Contact: Andrew Brooker ext: 7281 email: [email protected]

1. Introduction

1.1 Through the Social Services Department, Hampshire County Council has invested both time and money in focused activity to reduce delayed transfers of care.

1.2 This work has been reported throughout the County Council because it forms part of Hampshire County Council's PSA target and is part of the national policy framework related to the delivery of the NHS Plan which is monitored by the Department of Health. Most recently, the introduction of the Delayed Discharges (Community Care) Act and the reimbursement regime has required further analysis, preparatory work and reporting of the impact and potential risks to the County Council.

1.3 It is important to retain sight on the driving policy objective of this work. This is to ensure that an older person receives the right care at the right time in the right place. Hampshire County Council concurs with the view that it is not appropriate for patients to occupy acute beds when they no longer need acute treatment. However, it is clear that the number of patients remaining in hospital for reasons other than waiting for social care have not reduced " as much as social care waits".

2. The Context

2.1 Attached to this report in Appendix 1 is the report to the Cabinet meeting on 27^th October 2003 for the release of the £3.5m contingent funds for delayed transfers of care. This formed part of the Budget Monitoring Report of the County Treasurer. The Cabinet approved, among other decisions, the business case as set out in the Appendix, subject to agreement by the Leader at his Executive decision meeting on staged release of this contingency in line with commitments and improved performance.

2.2 Appendix 1 details the current performance, costs and capacity issues that support the business case for the release of the funds. It also outlines some of the immediate implications of the introduction of the reimbursement system.

2.3 There are complexities in this work when trying to explain activity and associated costs. The particular method used nationally to monitor performance is a weekly-snapshot measurement of delays broken down into categories. The activity level and turnover of patients in the days surrounding measurement day is not reported. What we know is that for every one reduction in the snapshot count, the Department will have been involved in arranging and securing discharge care packages during the preceding week for maybe 7 - 10 other patients whose delayed transfer of care has been avoided. The associated costs of this level of turnover and activity are explored in paragraph (2.3) of Appendix 1.

2.4 It is important to also consider that emergency admissions are increasing and targets are set for a reduction in the RATE of growth in this area of activity. This, coupled with the prescribed NHS targets for elective surgery and waiting lists, and the increasing numbers of older people in the population, mean the only significant influence on the level of activity and turnover is the numbers of actual acute hospital beds in the system.

3. Risks

3.1 There are risks attached to the implementation of the Reimbursement legislation.

3.2 We are using the shadow implementation period from 1^st October 2003 to 4^th January 2004 to test systems and evaluate numbers of assessments needed and workforce deployment as well as potential levels of reimbursable delays.

3.3 The reimbursement system requires a full complement of staff at all time in acute hospital settings. As a critical business area and the need to balance our priorities, there may be knock on effects for our community-based activity.

3.4 Also with intense focus and operational emphasis being placed on clearing delays from acute hospital beds, a bottleneck further down the health system for example in community hospital beds may be created.

3.5 Such pressures and the increased acute activity are steering us towards focussing on `interim' care solutions. To secure such arrangements, often necessitating the purchase of residential or nursing home care, we may need to pay above inflationary price rises to secure the necessary capacity. The most common reason for delay is nursing home placement and there is a time-lag between now and when the additional Hampshire County Council nursing home beds will be operational.

3.6 Above all there is a risk to our core business of care within the community. This comes both from: (a) attention being given to implementing the reimbursement `system' and speedier responses needed within acute settings at the potential expense of putting the needs and well-being of older people at the centre of activity; and (b) across our whole range of activities the increasing use and focus of resources within acute activity that will reduce our ability to maintain levels of service for older people who have ongoing and long term community care needs.

4.0 Recommendation

4.1 To note the Social Services Department's work and resource needs related to Delayed Transfers of care.

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.

Appendix 1

Release of the £3.5m contingency for delayed transfers of care

1 Purpose of Report

1.1 This report outlines the business case for the release of the £3.5m contingency for delayed discharges for hospitals.

2 Current Performance

2.1 Social Services has invested heavily to reduce delayed transfers of care from acute hospital beds.

2.2 For the week ending 30 March 2003 the total number of delays reported for Hampshire was 225, however only 116 of these were `Social Care Waits'. For the week ending 7 September 2003 the figures were 160 and 51 respectively. These much lower figures reflect the impact of the additional investment by the County Council and further improvements are anticipated by 1 January 2004.

2.3 However, because of throughput issues (i.e. reducing the Sitrep figures by one, may involve between one and five moves) the projected cost of halving the social care waits will have cost Hampshire (current spend plus commitment basis) £4,021,596 or approximately £60,000 for each reported reduction. Following this theoretically indicated that to clear the Sitrep list at current rates would cost Hampshire in excess of £8m, assuming capacity in the private sector.

2.4 The most common reason for delay is nursing home placement. Although this is being addressed in the future by Hampshire's County Nursing Home Strategy, there is an interim time lag before this additional capacity will be operational. Therefore the next twelve to eighteen months will be very difficult in respect of capacity.

2.5 Securing available care is essential to continue to reduce delayed transfers. New capacity does not become available at short notice, so it is important to maintain purchasing activity, and ensure the baseline of delayed transfers is as low as possible. The current spending and activity level have been based on the assumption that the £3.5 million contingency is available on an ongoing basis this year.

3 Reimbursement

3.1 Councils with Social Service responsibilities will need to make reimbursement payments for eligible and appropriate cases following notification from 5 January 2004. The implementation of shadow systems have been put in place from 1 October 2003 to provide a 3 month lead-in period.

3.2 The release of the contingency funds for delayed transfers of care is needed to minimise the risks of being subject to financial penalties and contribute towards the local public service agreement target:

"To provide high quality pre-admission and rehabilitation care to older people to help them live as independently as possible, by reducing preventable hospitalisation and ensuring year on year reductions in delays in moving people over 75 on from hospital"

3.3 This will be achieved through:

· continued attention to improving delayed discharge performance through activity and service developments to ensure necessary capacity is available, with £3m spend on additional care packages/placements.

· establishment of the necessary business process arrangements, including improvement of staffing resources in acute hospital settings, to meet the requirements of the prescribed reimbursement regime with the remaining £0.5m.

3.4 The current expected cost associated with a delayed transfer following the introduction of the reimbursement legislation in January 2004, is £100 per person per day. The estimated full year cost therefore of the activity level of delays of the 65 as at 3 August 2003 would be over £2.2 million.

3.5 The delayed transfer grant allocation that is proposed to offset these costs is £1.2 million for Hampshire, the highest allocation nationally in 2003/04, to cover 1 October to 31 March. This grant is expected to rise to about £2 million in 2004/05.

3.6 Comparing current discharge processes with the `ideal' (reimbursement) discharge process is underway at present. A review of the operational demands of the proposed regime has shown that there will be a need for additional staff at hospital sites to augment existing hospital arrangements for carrying out service user assessments and to prevent hospital admissions or delayed hospital discharges. This will include Saturday working as this falls within the notification period covered in the Bill.

3.7 The workforce plan (2003/04) details the requirements and the associated costs of these posts of approximately £600,000 full year effect. This will be allocated to recruit up to 21 full time equivalent qualified social worker/care managers. The estimated costs in 2003/04 are approximately £400,000 with over half of the posts already filled at the time of writing.

4 Conclusion

4.1 To safeguard its principles in respect of service users, corporate priorities and also its current performance status, it is one of Social Services imperatives to continue to invest in reducing the number of delays.