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Role
"Bed-blocking": Evaluation the
of
an of
Financial Incentives in Community Care (Delayed
the
Discharges ) Act 2003
etc.
Ana Manzano-Santaella
Submitted in for degree
the the
accordance with requirements of
PhD
The University Leeds
of
School Sociology Social Policy
of and
November, 2008
The
candidate confirms that the is his/her that
work submitted own and appropriate
has been
credit given where reference has been made to the work of others.
This has been
copy supplied on the understanding that it is copyright material and that
from
no quotation the thesis may be published without proper acknowledgement.
11
ACKNOWLEDGEMENTS
I like to thank the Economic Research Council for the award that supported me
would
during This have been
my three years of research. work would not possible without
both
disposition
the generous of the many research participants: patients and staff at
department helped
hospital this
the social services and the who moved research
but
forward. Confidentiality from their
agreements prevent me mentioning real names
I will never forget them; the time they found for this research in their hectic working
lives
the time illness. I to to
or at vulnerable of acute also wish express my gratitude
Prof. Ray Pawson helpful
my principal supervisor, and offered
who was abundantly
invaluable
wisdom, generosity, support and guidance throughout the research project.
Gratitude is due
also to Dr. Geof Mercer
my second supervisor, without whose
knowledge
detail
and attention to this have been
study would not possible.
I like
to Dr. Teela
would gratefully acknowledge the enthusiastic encouragement of
Saunders for idea University Leeds. I
suggesting the of undertaking the Phd at the of
furthermore like
would to acknowledge the help of Helen Rayfield and Belinda
Goode for their technical `writing My fellow PhD
advice on with style'. students
Mark Monaghan, Rachael Dobson Sarah Kingston have been fundamental,
and also
for
their but for
not only practical proof reading support the priceless conversations
friends Silvia,
about methods, references, thesis structure, etc. I am also grateful to my
Gemma, Javi, Rosa, Bea Alison for
and their continued moral and practical support,
kindness. I feel deep
for
care and a sense of gratitude my social work ex-colleagues,
Montserrat Roig i De Mariana Charo Cuesta Alvarez, taught I know
and who me all
hospital
believed in before I did ( Moltes
about social work practice and who me
Us
).
gräcies! porto sempre al cor!
Finally, I am forever indebted to two favourite English husband, Mark
my men: my
Wright, failed to doctor but determined
who marry a who was relentlessly when
helping his
to transform in Sam,
wife one of them. And my son, whose understanding
love
and endless were a gift and never a hurdle throughout the duration of my studies.
111
ABSTRACT
This financial incentives in
study contributes to the evaluation of the role of achieving
the hospital delayed discharges to the implementation the
reduction of attributed of
Community Care (Delayed Discharges ) Act 2003. This imposes financial
etc. policy
for departments in England to the
penalties social services unable provide community
discharge Once
to timescales.
care services required patients within set a
team decides that to be transferred the
multidisciplinary patients are safe out of
hospital, days discharge. If do
social services are given three to the patients
organise
leave the third day, fine is imposed £100/120 day
not on a to social services of per and
This
per person. programme to the issue `bed-blocking', the loaded
aims resolve of
describe
term used to patients whose discharge from hospital is not timed within the
desired by institution.
the
speed
This
thesis theory-driven basis
performs a the theoretical
evaluation, analysing
underpinning this complex policy following the framework. The
realist use of a case
based
data in `real-time' helps
study approach on multiple methods of collection
unravel the complexities of this initiative. Fourteen
multi-agency patients were
followed
through their hospital identify flows blockages in
to the
stay and
This data
knowledge from
programme. was compared with gained other evaluations
as a means to generalise the findings. The demonstrates that the
analytical process
Delayed Discharges
is
innovations
programme
an amalgam of multiple which
includes financial incentives.
Some intertwined fines
these the
of other measures with
to that, delays fines.
create mechanisms planned or unplanned, or avoid
reduce
Sometimes do it
they at the same time, but they do it in isolation.
on occasions
Consequently,
mechanisms are embedded in the designed theory that
programme
for fines be
to delays being
allow avoided without
necessarily reduced.
iv
TABLE OF CONTENTS
ACKNOWLEDGEMENTS ii
...........................................................................................
