1. REIMBURSEMENT IN PRACTICE THE LAST PIECE OF THE JIGSAW? A comparative study of delayed hospital discharge in England and Scotland. June 2007 Michelle Cornes Eddie Donaghy Mary Godfrey Gill Hubbard (Principal Investigator) Jill Manthorpe Jean Townsend

2. Key Questions In what ways, if any, has the reimbursement scheme contributed towards a reduction in delayed discharges? What has been the impact of the reimbursement scheme on partnership working between health and social care? How is the reimbursement scheme being implemented?

3. 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– Jan 2007

4. Tackling Delayed Discharge in Scotland and England 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 In Scotland, there are no penalties if an individual’s delay exceeds agreed time limits. However, the local health and social care partnership as a whole can be penalised if it does not meet its target for reducing delays.

5. Proportion of delayed transfers of care in England for people over 75 years from 2001- 2006

7. Partnership Working “If a patient isn’t being offered a half decent choice then all of a sudden that patient becomes an NHS delay, not social services delay. That’s another loophole in the system… If the resources are not in the system then you will find ways of manipulating the system…” Senior Hospital Manager (Site 3 England) “I think at my level and above, partnership has really improved in my time.” Social Care Manager (Site 1 Scotland)

8. Implementation – Reimbursement in England “If they come into hospital from their own home and then they need to go to a nursing home or residential home it’s quite difficult… These are complex discharges... You need to take time over the process to make sure you have got everything right for them. Three days for getting an assessment done isn’t very long.” Senior Hospital Manager (Site 4 England)

9. Moving too quickly? “Its like a sausage machine in that you get someone being transferred back to a nursing home who is very ill, and someone else coming in even worse into that bed the same day.” Service User (Site 3 England)

10. Implementation - Joint Action Planning Scotland “I’ve been in this job 15 years and we’re still having the same problem... Trying to discharge patients! You put a referral into social work… and it could be eight weeks before they’re allocated a care manager and in that eight weeks nothing happens”. Senior Charge Nurse (Site 1 Scotland)

11. Moving too slowly? “I used to like a laugh but it’s slowly wearing away. I just lost some of my spark, I felt so left out in the hospital, I thought I was never getting out” Service User (Site 1 Scotland)

12. Central Implications Combine advantageous elements of reimbursement and joint action planning to tackle delayed discharge Greater focus on dignity and person centred care.