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Delayed care transfers  – are the penalties just held over?

Delayed care transfers – are the penalties just held over?

🕔21.Nov 2017

It’s Budget Week, with all the attendant bogus briefings and space-filling speculation. So, with even Cabinet members not knowing for certain until Budget Day morning what WILL be in the Chancellor’s Statement, it seemed worth examining something financially significant we now know definitely WON’T be, writes Chris Game

We’re talking what until recently would have been labelled ‘bed-blocking fines’ for local authorities. It was an unpleasant, emotive term – the fines bit, obviously, but the bed-blocking bit too.

Technically it’s where a hospital patient is clinically judged ready and safe for discharge or transfer, but is still occupying a bed. But it conjured up distressing images of militant patients clinging on to their bedframes while needier souls were being trolleyed around hospital corridors, or queuing in ambulances – patiently, of course – outside in car parks.

Personally, then, I welcomed the new bureaucratic acronym – a genuine one, moreover, being pronounceable as a word: DToC.  It stands – disappointingly for computer gamesters – not for the Dark Tools of Camelot, but for Delayed Transfer of Care, and, predictably enough, it’s quickly created employment for a small army of bean – or, in this case, bed – counters. Some quite possibly Chancellor Philip Hammond’s former shorthand typists.

These counters – employed, I assume, by NHS England – produce monthly mountains of statistics not only totalling the DTs, but categorising them, and providing the NHS and ministers with ammunition – sorry, evidence – for determining and allocating responsibility. And indeed, there’s much to be allocated.

First, though, the numbers. In the OECD’s 2015 listing, the UK, with 2.6 hospital beds per 1,000 people, ranks 30th out of 35 countries. Japan has 13, Germany and Russia 8, France 6, most of Central and Eastern Europe between 4 and 7. We’ve experienced, moreover, one of the biggest falls in hospital bed numbers since 2000 (over a third) (pp.6-7).

Second – in a practice that obviously reflects the very separate institutional histories of health and social care, rather than their intendedly more integrated futures through instruments like the Better Care Fund – every DToC has to be attributed to either the NHS or local authority social care, or, if it’s really impossible to differentiate, both.

This is despite the NHS’ own DToC Guidance acknowledging that almost all possible reasons for delay – awaiting completion of assessment, awaiting residential or nursing home availability, awaiting care package in own home – can in particular situations be attributable to either body.

One brief example: if a care package involves the services of a district nurse or physiotherapist, who’s not in place when a patient is ready to be discharged, this delay is the responsibility of the NHS, yet it will almost certainly be attributed to social care and the relevant local authority.

Very few reasons for delay – one being ‘awaiting further non-acute NHS care’ – seem commonsensically devoid of ambiguity, yet around 93% of DToCs are in practice attributed to one body or the other – with, as currently, significant consequences.

In 2010, monthly DToC totals were only (!) fractionally over 100,000, with the NHS responsible for just under 60% and social care for about 35%. By 2013, overall numbers were about the same, but the responsibility percentages changed to 69% and 25% respectively.

From the winter of 2013/14, though, all DToC figures began to shoot upwards, last winter reaching around 200,000. By March 2017, social care was deemed responsible once more for well over a third of the now enlarged total, a three-year rise of 240%.

With council spending on adult social services per adult falling by 13.4% in real terms between 2010/11 and 2016/17 (and by nearer 20% in London, the NE and West Midlands, pp. 2-5), it wasn’t hugely surprising, but that ‘deemed responsible’ bit began seriously to matter.

It’s worth re-emphasising that the 2014 Care Act and the Better Care Fund were intended to get NHS bodies and councils working jointly to resolve DToC bottlenecks. But, despite the NHS’s own figures showing hospitals responsible for by far the greater number of DToCs, trusts managed to retain the right to fine local authorities for their deemed responsibilities.

To confirm, because it seems almost incredible: in this joint working arrangement, cash-strapped councils missing arbitrary DToC targets largely because of their shortage of funds can then be actually fined by their supposed partners. The Local Government Association (LGA) describes it as “completely counterproductive”, which in the circumstances seems completely understated.

According to the Association of Directors of Social Services (ADASS), fines of up to £280,000 were levied on 16 councils in 2016/17, but this financial year the screws were tightened by the Government on all top-tier councils.

Early good news: in his Spring Budget Chancellor Philip Hammond announces an extra £2 billion for social care over next three years, with £1 billion available immediately.

Bad news: in July, Health Secretary Jeremy Hunt adds some late extra conditions, including the threat to review 2018/19 adult social care allocations for any councils falling short this September of their Government-set, February-based DToC targets.

Particularly bad news: those with the worst DToC rates could face a triple whammy – failing to meet an unattainable target, unrelated either to their circumstances or volume of activity; losing some of their 2017/18 funding; and potentially being fined by their hospital trusts.

West Midlands councils, having already suffered some of the severest funding cuts, were particularly incensed. A group of 12 of their leaders [all but Solihull and Sandwell] wrote to Jeremy Hunt warning that for many councils, “including over half in the West Midlands”, the targets were “simply unachievable” in the timescale.

They predicted a “catastrophic local impact”, were any future funding to be withheld, and also questioning both the accuracy of the Government’s data and the whole DToC methodology.

The release earlier this month of the crucial September DToC figures more than justified the leaders’ concerns. While a majority of the 151 top-tier councils had managed some reduction in their DToC figures over the first half of the financial year, 106 or 70% had failed to meet their localised reduction targets, with seven – though none in the West Midlands – seeing their numbers more than double during the review period.

However, while councils had reduced their DToC numbers by 7.2% since July, the NHS had managed only a 3.4% reduction.

Whether it was these numbers that swung it, or whether it was ever seriously the Government’s intention cut miscreants’ shares of the £1 billion announced in the March budget, is unclear.

Whatever the explanation, NHS England issued a statement last week saying it had had now agreed DToC reduction targets with all councils, that these targets will be used in determining their 2018/19 funding, but that all allocations for the current year would be paid in full. Worth one and a half grudging cheers perhaps.

It’s very obviously not the end of the story, but, thanks to the work the public sector consultants, iMPOWER, have done on the NHS data, we can see the records of West Midlands councils and how near they may or may not have come to being penalised this year.

The tables are hopefully pretty self-explanatory. The first ranks the performamnce of all authorities against the Government’s national target of 9.6 delayed days per 100,000 population, and indicates why the leaders of Solihull and Sandwell didn’t feel it necessary to harangue the minister, but why all the other WM leaders did.

The second shows the current dramatic differences among the metropolitan councils in the proportions of their DToCs attributed respectively to them and to the NHS.


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