Reimbursement for delayed hospital discharges

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. 

Description

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):

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.

Credits

Links to other INTERLINKS practice examples

External Links and References

Key policy documents:

• Department of Health (2000) The NHS plan: a plan for investment, a plan for reform. London: Department of Health
• Department of Health (2002b) Delivering the NHS Plan: next steps on investment, next steps on reform. London: Department of Health
• Department of Health (2003) Discharge from hospital: pathway, process and practice. London: Department of Health
• Department of Health (2004) Dramatic fall in delayed discharges, Press Release 2004/0196, 17 May
• Community Care (Delayed Discharges etc) Act 2003

Key policy commentary:

• Glasby, J. (2003) Hospital discharge: integrating health and social care. Abingdon: Radcliffe Medical Press
• Henwood, M. (2004) Reimbursement and delayed discharges: discussion paper for the Integrated Care Network. Leeds: Integrated Care Network
• House of Commons Health Committee (2002) Delayed discharges (third report). London: TSO

For recent newspaper stories about a possible rise in delays, see Bed blocking on the rise as care cuts leave elderly stuck in hospital