Delayed discharges from hospital are a widespread and longstanding problem that can have a significant impact on both patients’ recovery and the efficiency and effectiveness of health and care services. In England, it has become normal practice for government to provide additional one-off funding to reduce delays every winter, as the problem is particularly acute during the colder months.
We interviewed commissioners and service providers in six local areas to find out how they experienced the process of receiving additional funds, making plans, and delivering and monitoring the plans in winter 2022–23.
Although they welcomed extra funding, they told us that it came with insufficient advance notice for effective planning, sometimes having to be spent on residential care that was available at short notice rather than developing more services to support people at home. Commissioners and service providers also wanted to be able to use the funds to prevent avoidable hospital admissions, and strongly criticised burdensome monitoring requirements.
Some areas did manage to use the funding to put services in place and support the social care workforce but were not confident they were spending funding as effectively as possible.
The six sites had varying depths of partnership working and did not all have a shared understanding of local causes of delayed discharges and priorities for action. This, together with fragmented and inconsistent data, could hinder their ability to use additional funding effectively.
Why we did this research
The research was primarily intended to provide feedback and learning to the Department of Health and Social Care about local areas’ experiences to help inform its planning for winter support in future years. We also drew out recommendations for local health and care partners to help them prepare for any future short-notice, one-off funding.
What we did
We recruited six areas to take part in our research. Each had different levels of delayed discharges and different characteristics, such as how many local authorities the hospital worked with. In each area, we interviewed key staff from the local authority, the NHS hospital, the integrated care board, Healthwatch and the local care providers’ association. To ensure that these places were not atypical, we also tested our findings with NHS and local authority staff from different areas, national bodies for providers, commissioners and service users, and academics.
What we found
The short notice of the funding, and the short timeframe within which it had to be spent, significantly constrained local plans. Usually, only a few organisations were involved in planning, and some short-term decisions conflicted with longer-term ambitions to reshape the social care market. Places did boost care services and staffing but were not confident they were spending the money in the most effective way possible.
Funding was allocated separately to the NHS and local authorities with an expectation that it should be pooled. In some places, this caused initial feelings that each had their separate money, even when it was nominally combined into one pot. Organisations had to work through a process to overcome this before they could start acting as one integrated local system.
Funding was provided in two tranches: one of £500 million and the second of £250 million. Each had different conditions, which were not known in advance. The first tranche required fortnightly reporting while the second required daily reports. Both required detailed, bespoke information rather than routinely collected data. There was strong criticism regarding the lack of co-ordination between the two tranches and the burden of reporting.
Causes and factors affecting delays varied significantly between each place. Where conditions of funding required bed-based care or did not allow for prevention of avoidable hospital admissions, it was often experienced as unhelpfully conflicting with the need for local flexibility.
Interviewees in all six areas claimed that they worked in close partnership, but generally went on to describe incompatible views on local causes of delayed discharge and who should do what. The depth and maturity of relationships varied widely; this was not helped by separate data rather than a single, shared view of performance. One place had put notable effort into developing shared understanding and winter plans, was better prepared when funding became available and appeared more innovative in using it.
The government should only use one-off, ring-fenced funding to reduce delayed discharges on an exceptional basis, rather than the pattern of ‘recurring non‑recurrent’ funding of recent years. If such an approach is necessary, then it will require sufficient lead-in time for effective planning. The Department of Health and Social Care has now published allocations for funding to reduce delayed discharges in 2023/24 and 2024/25, which is welcome.
The Department of Health and Social Care should ensure that mechanisms for allocating funding reinforce a sense of one shared funding pot for locally integrated health and care partnerships, rather than separate pots. It should avoid multiple systems for monitoring spending and separate funding criteria, or at least co-ordinate them.
Since the causes of delays, and the opportunities to reduce them, vary widely from one place to the next, it is essential that any conditions attached to one-off funding allow for local flexibility. The Department of Health and Social Care has already published funding conditions for 2023/24, but guidance should clarify whether there is flexibility to spend the money on preventing avoidable hospital admissions.
The more that one-off funding to reduce delayed discharges can allow for flexibility and avoid prescription, the more monitoring requirements will need to be higher level and potentially focused more on outcomes and overall system performance rather than on detailed inputs. The Department of Health and Social Care should review and improve the way it monitors future funding, involving the national representative bodies for local health and care partners in that process.
Local health and care partnerships
Although all sites used the language of working as integrated partnerships, only one really demonstrated a shared understanding of local causes of delays, current priorities and had plans that could be scaled up if and when additional funding became available. Developing a shared understanding should be a priority – partly because it can help places make best use of the available funding, and partly because working together to reduce delayed discharge offers rich learning to help increase the depth of local integration. As part of developing that collective understanding, joined-up information systems with a single, shared view of performance are likely to be essential.
About this report
This work was commissioned by the Department of Health and Social Care and funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme (grant number NIHR200702). Views expressed and any errors are those of the authors and not those of the NIHR or the Department of Health and Social Care.