Doctors face a struggle every day and everywhere in England: the fight to secure social care for patients well enough to leave hospital.
Even officially it worsens month by month, increasing harm to patients and financial strain on the NHS, at a time when it’s least needed.
The latest figures, aiming to size up the problem, broke records in October. Patients spent 200,000 days in beds they did not need that month, a rise of 25 per cent on the same month in 2015.
Known as ‘delayed transfers of care’, the NAO (National Audit Office) estimated that, in the case of older patients in England, the unnecessary days in hospital cost more than £800m last year.
As bad as it is, this official tally of costly and unnecessary hospital stays undercounts the problem ‘significantly’, the NAO admits in a study this year, by a factor of almost three.
And as usual, the language of audit does nothing to capture the human cost suffered by patients, their families and witnessed on wards daily by doctors, nurses and other professionals.
‘Delayed transfers of care are personally disastrous for older patients who are frail,’ is how BGS (British Geriatrics Society) president Eileen Burns, a care of the elderly consultant at Leeds Teaching Hospitals, puts it.
‘Frail older people who are nursed in bed are at great risk of losing their mobility if they aren’t supported and encouraged to get out of bed,’ Dr Burns adds.
‘The impact of 10 days of bed rest on muscle strength has been estimated to be equivalent to 10 years of ageing.
‘People who were able to just about manage to get up to potter about, who didn’t need help to walk, are very unlikely to get moving again. People with dementia get more confused.’
No end in sight
So what is being done to cut the time patients are stuck, immobilised and harmed in hospital beds they do not need? When will the struggle to get social care in place be eased?
Not anytime soon, is the indication from BMA analysis of the latest batch of rescue plans, drawn up by officials in the NHS and councils, to solve the problems.
These so-called STPs (sustainability and transformation plans) aim to chart a path to more seamless health and social care services, while cutting some £26bn from their budgets by 2021.
But analysis by the BMA has found fresh evidence of deep financial problems in social care across large swathes of England. In some areas, financial deficits almost match those facing the NHS.
For instance, Staffordshire and Stoke-on-Trent predicts a £256m shortfall in social care, according to the latest figures from its STP. That’s less than the £286m black hole in its NHS services, but not by much.
The eight London authorities in the north-east London STP, which stretches from Barking and Dagenham to Hackney, face a shortfall in social care of £238m and a larger £578m in the NHS.
In Hampshire and the Isle of Wight, social care faces a financial black hole of £350m by the end of the decade, a third of the £1bn total defect, which includes the health service shortage.
As might be expected, hospitals in STPs with big social care deficits include those that most struggle to find social care for patients.
Almost half the time patients were stuck in hospitals in Staffordshire was owing to struggles to secure social care, according to the latest NHS England figures, collected from trusts in October.
Hampshire, with its significant shortfall, is one of 28 authorities where more than half the time patients were stuck in beds was owing to social care problems.
Walsall, one of four councils in the Black Country and West Birmingham STP, which faces a £190m social care shortfall, is responsible for three-quarters of all delayed days.
These hot spots of ailing social care are masked by official national averages published in performance reports by NHS England each month. But even these show the struggle to secure social care grows tougher by the day. Two years ago, a quarter of delays were owing to council shortcomings; the latest NHS analysis found them responsible for a third.
After five years of austerity cuts, many town halls are in the teeth of a social care crisis, which has become headline news – forcing the issue on to the political agenda.
What the BMA’s analysis of STPs reveals is just how perilously dependent the future of the NHS is on social care. It finds many council services, already stumbling, face increasingly hard climbs to financial stability, threatening the NHS, as it seeks to get its finances back on track.
After months of limited influence over STPs, many councils are even rebelling against them, fearing efforts to save health costs will heap unbearable pressure on their own.
Sir Howard Bernstein, chief executive of Manchester Council, seen as one of the most capable authorities in England, says social care shortages threaten its plans for sustainable and seamless health and social care.
The anger of local politicians in England’s largest local authority, Birmingham, about its STP’s impact on social care in the city is undisguised.
Social care had been treated as ‘incidental’ to the NHS, says John Cotton, a Labour councillor who heads the council committee that keeps tabs on health policy.
While its STP puts the social care deficit at £130m, it offers ‘no indication’ of how this gap could be closed. Birmingham admits it is already one of the ‘worst’ authorities when it comes to finding care for patients fit to leave hospital. Yet its STP suggests pushing more patients on to social services to bring the NHS into the black.
Social care in the city, the largest in England after London, was now an ‘extremely precarious position’, councillor Cotton wrote in a paper for his council.
