17. Delayed transfers have been inching back up again
Delayed transfers from hospital due to social care are well below their peak but have increased
Delayed transfers from hospital attributed to social care are still well below their peak in the winter of 2016/17, but in September 2019 the monthly rolling average started to increase. However, it remains the case that the NHS rather than social care accounts for most delayed transfers.
- What is a delayed transfer of care?
A delayed transfer of care occurs when a patient is ready to leave a hospital or similar care provider but is still occupying a bed. It is sometimes described as ‘bed-blocking’ (and, even worse, the individuals described as ‘bed-blockers’) even though in reality it is typically the system causing the delay.
Administratively, delays are attributed either to the NHS or to social care (or both) and can occur when patients are being discharged home or to a supported care facility, such as a residential or nursing home, or are awaiting transfer to a community hospital or hospice. The most common reason for delay is awaiting a care package at home, followed by awaiting further non-acute NHS care. Other reasons for delay include waits for assessments, waits for funding, and patient or family choice.
The figures for delayed transfers attributable to both social care and the NHS are higher than they were in 2012, despite a concerted effort by local authorities and NHS organisations – under intense scrutiny from the government and NHS England – to reduce pressure on acute hospital beds. A key factor in the decrease in delayed transfers has been the extra money provided to councils through the Better Care Fund.
Clearly, it is important that people do not spend more time in hospital than is necessary, both in terms of the impact on their overall health and the need to make best use of beds, which are at record occupancy levels. However, there has been a concern that focusing too heavily on delayed transfers can detract attention from preventing avoidable admissions in the first place, and from ensuring that transfers are not just made promptly but also appropriately. In 2019, ADASS said it believed that pressure to get older people out of hospital was sometimes leading to them being moved directly into residential care when they did not need to be there.
The focus on delayed transfers of care can also overshadow the reality for councils: four in five of their referrals come not from hospitals but from community settings, and the greatest rate of increase in demand for social care services is coming not from older people but from working-age adults.
18. Fewer older people receive reablement
The trend for reablement services contrasts with that for short-term care generally
In 2018/19, 1,700 fewer people over 65 received reablement when they were discharged from acute or community hospitals – down 4 per cent on the previous year. This is despite a great deal of evidence that reablement works. The National Audit of Intermediate Care shows that 75 per cent of people improve their independence as a result of reablement, with typical gains in mobility and other abilities of more than 33 per cent. On average, four in five of those receiving reablement services are still at home 90 days after leaving hospital.
- What is reablement?
Reablement is one of a range of short-term services for people whose health has deteriorated and/or who need support to re-learn skills to keep them safe and independent at home. It is categorised as a type of intermediate care, most commonly delivered by social care staff. The other types are crisis response, home-based intermediate care and bed-based intermediate care. Reablement can be provided to anyone who would benefit but often, in practice, it is arranged as someone leaves hospital, with the aim of preventing them being readmitted.
The fall in numbers of people receiving reablement from hospital does contrast with the wider trend on short-term care to maximise independence (ST-Max), uptake of which rose by 3 per cent among older people last year and 22 per cent among working-age adults. This may suggest a more enablement-focused approach to social care generally. However, the growth is from a low base – only around 2 per cent of the older population access short-term care services and the proportion of older people using ST-Max per 100,000 population has in fact fallen slightly since 2015/16. The trend for working-age adults, for whom uptake of ST-Max has increased by 44 per cent since 2015/16, may be more significant – albeit it from an even lower base.
Why might reablement services from hospital have decreased? One possibility is that older people in particular are being routed into different types of care than reablement. Though it is hard to find data, many areas have an increased focus on ‘discharge to assess’ and ‘Home First’ approaches, either in people’s own homes or in residential care. This may mean that service users are receiving services that are not recorded as ‘reablement’.
However, there was concern from directors of adult social services in 2019 that discharge to assess approaches may be being used inappropriately, leading to a warning of the risk that short-term placements might become long term, permanent ones. It is noticeable that there was indeed an increase in the number of older people admitted to permanent residential care in 2018/19 (see indicator 16).
19. NHS Continuing Healthcare has shifted towards short-term provision
Fewer people are receiving standard, long-term CHC but more get fast track funding
NHS Continuing Healthcare (CHC) is a critical issue for local authorities and people who need social care because CHC funds not only an individual's health care – which would be free under the NHS anyway – but also their social care, which otherwise would be means tested. Since social care costs can be very expensive, it can make a huge financial difference to an individual if they have to pay these costs themselves or, if that person has low enough assets to qualify for publicly funded social care, to the local authority, who would otherwise have to pick up the bill.
Between 2013/14 and 2018/19, there has been a 13 per cent increase in the number of people receiving NHS Continuing Healthcare (CHC), but that overall increase involves a 16 per cent fall in the number of people receiving long-term ‘standard’ CHC and a 40 per cent rise in the numbers receiving short-term ‘fast track’ CHC. The overall rise also involves a small fall in the overall ‘rate’ of receipt – the number receiving CHC for each 50,000 of the adult population.