ABSTRACT iii
.................................................................................................................
TABLE OF CONTENTS iv
..............................................................................................
LIST OF FIGURES AND TABLES
vii
............................................................................
ABBREVIATIONS ix
......................................................................................................
INTRODUCTION 1
.... .................................................................................................. ...
1. THE CONCEPTUALISATION OF DELAYED DISCHARGES:
PRECURSORS AND INTERPRETATIONS 5
.............................. ... . .... . . . .. . ...................
1.1 Introduction 5
......... ... .. .......................................................................................... ..
1.2 Delayed Discharges the Contemporary Health Social Policy Trends 5
and
and
....
1.3 `Bed-Blocking' `Delayed Discharge': A Contested Concept 8
or
..........................
1.3.1 Reducing Length
Stay to Improve Hospital Efficiency 13
of
..........................
1.3.2 The Measurement
Delayed Discharges: Tensions Challenges 15
of
and
........
1.3.3 Most Common Reasons for Delayed Discharge 18
.........................................
1.4 Patients in Blocked Beds: Who Are They? 21
........................................................
1.5 Summary
23
...........................
.................................................................................
2. THE POLICY RESPONSES:
FINES TO REDUCE SOCIAL SERVICES
DELAYED DISCHARGES
25
.........................................................................................
2.1 Introduction
25
................
........................................................................................
2.2 Policy Responses
to Delayed Discharges Problem: A Historical Overview..... 26
2.3 Delayed Transfers
Care: A Performance Indicator 29
of
.......................................
2.3.1 Exploring
the Relationship Between the NHS Financial Reform the
and
Fines to Social Services Departments
36
..................................................................
2.4 Cross-Charging
Schemes in
the Scandinavian Countries 41
..................................
2.5 An Overview the Community Care (Delayed Discharges ) Act 2003 44
of
etc.
.....
2.5.1 Innovations Made Statutory by the Delayed Discharges Act 45
.....................
2.5.2 Evaluations
Date
to 62
....................................................................................
2.6 Summary
67
......................................
......................................................................
3. EVALUATION STRATEGY:
METHODOLOGY AND METHODS 69
..............
3.1 Introduction
69
.................
.......................................................................................
3.2 A Focus Programme
Theory: Understanding How Financial Incentives
on
Work
70
........................................................................................................................
3.3 Realist Strategy Evaluate
to Multi-Agency Programme 71
a
.................................
3.4 Case Study Research
74
......... .................................................................................
3.4.1 Selection
the Research Site 75
of
.....................................................................
3.4.2 Sampling Relevant
Discharge
Events 77
.........................................................
3.4.3 Sampling Hospital
Patients
78
.........................................................................
3.5 Multiple Methods for Data Collection in Real-Time Research 80
.........................
3.5.1 Case Recording
Data Management 83
and
......................................................
3.5.2 Participant Observations
Documentary Analysis 86
and
.................................
3.5.3 Qualitative Interviews
88
.................................................................................
3.6 Analytical Strategy:
Generalisation
From Reduced Number Cases........... 90
a of
3.7 Research in NHS
Premises
Ethical Considerations 95
and
....................................
3.9 Summary
97
............................................................................................................
4. SURFACING THE PROGRAMME
THEORY OF THE DELAYED
DISCHARGES ACT
98
...................................................................................................
V
98
4.1 Introduction
........................................................................................................
98
4.2 Programme Theory Social Systems
and
.
...........................................................
4.3 Discussions Around Complexity Delayed Discharges Programme 100
the the
of
4.3.1 The Macro-Social Phenomena 104
..................................................................
4.3.2 The Meso-Social Phenomena 108
...................................................................
4.3.3 The Micro-Social Phenomena 110
...................................................................
112
4.4 The Fines: A Complicated Solution
.................................................................
4.5 The Local Interpretation Nationally Designed Programme Theory...... 115
the
of
4.6 Summary 118
..........................................................................................................
5. CONTEXTUAL CIRCUMSTANCES OF THE RESEARCH SITE 120
....................
5.1 Introduction 120
......................................................................................................
5.2 Context Programme Evaluation 121
and
................................................................
5.3 Contextual Circumstances the Local Healthcare Services: A Financial
of
Imbalance 123
. . . .............. ..............................................................................................