‘There can be no more pressing priority than tackling the inadequate social care provision which causes disabled, frail, elderly and vulnerable people to suffer by being denied the care they need,’ he writes.
BMA council chair Mark Porter says STPs’ ambition to modernise and pull the NHS out of the red is threatened by the extent of social care shortages, revealed by BMA analysis.
‘Many of the STPs and future financial sustainability of these areas is predicated on being able to integrate health and social care,’ he adds. ‘If nobody has any confidence that the black hole in health is going to be filled, there is even less confidence that this black hole in social care will be. That will imperil the delivery of the STP programme.’
Dr Porter notes another known ‘knock-on effect’ of delayed transfers of care, which further piles pressure on health service: the filling of surgical wards by patients awaiting social care.
‘The human cost is for two sets of patients,’ he adds. ‘Medical patients, who are exposed to increased risk of thrombosis, infection and institutionalisation, and those whose operations and treatments are cancelled, sometimes on the day, because there is no room on the wards. There’s nowhere else to put them’.
While doctors’ and councils’ concern for social care is shared by health analysts and political leaders, from all parties, they appear to have been side-lined by the Government.
NHS England’s chief executive Simon Stevens said there was a ‘strong case’ for extra social care funding in a speech to hospital managers at the NHS Confederation conference in June.
In November, social care was raised as an ‘immediate concern’ by the Commons health select committee, before the chancellor gave his first major speech on the country’s finance.
‘Reductions are having a serious impact on the NHS,’ says the letter signed by the Conservative MP for Totnes and committee chair Sarah Wollaston – and several committee members, including Labour’s Emma Reynolds and the Scottish National Party’s Philippa Whitford.
But despite concerns being raised about social care from Parliament, councils and within the NHS itself, there was no extra resource announced by the chancellor in his autumn statement in November.
‘Daft’ funding plans
Of further concern is the standing of the Government’s claims on social care funding, which are seen as exaggerated and have even been described as plain ‘daft’.
While authorities have been allowed to increase council tax to raise extra funds for social care, only £382m has so far been collected. Not all town halls are taking up this politically tricky offer.
Ministers’ latest extension of this tax raising powers, announced just weeks ago, was described as ‘inadequate’, by Dr Porter. ‘This alone will not help address the long-term national crisis we are facing in this area.’
The measure is predicted to raise little more than £200m, a sum dwarfed by the £4.7bn shortfall councils face, according to BMA analysis of STP plans.
When quizzed about social care shortages, ministers will also point to the £1.5bn ploughed into the Better Care Fund, which aims to help councils and the NHS bring social and health services together.
But almost half this fund is supposed to come from another Government scheme: the ‘new homes bonus’ – a grant paid to councils which boosts the number of homes in their areas.
This means of funding social care ‘beggared belief’, Bernard Jenkin, the Conservative MP for Harwich and North Essex, who chairs the parliamentary public administration and constitutional affairs committee, has said. ‘It is a daft way of predicating funding for such an underlying fundamental public service.’
Most councils, after years of austerity cuts, are even using their ‘new homes bonus’ to prop up other services, according to research by the magazine Inside Housing.
As they are free to do this under Government rules, it’s unlikely the Better Care Fund will be a saviour of social services.
Ms Burns says the pace at which STPs have been drawn up, combined with huge shortfalls in social care funding, is hampering efforts to improve the relationship between health and social care.
‘There has been pressure on people to crack on and write these STP so some haven’t had the time to consult,’ she adds.
‘Locally our social care colleagues were involved in the STP but nationally, the criticism is that clinicians have not been involved. And the more underfunded social care is, the more difficult it will become to integrate. Councils are already coming to the table with huge deficits.’
While the BMA supports integration of health and social care and long-term planning, our analysis has raised fresh and serious questions about the credibility of the current plans on offer for this.
The NHS still faces a far bigger cash crisis than social care: a £21bn hole by 2021 compared with £5bn for social care.
But as the analysis shows, the ability of the health service to close its own gap relies on the safety net of social care for patients. When councils can’t find care for patients ready to hospital, the NHS can and will.
The social care safety net has been left unprotected since the days of austerity began, is looking close to complete collapse, and will not be sustained by the paltry, holey patches applied by ministers.
There is a solution, of course, as Dr Porter points out: a fully resourced public health and social care sector. ‘We don’t agree that the Government’s demands for health efficiencies can be met,’ he says.
‘Social care has been cut to the bone but unlike health it is not a protected budget. Politicians from all sides need to come together to agree a long-term solution to this growing problem.’
But until they do, the struggle to find patients social care can only get worse, causing even greater harm, frailty and even more demand on a service already buckling.