfordshire fines more than doubled.
Until recently a number of trusts agreed not to levy the fine but to instead help social services invest in increased capacity. In at least three areas however – including Wiltshire and Hertfordshire – NHS trusts have now begun fining their local authorities and a senior source told PF NHS trusts were now viewing the fines as 'an additional revenue stream to help reduce their deficits.'
A spokesman for East and North East Hertfordshire trust said the number of delayed patients was equivalent to one and a half wards and that the trust 'had no option other than to start fining the council.' The rate of fines levied in April 2006 was equivalent to 8% of the trust's projected deficit.
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