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Delayed discharge: 'It’s not just about the money'

Sustained concern about the state of adult social care – most recently expressed by Conservative-controlled county councils such as Surrey and Kent – has led the Prime Minister to ask the Cabinet Office to look at options for a more sustainable social care system in the longer term. And with A&E pressures currently in the headlines, it is not surprising that delays in discharging patients who need social care have come under the spotlight.

The Prime Minister recently told parliament that ‘Some local authorities, which work with their health service locally, have virtually no delayed discharges. Some 50 per cent – half of the delayed discharges – are in only 24 local authority areas. What does that tell us? It tells us that it is about not just funding, but best practice.’

She has a point. Our analysis of the latest figures available, covering November 2016, shows very wide variation between councils in the number of days delayed for social care reasons (such as delays in assessments or arranging care at home). Taking account of the size of each area’s older population this ranges from 0 to 25 days (Figure 1). Some 13 per cent of councils account for a third of all delayed days, 22 per cent account for half.

Figure 1: Social care delayed days per 1,000 population aged over 65, by local authority (November 2016)

Figure 1: Social care delayed days per 1,000 population aged over 65, by local authority (November 2016)

There is no clear relationship between the level of funding and the number of delays, as shown by the wide and scattered data points in Figure 2. Councils that have cut spending the most on social care for older people over the past six years perform no worse than councils which have maintained or increased spending. This may be because all councils, irrespective of their financial position, are expected to give priority to supporting timely hospital discharge in how they use their Better Care Fund grant.

Figure 2: Social care delays compared to changes in spending on older people

Figure 2: Social care delays compared to changes in spending on older people

Good partnership-working between local government and NHS obviously helps to avoid delayed discharges but is no guarantee of good performance – for example, some of the Greater Manchester councils had the highest level of delays but other places also in the forefront of integrating health and social care like Northumberland, Nottinghamshire and North East Lincolnshire had the lowest.

But if we turn to delayed transfers for which the NHS is responsible – usually waits for other NHS services – the variation is even wider – from 2 days to 33 days per 1,000 population over the age of 65.

It is clear that places with higher delays for social care reasons are much more likely to also have higher delays for NHS reasons. This implies that there are issues within the local health and social care economy as a whole that drive the level of delays and so the focus ought to be on the performance of the system rather than individual organisations within it.

And although delays for social care reasons have increased sharply over the past 12 months, the majority of delays – 57 per cent – are still due to waits for further NHS services. The fact that most places no longer ‘fine’ councils for delays suggests a recognition that this is shared problem requiring collaboration not blame. Holding councils culpable for delayed transfers is therefore inaccurate, inappropriate and unhelpful. But that does not let them or their NHS partners off the hook.

The fact that there is no single or simple national explanation for the variations places the onus squarely on local leaders to understand what drives local performance and to explain why, as the National Audit Office found, basic good practice is still not in place everywhere, 14 years after the Department of Health first issued comprehensive guidance. Unacceptable variations in basic performance undermine the case for additional funding. As the NHS Providers' review showed, there is no shortage of excellent local initiatives.

There in an important caveat about the accuracy of these figures. If anything they are likely to underestimate the scale of the overall problem, irrespective of which organisation is responsible – as Nigel Edwards, Chief Executive of the Nuffield Trust, has discussed. Some of the variations may be due to local differences in how delays are recorded.

The Prime Minster is right to say that the pressures on health and social care are not just about money, but that does not mean that money is not an issue. Delayed transfers are a symptom of the system’s deeper failure to offer the right care, in the right place, at the right time. In our Home truths report with the Nuffield Trust we highlighted underinvestment in a range of services – primary care, community health and social care services – that are vital to support older people to remain at home and avoid admission to hospital and residential care. If it is not ‘just’ about the money, neither is it ‘just’ about social care. The lack of these basic services offers a more plausible explanation for more older people ending up in A&E and getting stuck in hospital when they are medically fit for discharge. This is especially so for very old people with high levels of acuity and co-morbidity.

It is hard to see how current pressures on social care services or hospitals will be assuaged without substantial additional investment in community-based services alongside local reform and improvement. The Cabinet Office review is looking at how to secure sustainable funding for adult social care – the question is no less urgent for the NHS.