Health systems and long-term care for older people in Europe. Modelling the interfaces and links between prevention, rehabilitation, quality of services and informal care
Policy and Governance Policy policy barriers and opportunities in terms of linking social and health care
COUNTRY / LOCATION: United Kingdom Keywords: Acute hospital discharge, Delayed hospital discharge, Home services after hospitalisation, Collaboration, Hospital/home care services
Reimbursement for delayed hospital discharges
The controversial national policy of ‘reimbursement' was launched in England in early 2004. The policy gives local hospitals the right to fine local social services if a patient's transfer is delayed for social-care related reasons. From the beginning, this has been a contested area of policy and practice – while some felt that this would help to concentrate the mind of local managers and provide appropriate incentives for swift discharge, others felt that it would undermine existing joint working and penalise one partner for a whole system issue. The example was developed as part of a drive to improve the efficiency and throughput of the acute sector. It targets an improvement of the interface between health and social care organisations and between hospital and non-acute settings, providing incentives for social care provision to be arranged in good time where needed. Although dramatic falls in delayed discharges are often attributed to reimbursement policy, more recent research paints a more complex picture. The example explores how it is difficult to attribute causality to this one policy and critically assesses the effectiveness of the policy drawing on a range of quantitative and qualitative evidence.
What is the main benefit for people in need of care and/or carers?
The intended benefit for service users is to prevent delayed discharges from hospital. Although delays fell rapidly after the introduction of ‘reimbursement’ these changes have also been attributed to increased funding for intermediate care services.
What is the main message for practice and/or policy in relation to this sub-theme?
Reimbursement policy may have had some success in England, but there is no clear evidence to support the policy. It is more frequently associated with various unintented consequences distorting the priorities of social services (towards hospital discharge and away from preventing hospital admission) and creating conflict between acute and community service organisations.
Why was this example implemented?
With an ageing population, medical advances and changing public expectations, hospital beds are scarce resources for which demand frequently outstrips supply. Within the UK, successive governments have explored different ways of trying to avoid hospital admissions and/or reduce the number of delayed hospital discharges. This is complicated by the fact that the UK system is based on a historical division between people who are ‘sick’ (who receive health care free at the point of delivery from the National Health Service) and those who are ‘frail/disabled’ (who are deemed to have social care needs, met by local authority social services departments and subject to means-testing/user charges).
For these reasons, the hospital discharge of older people has long been a problematic area of policy and practice in the UK. While the New Labour government of 1997-2010 introduced various measures, the most controversial was the 2003 Community Care (Delayed Discharges etc.) Act 2003 – which charged social services departments for hospital beds unnecessarily ‘blocked’ by people awaiting social services provision (a system known as reimbursement).After difficult debates in Parliament, the Bill was passed but extra funding was provided for adult social services in the short-term to smooth the passage of the legislation.
As the Department of Health explained in the 2002 Delivering the NHS Plan (p.33):
“We have been impressed by the success of the system in countries like Sweden and Denmark in getting delayed discharges from hospitals down. We intend to legislate ... to introduce a similar system of cross-charging [also known as ‘reimbursement’]. The new social services cash announced in the Budget includes resources to cover the cost of beds needlessly blocked in hospitals through delayed discharges ... Councils will need to use these extra resources to ... ensure that all older people are able to leave hospital once their treatment is completed and it is safe from them to do so. If councils reduce the number of blocked beds, they will have the freedom to use these new resources to invest in alternative social care services. If they cannot meet the agreed time limit they will be charged by the local hospital for the costs it incurs in keeping older people in hospital unnecessarily ... There will be matching incentive charges on NHS hospitals to make them responsible for the costs of emergency hospital readmissions, so as to ensure patients are not discharged prematurely.”
Subsequent guidance clarified that hospitals must notify social services of patients needing further support on discharge, whilst social services had set timescales (governed by complex rules but often around three working days) to assess patient needs and find/fund appropriate community services. Where someone was delayed beyond this in hospital for social care reasons only, the hospital could ‘fine’ social services £100 per day (£120 in London). In practice, corresponding charges on hospitals for premature discharges/emergency readmissions were not introduced.
This system applied only to England, and other UK devolved governments chose other routes without using these financial incentives/penalties.
What are/were the effects?
In advance of the new policy, government argued that this was a sensible way to resolve a longstanding policy problem – and that hospital was not an appropriate place for older people who no longer needed such services. At the time, there were some 7,000 older people delayed in hospital at any one time, representing 6% of acute beds. They therefore saw reimbursement as a way of ‘concentrating the mind’ of social services leaders and encouraging the development of alternative community services.
In practice, the numbers of delays fell dramatically (from 7,065 to 2,895 from September 2001 to March 2004 – a fall of 59%). However, the biggest falls came before the legislation was introduced and might result from the extra funding provided from 2001. This progress has also not been fully sustained – by 2011 there were some 4,400 delays.
Two key studies shed some light on these issues in more detail (see below for details of further sources):
A comparative study of approaches in England and Scotland found that delays were falling in both countries, but that reimbursement may have led to increased bureaucracy and that patient throughput may have sped up too much (described as ‘spinning the carousel faster’). Overall, reimbursement may have had some success but is insufficient by itself (without further whole system working and joint investment).
A national survey of 150 social services departments/an analysis of routine data found that delays had fallen but that this was a long-term trend preceding the 2003 Act. Contrary to popular opinion, most delays were to do with internal NHS issues (not social care). The authors also questioned the safety and quality of early discharge and identified a potential rise in emergency readmissions. Overall, they found no evidence to support a policy of reimbursement.
What are the strengths and limitations?
For some commentators, reimbursement could lead to “an unproductive culture of buck passing and mutual blame between health and social care” (House of Commons Health Committee, 2002: 52 – see below for further sources). It is also possible that financial penalties have damaged rather than improved local relationships across the health and social care divide. There are also concerns that reimbursement has:
Distorted social care priorities by focusing on delayed discharges at the expense of other issues
Focused on swift discharges rather than on preventing admissions in the first place
Blamed one partner for a whole systems problem
Introduced a policy from Sweden/Denmark (which have very different systems) without testing whether this would work in an English context
Anecdotally, many health/social care communities seem to have responded by agreeing to invest the new money they received in alternatives to hospital – with the hospital agreeing not to ‘fine’ social services until the levels of fines that would have accrued reached the level of investment that social services had made. However, this was for local negotiation and such informal agreements have often proved controversial as pressures have increased and as public sector spending has been significantly reduced.
Author: Jon Glasby Reviewer 1: Laure Com-Ruelle Reviewer 2: Hannelore Jani Verified by:
Godfrey, M., Townsend, J., Cornes, M., Donaghy, E., Hubbard, G. & Manthorpe, J. (2008) Reimbursement in Practice: The Last Piece of the Jigsaw? A comparative study of delayed hospital discharge in England and Scotland, Stirling, Leeds and London: University of Stirling, University of Leeds, King's College London.
McCoy, D. , Godden, S., Pollock, A.M. & C. Bianchessi (2007) 'Carrot and stick? The Community Care Act (2003) and the effect of financial incentives on delays in discharge from hospitals in England' in: Journal of Public Health, Vol. 29: 281-287.