Hospital delayed transfers and the social care crisis
Over the past months, the press has been full of emotive headlines about how social care is in “crisis” and how a lack of funding within social care causes delays in assessment and discharge of patients, which in turn causes bed blocking within hospital wards, placing a further strain on NHS resources. Some have directly blamed government cuts – social care is funded and managed by Local Authorities, many of whom have seen reductions in funding from central government over the last decade, while others in the media have called for the reform of a system that they see as broken. In the recent budget, the Government earmarked £2bn over two years as a temporary measure for Local Authorities pending the publication of a green paper to look at social care funding.
Is the reality this simple?
The question of funding is straightforward: ageUK has stated that the net expenditure on social care has decreased in real terms from £8.1bn in 2005/6 to £6.3bn in 2014/5. And then there’s the issue of both a growing and aging population. The Office for National Statistics estimates that both the population as well as the over 65 demographic will continue to grow over the next thirty years. There are currently around 65.5m people living in the UK, which is up from an estimated 60.4m in 2005. Those aged 65 years and over accounted for 15.9% of the population in 2005 and 17.8% in 2015. At the same time, studies by ageUK evidence a “flat-lining” rate of disability free life expectancy (i.e. the number of years that a person will live without significant health or social care needs), which coupled with a general trend for increasing life expectancy over time means that it is more likely that a greater pressure will be put on both health and social care.
It is doubtful that efficiencies realised since the 2005/6 financial year have managed to account for the almost £2bn in expenditure, while at the same time population has grown and appears likely to continue to grow. The £2bn promised by central government over the next two years, while welcome, will only reinstate half of what has been lost in real terms since 2005/6. Therefore, we can see barring no innovation, health and social care will need greater funding to meet demand by the rising population. It follows that if health and social care does not obtain greater funding, and if innovation and efficiencies are unable to plug the gap, and if threshold criteria remains constant, delays will result as the workload will increase without the resource to manage it effectively.
Returning then to the question of one of the main health and social care touch points, that of hospital discharge, and the question of wasted resource caused by delayed discharges. At the time of writing, the latest statistical press notice from NHS England regarding the delayed transfers of care shows an increase from 169,900 delayed days in March 2016 to 199,300 in March 2017, a rise of just over 17.3%. Of the delays in March 2017 55.3% were attributable to health, 36.8% were attributable to social care (up from 32.2% the previous year), while the remaining 7.9% were attributable to both. This in itself is interesting, as while the percentage attributable to social care delays is high (and increasing), the delays in transfer internally within the NHS itself is significantly higher. Looking at the delay reason, by far the greatest number of hours delayed in March 2017, at 29,509 was found in the acute sector, where the patient was awaiting further non-acute NHS care (including intermediate care, rehabilitation services, etc.). In contrast, the highest number of social care delays were 15,661 hours where the reason for the delay given was that the adult was awaiting a care package in their own home. It would be interesting to further break down the delays within the NHS itself, however, such figures are not easy to obtain – are the delays from acute to non-acute because the non-acute places themselves are blocked by social care, or are there other issues within the NHS causing these – or is it a mixture of both? Put simply, would eliminating the delays in transferring to social care allow the NHS to move patients through their system more smoothly, or are there other, more significant issues that need to be addressed within the NHS – where (or in what proportion between health and social care) would the money be best spent?
In some areas, a solution has been used whereby the adult, upon being deemed to be medically fit for discharge has been moved into either a residential reablement type setting, into a short term residential unit, or onto ‘bed blocking wards’ within the health system. This may be done, for example, to relieve pressure on NHS acute wards while home based reablement is found, or a care package put in place. However, it is not without its drawbacks – from a local authority perspective residential is charged differently to domiciliary care, and as it is not legal to charge for services without doing a financial assessment, it is likely that the cost of these short term periods of residential stay will need to be met entirely by the local authority. More seriously, however, is the impact upon the adult of additional moves and being in unfamiliar surroundings. Clearly, if the care provided is in the form of residential reablement, and the service has been assessed as a best option to be provided in order to assist the person to recuperate from their hospital stay, the experience could be positive, but I have more concerns where the move is just a warehousing of the adult in a limbo between hospital and a final package being provided in a short term residential bed with possible unassessed and/or unmet need. This is particularly concerning when an enormous amount of evidence points to unfamiliar surroundings as presenting particular issues for suffers of many dementia-related illnesses. I therefore think that while there is a place for short term residential placements following a hospital stay, it must be done following assessment and be in the best interests of the adult, and not solely for the convenience of the health and social care services.
While on the subject of hospital discharge, with the introduction of the SALT returns, it is clear that there has been an interest taken by central government in the effectiveness of short term support to maximise independence (or reablement to you and I). The theory is that reabling support being offered upon hospital discharge or as a diversion from hospital services should in many cases reduce the rate of readmission – some studies have shown that this is the case, while others have shown it may reduce the requirement for ongoing social care support. However, more data and study is currently needed in this area to determine where the greatest benefits lie and the optimal amount of investment required in reabling services.
The next question is whether technology can offer further efficiencies. Certainly, there are some technologies both established and in pilot stages which can offer some efficiencies in order to speed the social care assessment and discharge process. Systems integration to allow the automation of assessment, discharge, and withdrawal notifications is a reality in some areas, such as the London Borough of Islington – meaning social care are alerted immediately to new patients potentially requiring social work assessment so that the process can be started earlier, existing services suspended, and a prioritisation of the assessment itself occurring, without the need to manually re-type data between systems. Newer technologies such as mobile devices offer the ability to carry out assessments completed in part with the adult on a ward without a need to return to the office to type up handwritten notes. Still in the early stages of use are electronic brokerage and marketplace solutions, which may also allow care to be commissioned more quickly, and services restarted upon discharge without a lot of telephone calls being made, and therefore reducing delays. Another interesting new technology is that of self-service portals; these can allow carers, relatives, and advocates to see the social work assessment upon completion and communicate electronically with the assessing worker. This has the potential to facilitate communication between a busy working relative and a busy social worker using electronic messaging, at a time that is convenient for both, rather than leaving constant messages for call backs because one or other party is unavailable, and remove the costs and delays associated with written and postal correspondence. Finally, data warehousing and aggregation has a great part to play to both measure outcomes improvement on a whole population level (as well as a team/locality or individual basis) about the effectiveness of a particular service (e.g. reablement at reducing hospital readmission). This can also be used in predicting future need by the use of modelling different service mixes and population – something which I am aware that NHS Digital are interested in expanding in their future works programmes.
In conclusion, I believe that, notwithstanding the additional research required into the effects of both, while reablement and new technology can provide efficiencies, the twin challenges of an increasing elderly population and cutbacks in spending on social care is already having a significant impact on the health service and the care able to be provided by some local authorities. While the entire problem of delays in health cannot be laid at the door of social care, it is likely that unless funding is increased, delays in social care will continue to worsen and these delays will have an increasing impact on the NHS. We all await with interest the green paper into social care funding reform that the government committed to at the last budget.
Statistical Press Notice – Monthly Delayed Transfers of Care Data, England, March 2017, NHS England, online: https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2016/06/March-17-DTOC-SPN.pdf
Overview of the UK Population, March 2017, Office for National Statistics, online: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/articles/overviewoftheukpopulation/mar2017