REIMBURSEMENT IN PRACTICE THE LAST PIECE OF THE JIGSAW? A comparative study of delayed hospital discharge policy in England and Scotland. February 2008 Dr Michelle Cornes Dr Eddie Donaghy Dr Mary Godfrey Dr Gill Hubbard (Principal Investigator) Professor Jill Manthorpe Dr Jean Townsend

Policy Background England - Community Care Delayed Discharge Act 2003: Came into effect October 2003 ‘Reimbursement ’- In England, social services can be held liable to charges of £100 per day (£120 in London) if set time limits are exceeded and a patient is found to be occupying an NHS acute hospital bed for the sole reason that they are awaiting community care assessment and the delivery of community care services

Policy Background Scotland Delayed Discharges in Scotland: Report to the Minister for Health & Community Care from Chief Executive NHS Scotland Joint Action Plans NHS Boards and Local Authorities Quote : Funding will not be provided where a NHS Board or Local Authority reduces its present level of funding, or diverts funds into other areas of activity. The Scottish Executive will monitor performance closely, and where partnerships fail to deliver will not release further funds until the Support Team has helped the partnership resolve their difficulties (p.15).

Policy Background Report of Scottish Tripartite Working Group on Delayed Discharge 2005, considered and rejected reimbursement – opted for ‘Whole Systems’ approach Quote - A whole system approach or whole systems working, puts the patient or service user at the centre of the service provision. The users’ experience will define the effectiveness of the system……We are in no doubt that the way ahead for Partnerships is to adopt a whole system approach.

Key Questions In what ways, if any, has Reimbursement and Joint Action Planning contributed towards a reduction in delayed discharges? What has been the impact Reimbursement and Joint Action Planning on partnership working between health and social care? How is Reimbursement and Joint Action Planning being implemented?

Our Approach Individual Perspective – 15 Patients and 15 Carers per site Organisational Perspective – Practice level - staff responsible for above patient cases (Social Worker, Nurse, OT’s, Physio, Consultant (30 interviews per site) Structural Perspective – Strategic planners at Health Board & Local Authority level (Chief Execs, Directors of Strategic Planning, Medical Directors, Care of Elderly Leads, Lead Consultants, Care of Elderly planners (10 interviews per site)

Study Design Conducted in five sites, three in England and two in Scotland. Qualitative study – broad focus on delayed discharges and then specifically on the effects of reimbursement Interviews with strategic and operational managers (n=56), older people (n=68), carers (n=38) and front-line staff (n=132) from Jan 2006– Feb 2007

Proportion of delayed transfers of care in England for people over 75 years from

Delayed Discharges in Scotland 6 weeks and over

Similar trends in England & Scotland

Effects of Joint Action Planning in Scottish Sites Site 1 – April 2002 approx. 150 delays October 2007 approx. 50 delays 67% reduction Site 2 – April 2002 approx. 307 delays October 2007 approx. 55 delays 80% reduction

What Worked Well? In Scotland partnership working on delayed discharge between health and social work at strategic level has improved considerably since April 2002 following Joint Action Planning Since JAP, delayed discharge is seen as a top priority by strategic planners in health and social work

Partnership Working has raised Priority of DD It is a high priority. In last three years it’s never not been one of the four corporate objectives. It’s now incorporated into what we call our monthly governance and scrutiny programme, this will retain it at a very high level Senior Strategic Local Authority Manager Site 2

Joint Action Planning has Improved Partnership Working at Strategic Level in Scotland I think there’s much, much better partnership now. I mean absolutely no comparison with four or five years ago. We go along every month and meet with social work, we openly discuss what’s happening with delays…… previously it was a them and us attitude. Strategic Health Care Planner Site 1

Barriers to Partnership Working Strategically Lack of transparency over budgets can negatively affect partnership working I think partnership working works in the main very well, until you start speaking money…especially when the money is being spent on things its not supposed to be spent on, usually when a crisis occurs Strategic Health Care Planner Site 2 I know for a fact some of the delayed discharge money is being spent on other things…. Its being used to fund what I would call recurring services. Just part of the day job! Strategic Planner Social Work Site 1

Partnership Working at Practice Level Progress strategically not matched at practice level Some tension between health and social work staff particularly in acute sector Advances in multi-disciplinary working but continued dominance of medical profession

Partnership Working at Practice Level in Scotland Uneven momentum, tends to be high intensity around census time Over–reliance on delayed discharge co- ordinators Partnership working needs to be more developed at everyday practice level

England Partnership at strategic level not as developed as in Scotland Reimbursement ‘focused minds’ by providing benchmarks for different stakeholders at practice level & not as divisive as forecast However where health and social care economy under pressure, reimbursement could be divisive

Similarities between England & Scotland Variable Patient & Carer experiences Experience of lengthy hospital delays: tedium, boredom, loss of confidence, physical deterioration, noise levels, mixed sex wards Dignity issues around older peoples’ care and need for better information

Central Implications Combine advantageous elements of Reimbursement (at practice level) and Joint Action Planning (at strategic level) to reduce delays to zero. Greater focus on dignity and person centred care.