Contact: Lynn Waight ext: 7265

1. Introduction

1.1 The Delayed Discharges (Community Care) Act was given Royal Assent in April. This piece of legislation requires acute hospital trusts to invoice social services departments at the rate of £100 or £120 (dependent upon area - Hampshire £100) per day for every delay in an acute hospital bed that can be attributed to a broad range of social care reasons as laid down by the Department of Health. Both elective and emergency patients are included.

1.2 The Act states that acute trusts and local authorities have to implement a shadow system for operating this regime (also known as `Reimbursement') on 1 October 2003. The `live' date is 5 January 2004 and it will be from this date that transactions will involve authentic payments, where delays fulfil the criteria.

1.3 The official Guidance was issued for consultation at the beginning of August and a response to it will be sent to the Department of Health by the 6 September 2003. This guidance and further information can be found at http://www.doh.gov.uk/reimbursement

1.4 It is stated within the guidance, that the object of the legislation is not to financially penalise and to establish perverse incentives, but to force health and social care partners to work together to improve whole system working. It is understood that future phases of reimbursement will include all beds and not just those which are currently designated as `acute'.

1.5 Local authorities have been directly allocated delayed discharge grants to offset the costs of fines. Hampshire has the largest allocation of £1.2m (half a year), presumably in recognition of the specific mix of capacity, workforce recruitment and price problems experienced in this County. The grant, however has not yet been paid due to a delay in parliamentary business. It is expected that it will materialise some time in the Autumn.

2. Background

2.1 This report is to document the progress of the project to establish adequate systems to ensure a smooth transition to the reimbursement regime.

2.2 In parallel to the work of the project, emphasis has been placed upon the work of the Social Services Department to reduce delayed transfers of care. The County Council has set aside additional funds (£3.5m) to support this initiative and a business case has been prepared for cabinet approval to release the funds.Further additional funds (another £3.5m) have been made available to help older people live at home whilst receiving intensive home care. This will also impact positively on delays.

3. Process

3.1 The project team have engaged with health and social care partners across the whole of Hampshire. A pan-county group has been established whose membership includes reimbursement lead officers from each of the five acute trusts, nine primary care trusts and the strategic health authority; it is also in contact with three social services departments from outside the County within the context of the project.

3.2 It acts as a conduit for information and a good practice forum and informs the work of the operational and financial groups and provides local support where needed.

4. Operations

4.1 Five operational process groups are working on the necessary systems that will need to be in place at the interface between acute trusts and social services staff to standardise the discharge process in order for it to support reimbursement.

4.2 The legislative requirements have highlighted anomalies in several areas of practice for both social services and acute trust staff.

5. Finance

5.1 At the first meeting of the pan-county group the finance leads also attended to make contact with colleagues. Discussions are now taking place in respect of validation of data, invoicing protocols and other individual organisational financial requirements.

6. Information Technology

6.1 An electronic solution to the data collection problems has now been identified - known as `Eworks'. A detailed proposal is due to be completed shortly.

6.2 The exchange of information at the interface between acute trusts and social services hospital teams will be initially carried out via a manual paper exercise which will run parallel to the initial trials of the `Eworks' solution. It is envisaged that providing all is well, the electronic version will stand alone early in the New Year.

6.3 A scoping exercise is currently nearing completion which will highlight kit and access needs from each acute site.

6.4 The Department of Health have agreed to allow social services departments access to health's SITREP information collection system. This system will show us total reported SITREP delays and their reasons, both health and social care.

6.5 The inhouse spreadsheet which is used for validation of social care delays and will in future be used to identify `reimbursable' and `non-reimbursable' delays is in the process of being redeveloped.

6.6 We are still awaiting definitional work to be completed by the Department of Health and our systems and staff training for reimbursement cannot be finalised until they are made available.

7. Recruitment

7.1 One of the first scoping exercises carried out by the project team was to estimate the number of additional care management staff that would be needed to support the extra work generated by the reimbursement legislation. As a result of this piece of work it is envisaged that an additional nineteen care management posts countywide, including five senior practitioners, are needed.

