‘Medical outliers’, ‘medically fit’, ‘bed blockers’. These are all terms to describe the same problem: patients who are ready to leave hospital but can’t because the right social care package is not in place.
The problem has been described over and over again, for decades. One of my first memories of problems with the NHS was the winter crises in the late 1990s – caused by ‘bed blockers’.
When patients are not discharged when they need to be, the system breaks down. People cannot have surgery, because there isn’t a bed for them when they come out of operating theatre. A&Es cannot admit patients to hospital, so the A&E fills up and struggles to treat newcomers.
It is clear that what we need is a better, more responsive social care system which will mean patients are discharged from hospital more quickly, and allowing the whole system run more smoothly.
Instead, time and again, politicians, commentators and NHS workers call for two things which will not help at all:
1) “The NHS needs more money”. Extra money for the NHS may help it cope better with the crisis, but it will not solve the crisis. This is because social care is not paid for by the NHS – it is paid for by Local Authorities. Extra money for the NHS will not get patients discharged.
2) “There should be more hospital beds”. Again, having more wards and beds in hospitals may help the NHS cope better with the crisis, but it would not solve it. The NHS has more than enough beds for the people who do need to be in hospital – it breaks down because people stay in hospital when they do not need to be there.
Put together, the proposed solution of putting more money in to the NHS so that it can have more beds is the most expensive way of dealing with the crisis – hospital beds cost £300-£450 per day to run, much more expensive than care homes or social care at home. But, more importantly, it’s also the worst thing for patients – especially elderly patients. When older people stay in hospital longer than they need to their prospects for recovery are much worse. In hospital, patients can become institutionalised. They are less mobile, less happy, and less independent. The longer the stay, the more likely a patient is to pick up a hospital acquired infection. Once a patient is medically fit to go home, home is the best place for them.
Bigger budgets for social care would undoubtedly help, and that can be achieved in one or a combination of three ways:
- The government can allocate more money to Local Authorities for social care, perhaps reducing the NHS budget in order to do so.
- Local Authorities can increase council tax to fund social care.
- Local Authorities can cut other services and put more money in to social care.
I think Local Authorities do quite a lot of ‘nice to have’ things that are not nearly as important as making sure our older people are cared for with dignity and respect, so I would like to see councils cut back on those and boost social care budgets before raising any taxes.
The fact that only a third (or less, in some places) of the eligible population votes in local elections is a big issue here too – when you don’t vote, you let inadequate local politicians making poor decisions get away with it. For goodness sake go and vote.
However, despite what many people may argue on the TV, money is very rarely a solution to anything on its own. And the crisis in social care and the NHS is no different. Instead, we need to dig down into how these budgets and services interact.
At present, even if social care budgets were enormous, Local Authorities have absolutely no incentive to design more timely and responsive social care services that help get people discharged from hospital more quickly.
When a patient stays in hospital longer than they need to be there, the NHS pays. For the time that a patient who needs social care is in hospital, and the NHS is paying, Local Authorities are saving money. Put simply:
The current crisis in delayed discharge costs the NHS money, and saves Local Authorities money.
The solution to that crisis would save the NHS money, and cost Local Authorities.
No additional amount of money in either NHS or social care budgets will change the realities of the underlying incentives. The only thing that will actually begin to solve the crisis is the change the structure or system of care and payments.
This has led many people – including the Labour Party – to call for integrated social care and NHS budgets. I do not favour this, because NHS managers are largely incompetent and giving them more responsibility will not help anyone in the long term.
Instead, I propose we make Local Authorities pay for people whose discharge from hospital is delayed by the lack of a social care package. Under this system the NHS would continue to pay for patients who need to be in hospital, but once they are medically fit to leave the Local Authority pays. It would be sensible to build in a notice period, for example making it so the hospital has to inform the Local Authority 36 hours before the patient is to be discharged – and if they don’t, the NHS picks up the bill for 36 hours after the Local Authority has been informed.
A bed in hospital is much more expensive than a care home bed and even more so than a care package for at home, so the financial incentive for getting patients out of hospital will be enormous. And whilst the current system and disincentives for Local Authorities halts action, my proposed new structure would spur them in to action – meaning our older people get the care they really need, and pressure on the NHS is relieved.
Emily is the chairman of Conservatives for Liberty. Follow Emily on Twitter: @