A joint response from the BGS and Royal College of Physicians (London) in response to consultations on proposals for reimbursement around delayed discharge from hospital

Introduction
The BGS and RCP (London) applaud the Department of Health for recognising the problem of patients occupying acute hospital beds who no longer need acute care and whose recovery and rehabilitation is adversely affected by the delay, and for setting out to identify an innovative solution.

We agree that that it is essential to bring this issue to the forefront of social services planning. So far, the perverse incentive to leave older people inappropriately in health care facilities has meant that changes in social services departments’ (SSD) working practice, (including assessments and care management continuing over weekends and holidays), have failed to occur. In addition, process delays, such as time waiting for care manager allocation and time to assessment, urgently need to be tackled.

Issues for implementation
In registering the response above we wish, however, to highlight four key concerns:

It will be essential in safeguarding the interests of patients to ensure that the assessment, care planning and decision making for each patient in hospital are at all times driven by best clinical and multidisciplinary practice, underpinned by sound clinical governance.

This is implicit, but insufficiently explicit in the document. It presupposes a central and mandatory role for physicians and their allied professional colleagues (including social workers) in this speciality.

If the detail is not right, this proposal may not necessarily achieve effective change, whilst coincidentally undermining the developing relationships between health and social services departments, particularly in the community.

This would stifle the innovative thinking, which has led to some examples of excellent joint working. There are well recognised cases where the delays in discharge are not related to any factor which is necessarily under the control of social services (such as the recruitment crisis in home care in some parts of the southeast England, and the closure of many care homes).

We are concerned that this proposal will increase bureaucracy and thus divert money from direct care.

This will have adverse consequences for patients, will be self-defeating for the whole system and will not succeed. Rather, this initiative must be seen to drive health and social services professionals into meaningful collaboration within a single cause - the hallmark (where it happens) of successful service delivery in this field.

We would strongly wish the effects of these changes to be monitored and indeed would suggest a research program be commissioned to analyse the full effects.

Responses to questions
We have attempted below to answer specifically some of your consultation questions.

Q: Are there issues for patients delayed in other settings (such as mental health or non-acute NHS services) which would mean that a system of reimbursement would need to operate differently for these patients?

In non-acute NHS settings there is proportionately a greater problem with patients whose discharge is delayed. This has an obvious knock on effect for patients in acute settings, which often means that patients may be inappropriately placed as they have not had the opportunity for rehabilitation. Tackling the problem in acute beds is not a whole systems approach, as SSD will simply concentrate all their efforts on the acute beds. This will also give the acute sector the perverse incentive to bypass possible rehabilitation.

Were the system to be introduced for non acute NHS (e.g. rehabilitation settings), our expectation is that the culture of multidisciplinary goal setting would enable discharge dates to be predicted well in advance (1 - 2 weeks) and it would be much easier to penalize for systematic delays due to inefficiency.

Q: A number of delays are associated with housing services, which may be handled by a different tier of local government. How can we ensure that housing partners are effectively brought into this system?

Commissioning of the care of older people must utilise all the partners who may be involved in the process, and primary care trusts should be encouraged to enter into discussion with all relevant parties.

Q: Are there other key steps which need to be in place to avoid conflict over the decision that a patient is ready to move from the acute setting and to ensure a robust plan is in place for the patient, which means that they get the right care at the next stage in their care and change processes and practice to enable a discharge plan to be put together within 3 days for every patient?

• In addition to ensuring the necessary up-front involvement of medical and multidisciplinary staff in this speciality, require trusts to have local resolution procedures in place which require and rely on their expertise.
• Require trusts to define with SSD and Community Services in advance what does constitute a require-ment for acute care; (e.g. patient must have a diagnosis or plans to make one, patient does not need to see a doctor in the next week, patient does not need intravenous drug use - with the obvious exception of schemes specifically designed to deliver IV drugs).


• Ensure all patients get a comprehensive assessment on admission, which includes social details. This may mean acute hospitals changing the expectation that other members of a multi-disciplinary team other than physicians and nurses (i.e. other allied professions i.e. the Allied Health Professions) do not routinely undertake such work at weekends.


• Acute health teams should make themselves available to discuss cases with SSD.


• Invest in the IT support needed for the Single Assessment process so that teams in the acute setting know what the background information is - and this can be shared without delay with the local SSD.


• Use care managers who work seven days a week in acute settings, who have real knowledge of the local care systems (although they could still be locality based operating an “inreach” service).


• Accept that in the same way acute beds need to operate at approximately 85 – 90 % occupancy to be efficient, community based social care needs to operate with spare capacity in order to be flexible, which will increase costs.

Q: In general, would such a scale of payment provide the incentives described in paragraph 41?

The arguments on which the scale is based appear to be sound and therefore the incentive would be there. However, we do not believe that the threat of loss of income through readmission is a sufficient disincentive to acute trusts to stop them identifying patients as ready for discharge too early. Many patients will not be readmitted (because they refuse or the care home tries to cope) or will be readmitted to another Trust or care facility.

Trusts should be required to audit a percentage of their reimbursements and discharges to follow up the eventual outcomes for their patients.

We would wish guidance to clarify the reimbursement situation where the patient is defined for NHS continuing care. Since the responsibility for this lies with the PCT, is there an expectation that a system of reimbursement will apply to them also?

Finally, we would wish you to consider rephrasing paragraphs 26 and 27 to be clear about choice. Current Continuing Care Guidance (HSC 95(8)) still leaves the choice about discharge to a Care Home to the patient.

Cameron Swift