7.2 At the time of writing over half of these nineteen posts are filled.

8. Service Development

8.1 The work of social services teams across the County focusing on reducing social care delays in acute trust settings has shown notable results over the last six months. The numbers of social care delays recorded have been halved overall.

8.2 Valuable experience relating to definitional anomalies has been gained and management awareness of the complexities of individual situations has been further raised. `Hotspot' areas are easily and quickly identifiable and responses are speedy and informed. This work requires constant and vigilant attention which is not easily facilitated because of the range and geography of situations and sites. The management of the balance of expediency and consistency needs careful monitoring.

8.3 The identification of further areas for development lies with local implementation teams (LITS), already established for a variety of combined tasks, not least to drive the National Service Framework standards forward. LIT membership would usually encompass local stakeholders from each PCT area.

8.4 Some other local authorities are considering pooling the grant in an officially pooled budget with the local PCT and that money will be used during this current financial year to fund jointly prioritised schemes to offset delays. Reimbursable delays would need to be tracked, but fines would not be levied against reimbursable delays until the amount of the grant had notionally been exceeded.

8.5 Hampshire Social Services have not felt this course of action to be a prudent one, not least because of the financial risks and the complexity of the health economy, but largely because of the developments that have already been funded from the additional monies made available by the County Council over and above base budgets. This investment exceeds the amount of the (whole year) Grant.

9.0 Evaluations

9.1 It is to every stakeholders' advantage that the shadow period between 1^st October and 5^th January will provide three months in which to test systems and to ensure that appropriate support is in place.

9.2 The areas that will need evaluation are as follows:

9.2.1 The number of shadow reimbursable delays/reasons and therefore data validation to inform financial modelling.

9.2.2 Measurement of the feasibility of the staffing for the additional work for reimbursement, both in terms of post numbers and types.

9.2.3 Evaluation of service development actions and identification of areas for improvement. The results of the intermediate care evaluation will also assist with development work.

10. Risks

10.1 Outlined below are the apparent risks to the organisation from the implementation of this legislation.

10.2 At the current level of delays (Social Care reasons) we would be paying an estimated £2.5m per annum. We envisage a continued reduction in the number of delays but believe that the turnover and volume of acute patient movements make some fines likely. Also, the pace of service development, like the Nursing Homes Investment Strategy, means a time-lag beyond 5/1/04 in improvements to service capacity.

10.3 Also with intense focus and operational emphasis being placed on clearing delays (i.e. from acute beds), a bottleneck further down the chain for example in community beds, may be building up and therefore create pressures across the system.

10.4 National pressures are also directing social services teams towards `interim bed' solutions for delays. There is a risk that this may be only a very short term answer and could potentially stack-up costs of institutional care and again produce bottlenecks in the system.

10.5 The DoH definitional work needs to be completed and made available to local authorities. If this is not received systems and training will not be in place within manageable timescales.

10.6 In addition the evaluation work must take place between October and January. The risk attached to not doing so would mean there will be no indications of the numbers of assessments needed (or not needed) and we would therefore not be able to adjust staffing and systems support. The Department would thereby be vulnerable to incurring fines.

10.7 This model and system of working requires a full complement of staff at all times on acute hospital sides. Not withstanding recruitment issues there will need to be a balance of priorities across all critical areas of our business, including responses to Older People in the community. This will require a particularly flexible approach to staff deployment.

10.8 One risk which we cannot overlook is the focus of attention being misplaced onto system and process implications, at the expense of putting the needs and well-being of older people at the centre of our activity. This message has bee reported in our responses to consultation requests from government and will be reiterated to staff groups directly involved in the implementation.

11.0 Recommendation

11.1 To note the Departments Preparation for the Implementation of the Legislation and the associated risks.

Section 100 D - Local Government Act 1972 - Background Documents

The Following documents disclose facts or matters on which this report, or an important part of it, is based and has been relied upon to a material extent in the preparation of this report.

NB the list excludes:

1. Published works

2. Documents which disclose exempt of confidential information as defined in the Act.