From Monday (October 1) the new GP-led Wiltshire Clinical Commissioning Group (CCG) take over operational running of the county’s health services from NHS Wiltshire (the Primary care Trust or PCT.) It’s one of the quirks of the coalition government’s restructuring of the NHS that statutory responsibility for the service remains with the PCT until the end of March 2013.
One of the major problems the CCG inherits is the seemingly unstoppable drain on the NHS budget for Wiltshire from delayed discharges from hospital – known as DTOCs (for delayed transfer of care.)
This is not only a local problem. Here’s Katherine Murphy, head of the national Patients Association, getting to the heart of the matter: “At the moment, health and social care are not joined up, so people are left occupying beds in hospital when they could be treated in the community if the right services were provided there – domiciliary care, physiotherapy and so on. That would mean happier patients, less chance of people getting hospital-acquired infections and less cost for the NHS.”
NHS Wiltshire’s Chairman, Tony Barron, puts it simply: “DTOCs are the end product of an appalling pathway of care” – care is not being planned beyond hospital admission and treatment. The trouble is, as Katherine Murphy underlined, it’s not ‘joined up’ – hospitals are in the hands of the NHS and social care is in the hands of Wiltshire Council.
In Wiltshire the situation is bad and is draining money from a very stretched budget. The latest figures from NHS Wiltshire show that in the week to September 20 there were seventy-four patients in hospital beds who need not have been there – that was ten more than the previous week and sixty-four more than was planned and budgeted for.
Thirty-nine patients were waiting for care homes; nine for assessment as to where they ought to go; seven for a ‘care package’ to be arranged; six for transfer to non-acute hospitals; five were the subject of disputes; and three were waiting for their care home of choice. Over the week there were 414 lost bed says – up forty-four from the previous week – which equates to an extra cost against the PCT’s budget of £100,602 for the week.
They used to be called “bed blockers” – which seemed to imply that they wanted to be in the beds, when in reality it was the social care authorities keeping them there. So they now called DTOCs – and during that week they were spread across the hospitals used by NHS Wiltshire: eighteen in community hospital beds; thirteen at Salisbury Foundation Trust; twenty-five at Bath’s RUH; twelve at Swindon’s GWH; and six in beds run by the mental health partnership.
It is the view in the PCT that “Wiltshire [Council] have not got the infrastructure in place” to cope with this problem. The Council have made changes and are still making changes – some of these were described recently to Marlborough News Online by the Council leader, Jane Scott.
And there are other changes in the pipeline such as increasing the Council’s teams working within the three acute hospitals (Bath, Salisbury and Swindon) so they can achieve faster assessment of patients’ needs as their treatment ends and they are ready to be discharged.
The PCT have over the past three years passed funding to Wiltshire Council aimed among other things at resolving the DTOC problem. In 2010-2011 it was £1,420 million; in 2011-2012 it was £7,082 million (including a payment for winter pressures.) This year it is £4,651 million so far with another £2,268 million in the budget which can be passed on as soon as agreement is reached on how it will be spent.
Some of the results can be seen. In 2011-2012 the NHS money helped the Council provide 175 extra long-term care home places; more extensive care to support people at home; an extra five social workers in the acute hospitals; and support for a 24/7 telecare response service.
There is also the Council’s STARR scheme which finds short-term beds – on the one hand to prevent people going into hospital because they urgently need social care, and on the other hand to help people coming out of hospital. This may become part of an urgent social care response service that could be better for patients and for the NHS budget.
Aditional information: Wiltshire Council runs twenty-two re-emablement beds which are at present in the STARR scheme – these will be increased to ‘thirty plus’.
In June, Sue Geary, Wiltshire Council’s Head of Social Care Policy, confirmed to NHS Wiltshire that the Council had received extra funds due to the increase in patients being admitted to hospital. She said there were enough beds available, but thought too many patients were being transferred to residential beds unnecessarily.
In July, Ms Geary admitted that much work still had to be done on the STARR scheme, and the CCG’s leader, Deborah Fielding, urged that the funds should be put to use by the Council ‘as a matter of urgency’.
It was suggested to the Council that they could use an empty ward at Salisbury Foundation Trust hospital as a temporary measure to take patients ready to be discharged. The PCT is firmly against this. As Tony Barron put it: “I’m totally opposed to a bed-based solution – hospital is not the right place for people to be – to use that ugly word – warehoused.” This suggestion was quickly turned down by Wiltshire Council.
The GPs and their CCG will have to take this problem on. And it is an enduring problem partly because there is no one solution – as the PCT was told last week: “It needs a multi-pronged approach and we have to keep working on every prong all the time.”
The GPs will find themselves in something of a quandary on this issue because they are both commissioners and providers of health care. In the former role they have a budget to control and use as they think best. In the latter role they will be told by the executives in their CCG that they have to stop admitting people to hospital unnecessarily – people who when they are ready to be discharged have nowhere suitable to go.
The transition from PCT to GP-led commissioning that is the foundation of the government’s restructuring of the NHS, has six months to run. As it continues the PCT’s risk register is showing a lot of red ink – and will do so until March 31, 2013. The red ink that surrounds DTOCs may continue a lot longer.
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