5.3.1 The Foundation Trust Hospital 124
.................................................................
5.3.2 The Primary Care Trust 128
............................................................................
5.4 Local Contextual Features Social Care: Lack Money Lack
of of and of
Fines
130
...................................................................................................................
5.4.1 Social Services Financial Situation 131
...........................................................
5.4.2 Residential
Nursing Care Provision 134
and
...................................................
5.4.3 Domiciliary Care Services 137
........................................................................
5.4.4 Housing Capacity
139
......................................................................................
5.5 The Health
and Social Care Multi-Agency Arrangements 140
..............................
5.5.1 Intermediate Care Services 141
.......................................................................
5.5.2 NHS Continuing Healthcare 144
.....................................................................
5.6 Summary
146
............................
. ...... ..................................... ... . . ... ...... ... . ............... .
6. PRIMARY ADJUSTMENTS:
MECHANISMS AND CORE PROGRAMME
OUTCOMES
147
..............................................................................................................
6.1 Introduction
147
............. .........................................................................................
6.2 Mechanisms Outcomes 147
and
.............................................................................
6.3 Significant Reduction Delayed Discharges: Outcome Achieved 149
of
................
6.4 Total Absence Fines: Outcome Achieved 151
of
...................................................
6.5 Working
towards `Seven Days Discharges': Unnecessary Mechanism..... 156
an
6.6 Multidisciplinary Team Decisions: Instant Reduction Delayed Discharges 159
of
6.7 Weekly Census Reasons for Delayed Discharges: Easy Way Out........ 161
of
an
.
6.8 The Conceptual Construction
New `Social Services Patient' 165
of a
..................
6.9 Interim Beds, Planned
Mechanisms to Reduce Delays 169
.................................. .
6.5 Summary
172
.........................................................................................................
.
7. THE CASE STUDIES: HOSPITAL
DISCHARGE JOURNEYS UNDER THE
REALIST MICROSCOPE
173
............... ......................................................................... .
7.1 Introduction
173
.....................
................................................................................
.
7.2 Living Outcomes
174
....................
.........................................................................
.
7.2.1 Case Study 1: Mrs Ackroyd
177
..................................................................... .
7.2.3 Case Study 3: Mr Catford
184
........................................................................ .
7.2.4 Case Study 4: Mr Derwick
187
....................................................................... .
7.2.5 Case Study 5: Mrs Edington
191
.................................................................... .
7.2.6 Case Study 6: Mrs Falshaw
194
...................................................................... .
7.2.7 Case Study 7: Mrs Grange
197
....................................................................... .
7.2.8 Case Study 8: Mrs Hanslow
200
......................................................................
7.2.9 Case Study 9: Mrs lanson
203
.........................................................................
vi
206
7.2.10 Case Study 10: Mrs Jones
.......................................................................
209
7.2.11 Case Study 11: Mr Kingsley
...................................................................
212
7.2.12 Case Study 12: Mrs Leachman
...............................................................
216
7.2.13 Case Study 13: Mr Marshall
...................................................................
218
7.2.14 Case Study 14: Mrs Naylor
.....................................................................
221
7.3 Summary
..........................................................................................................
223
8. RESISTANCE, SECONDARY ADJUSTMENTS AND REALIGNMENTS......
223
8.1 Introduction
......................................................................................................
223
8.2 The Context-Mechanism-Outcome Configurations
.........................................
225
8.3 The Fines: Absent Deterrent?
an
......................................................................
228
8.4 How did the Fines Work for Cases that Were Delayed?
.................................
by Programme?
8.4.1 The Self-funders: Difficulty Created Reinforced the
a or
229
............................................................................................................................
235
8.4.2 The In-betweens: Cases Complex Specific Needs
with or
.......................
8.5 How Did the Fines Work for Cases Were Not Delayed? 239
the that
...................
8.5.1 Outcomes for Intermediate Care Cases: Contextual Difference between
the
`Rehabilitation' `Recuperation' 239
and
..................................................................
8.5.2 Cases that Could Be Potential Fine: Tacit Alteration Mechanisms to
a of
Reduce Delays 241
...................................................................................................
8.6 Summary 250
..........................................................................................................
