The new Health and Social Care Secretary, Thérèse Coffey, presented a plan in September whose only substantive social care measure – a £500m Adult Social Care Discharge Fund – was intended to reduce the problem that hospitals are experiencing with delayed discharges. At the end of August, there were over 13,000 people in NHS hospitals who were fit to leave but had not done so.
However, the extent of social care’s role in delays is unclear and, even where it is a factor, fixing it will not be straightforward.
To begin with, most new requests for adult social care come not from people in hospitals but from the community, by a factor of four to one. In 2020/21, 365,000 new requests for social care came via hospitals but over 1.5 million came from the community. So the main driver of demand for social care is not hospitals.
Nonetheless, 365,000 is a big number and it is certainly not in patients’ interest that they are stuck in hospital when they don’t need to be (although forget that ‘fact’ you may know about 10 days in bed causing 10 years’ muscle wastage in older people – it’s an urban myth).
So, what causes people to be stuck? You will find no shortage of opinion that it is a lack of social care and no one disputes that this is now – and for many years has been – a significant issue. The first blog I ever wrote for The King’s Fund in 2017 concerned a row that had broken out when the then Health and Communities secretaries (Jeremy Hunt and Sajid Javid – you may remember them) had written to 32 councils threatening to withdraw funding if they didn’t improve their performance on delayed discharge.
Yet, just prior to COVID-19 (when the Government invested large sums through a Hospital Discharge Fund to clear beds), NHS data showed that delayed transfer of care was due to a wide range of factors, from delays in assessment to disputes. Waits for residential home, nursing home and homecare services (whether NHS or local authority arranged) were major causes but another was people awaiting further non-acute NHS treatment. These statistics are no longer recorded, though recent Nuffield Trust analysis of NHS data, which uses different criteria, finds that the biggest reason why patients face delays is also because they are awaiting community services, with homecare most often cited.
So, there is no precise answer about the extent to which social care causes delayed discharges and, particularly, whether it has changed since before COVID-19. Nonetheless, it’s certainly feasible that issues within social care may be contributing more than in the past. Why? Because of the workforce crisis in adult social care which led to a 10.7% vacancy rate in 2021/22, up significantly from the 6.5% when I wrote my blog in 2017. Providers now say openly and clearly that they have to turn down hospital discharges – and of course other support – because they don’t have the staff.
There is a logic, then, to the £500m fund being established, since it can be used to help recruit and retain staff. (It should also smooth over the ‘who pays – NHS or social care?’ disputes that can hold up discharge.) But both the size of the fund and its short-term nature mean we must question whether it can really make a significant difference to the vacancy rate. Pay is critical to recruitment, yet social care pays less than entry-level posts in major supermarkets. Even if the full £500m were spent on pay, it would represent just 2% of the total social care wage bill of £23.8bn. Worse, the fund is only expected to operate for six months, so providers will be extremely cautious of feeding anything they get from it into underlying pay.
So, can the fund do something about delayed discharge in the short term? You’d expect so. Can it tackle the long-term systematic problems in social care that underpin delayed discharges? Sadly, no.
Simon Bottery is a Senior Fellow in Social Care at The King’s Fund. Email: [email protected] Twitter: @blimeysimon