Hospital discharge funding: why the frosty reception to new money?

The latest announcement of an additional £200m to speed up hospital discharge into social care services means that in a matter of months the government has committed a total of £750m to free up beds in beleaguered acute hospitals throughout England. That’s a weighty sum, yet the response from many social care leaders and health professionals has been decidedly mixed, if not hostile. When social care is desperate for resources and hospitals are desperate for beds, why the negativity?

The first concern is timing. The adult social care discharge fund of £500m was first announced by then Secretary of State Thérèse Coffey in September, but the money was slow in getting through to council and NHS commissioners – delays which some Whitehall insiders suspect might be aggravated by ministerial churn. Details of how the grant was to be allocated were not announced until November, with a first tranche of 40% of the grant not due to go out until December and the remaining 60% to be paid in January.

Steve Barclay’s latest announcement of a further £200m was made before the first grant had even reached the front line. No wonder care providers complain the money isn’t getting through and this large sum has so far had such little impact on the numbers of people stuck in hospital. The apparent lack of urgency in getting the money to where it’s needed is bizarre given the well-documented crisis in acute and emergency care in many parts of the country, and the known risks of harm for older people stuck in hospital.

Another problem is the convoluted way the money is being distributed, with a twin-track funding route split between councils (£200m) and integrated care boards (£300m), each calculated using different formulae, with the NHS share focused more on places with the biggest number of delays. It is not yet clear how the latest £200m will be distributed, but apparently it will be made available ‘immediately’.

The strings attached to the grant have also raised eyebrows. To get the second tranche of the initial discharge fund, councils and integrated care boards had just 4 weeks from the November announcement to set out how they planned to the use the money, then a fortnightly activity report concluding with a final report in May this year. While some national oversight of public money is not unreasonable, the imposition of prescriptive and onerous reporting requirements from the centre is an unhelpful distraction at a time when local organisations and staff are wrestling with arguably the biggest operational challenges they have ever faced. It is also at odds with ministerial rhetoric favouring efficiency over bureaucracy.

Some of the biggest worries of all are about the headline purpose of the latest £200m, as described by the Secretary of State: ‘to block-book beds in residential homes to enable some 2,500 people to be released from hospitals when they are medically fit to be discharged’. The obvious problem here is that the vast majority of people leaving hospital do not need to be in care homes. The government’s own guidance indicates that less than 5% of people discharged from hospital will need ‘24-hour bedded care’. Residential and nursing home care is also usually the most expensive way of meeting care needs, assuming that places are available and homes have sufficient staff.

There’s real danger that the risks of staying too long in hospital will be transferred to care homes, especially where placements are rushed, with little access to rehabilitation and enhanced health care or in places far away from home, as the British Geriatrics Society has warned. The logistics of then getting people back to their own homes becomes even more complicated. In the rush to clear hospital beds, legal safeguards in relation to mental capacity and choice could easily fall by the wayside. Then there is the further fragmentation of commissioning when NHS bodies start to buy care home places, probably at a higher rate than councils can afford, and the knock-on effects when places for people who do need residential care are not available or affordable to councils. In a fragile provider market, the NHS competing with councils for limited capacity will not end well.

There is a deeper lesson about the government’s continuing reliance on last-minute, short-term, hand-to-mouth cash bungs to fund social care instead of a sustainable long-term plan for funding and workforce. While the discharge fund could help boost capacity in some places, so much more could have been achieved if just a year ago the government had sat round the table with commissioners and providers to plan what could be done with £750m. There would have been no shortage of ideas to reduce the current pressures and bolster capacity in home and community care – the superior option in terms of user choice, cost and outcomes. Instead, this could well become a case study in how to disburse a large amount of public money to so little effect.

Richard Humphries (@RichardnotatKF) is a senior advisor in the policy team at the Health Foundation.