In terms of expenditure, in July 2017, the National Audit Office reported that NHS England estimated spending on CHC, NHS-funded nursing care and assessment costs would increase from £3.6 billion in 2015/16 to £5.3bn in 2020/21. It reported that NHS England wanted CCGs to make £855 million of savings on CHC and NHS-funded nursing care by 2020/21 on this prediction of growth.
Data supplied to us by NHS England and adjusted for inflation (see table below) shows that real-terms expenditure on standard and fast track CHC had both increased from 2014/15 to 2016/17. Since then real terms expenditure on standard CHC has fallen and fast track has stayed level. However, spending on CHC through personal health budgets has increased significantly since 2014/15.
The data shows large disparities in spending between CCGs. For example, in 2018/19 the highest-spending CCG spent £13.7 million on ‘standard’ CHC per 100,000 of the adult population, whereas the lowest-spending CCG spent £1.5 million. For ‘fast track’ CHC, the lowest-spending CCG spent £0.2 million and the highest £2.8 million.
There is little agreement about what accounts for these trends in take up and spending.
A revision to the national framework on CHC and FNC was published in 2018 but NHS England told us that national eligibility criteria, as set out in the Department of Health and Social Care NHS CHC policy and associated guidance and tools, have not changed and that a factor in the reduction of the rate of receipt may be attributed to carrying out assessments for CHC in the community or at home, rather than in hospital where an individual is most vulnerable and may be assessed for care that they don't in fact need.
Campaign groups argue this is not the main reason for the reduction and instead say there has been an effort by some clinical commissioning groups (CCGs) to reduce their costs by in practice setting the eligibility bar higher than previously. They argue the wide variation in individual CCGs’ provision of CHC goes beyond demographic variation. In addition, in an annual survey of Directors of Adult Social Services, four in five councils said they had been subject to additional cost pressures due to reduced CCG funding of CHC.
NHS England told us CHC is 'part of a complex health system and there are multiple and complex drivers which may impact on levels of NHS CHC, including the availability of, and access to, other community services. These cannot be "quantified" and therefore it is not possible to analyse the levels of NHS CHC using data alone.'
Total spending on funded nursing care has increased in real terms from £512 million in 2014/15 to £678 million in 2018/19. This may be related to a significant increase in the rate paid for funded nursing care, from £112.00 (standard) and £154.14 (higher) per week in 2015/16 to £158.16 (standard) and £217.59 (higher) in 2018/19.
However, funded nursing care has also shown a decline in the rate of receipt and again the reason is difficult to unpick. There may be a connection to the fall in the number of nursing home beds in relation to the over-75 population (see indicator 16), which in turn may be related to the trend towards supporting people in their own homes for longer.
- How do NHS Continuing Healthcare and NHS-funded nursing care work?
NHS Continuing Healthcare (CHC) is a package of care provided outside of hospital that is arranged and funded solely by the NHS – via local clinical commissioning groups – for individuals who have been assessed as having a 'primary health need' as set out in the National Framework for NHS Continuing Healthcare and NHS-funded nursing care.
NHS-funded nursing care is when the NHS pays for the nursing care component of nursing home fees. The NHS pays a flat rate directly to the care home towards the cost of this nursing care.
- What is fast-track CHC?
Individuals are eligible for fast track if they have a rapidly deteriorating condition that may be entering a terminal phase; for this reason, fast track is usually provided for a much shorter period of time than standard CHC.
20. Grants to improve disabled people’s homes have increased
Increased central government funding has led to more Disabled Facilities Grants
Central government funding for Disabled Facilities Grants (paid through the Better Care Fund) has increased significantly since 2015/16 and this has led to a rise in the number of people with disabilities’ homes being adapted by local authorities. The average number of grants by each local authority rose from 123 in 2015/16 to 165 in 2018/19.1
- 1. The computer system for processing Disabled Facilities Grants changed in 2017/18, affecting data capture.
- What do Disabled Facilities Grants cover?
Disabled Facilities Grants help the growing number of homeowners on low incomes to fund essential adaptations like level-access showers ('bathroom modifications' make up over half of all grants), stairlifts and ramps. They are not the only source of adaptations; local authorities and CCGs provide smaller adaptations (such as grab rails) and loaned equipment (such as bath seats) through the Integrated Community Equipment Service. However, it is not possible to identify nationally the numbers provided or the amount spent on them.
Disabled Facilities Grants are potentially an important part of strategies to enable older and disabled people to live independently in their homes for as long as possible, so the increase in the number of grants is good news. There may be some caveats though. Local authorities do not appear to have matched the increase in central funding with their own money, because while central funding has more than doubled since 2015/16, the number of grants increased by only a third.
The 53,500 completed grant applications in 2018/19 is a significant improvement on the 41,000 estimated to have been completed in 2014/15, though there is still some way to go to meet expectations that grants would double from that point.