9. RECAPITULATION AND RECOMMENDATIONS 251
..........................................
9.1 Introduction 251
......................................................................................................
9.2 Thesis Overview 251
..............................................................................................
9.3 Reflections Findings 256
on
...................................................................................
9.4 Reflections Methods 258
on
...................................................................................
9.5 Policy Recommendations 260
.................................................................................
REFERENCES 263
..........................................................................................................
APPENDIX 283
................................................................................................................
Interview Social Services Care Manager 283
with
..........................................................
VI'
LIST OF FIGURES AND TABLES
Chapter 2:
Figure 2.1: Delayed Discharges Contextualised in Hospital Performance Indicator
the
32
Map
..............................................................................................................................
Table 2.1: Delayed Transfers Care Performance Indicator for Acute Care
of as a
(Source: Healthcare Commission, 2006) 33
.....................................................................
Table 2.2: Delayed Transfer Care Performance Indictor for Social Care
of as a
(Source: Commission for Social Care Inspection, 2005a) 35
...........................................
Figure 2.2: The Purchaser/Provider Roles in Acute Care before the Delayed
and after
Discharges Act 39
.............................................................................................................
Figure 2.3: Process Map Discharge Planning Delayed Discharges Act.... 46
of the
after
Table 2.3: Innovations Made Statutory by Delayed Discharges Act 47
the
.....................
Table 2.4: Reasons for Delay 54
SitReps Guidance
to
according
....................................
Chapter 3:
Table 3.1: Example Systematic Case Study Data Recording 84
of
..................................
Table 3.2: Activities Case
85
per
......................................................................................
Figure 3.1: Evaluative Research in Adaptive Systems 91
................................................
Figure 3.2: How to Bank Contexts 93
..............................................................................
Figure 3.3: How to Bank Mechanisms 94
Outcomes
and
................................................
Chapter 4:
Figure 4.1: Social Contexts in Which the Fines Embedded 102
are
................................
Figure 4.2: Main Stakeholders in Discharge Planning Decision-Making Process 112
....
Figure 4.3: Logic Model the Delayed Discharges Programme 114
of
.............................
Table 4.1: Local Interpretation the Main Programme Strategies 117
of
..........................
Chapter 5:
Table 5.1: List Contexts
123
of
.........................................................................................
Figure 5.1: Main Institutional Relationships in Healthcare to National
according
Policy
124
.........................................................................................................................
Figure 5.2: Local Progress in Achieving
the Target for Performance Indicator
the
'Delayed Transfers Care'
127
of
........................................................................................
Table 5.2: Comparisons
FACS Needs Funded by Neighbouring Councils in 2006
of
(from Confidential Reference
8,2006)
132
......................................................................
Chapter 6:
Figure 6.1: Number of Lost Bed Days Due to Delayed Discharges in the Local
Hospital (Source: Hospital
Discharge
Liaison Team Performance Data Collection) 151
Figure 6.2: Amount of Fines Paid by the Social Services Department in the Research
Site from 2003-2008 (Source:
Reimbursement
Office, Local Social Services
Department)
152
...............................................................................................................
vi"
Figure 6.3: The Construction 'Social Services Patient' before the
the and after
of
Delayed Discharges Act 168
.............................................................................................
Chapter 7:
Table 7.1: Table Contexts, Mechanisms Outcomes 176
of
and
.......................................
Figure 7.1: CMOs for Case Study 1: Mrs Ackroyd 177
...................................................
Figure 7.2: CMOs for Case Study 2: Mrs Beamont 181
...................................................
Figure 7.3: CMOs for Case Study 3: Mr Catford 185
......................................................
Figure 7.4: CMOs for Case Study 4: Mr Derwick 188
.....................................................
Figure 7.5: CMOs for Case Study 5: Mrs Edington 192
..................................................
Figure 7.6: CMOs for Case Study 6: Mrs Falshaw 195
....................................................
Figure 7.7: CMOs for Case Study 7: Mrs Grange 198
.....................................................
Figure 7.8: CMOs for Case Study8: Mrs Hanslow 201
....................................................
Figure 7.9: CMOs for Case Study 9: Mrs lanson 204
......................................................
Figure 7.10: CMOs for Case Study 10: Mrs Jones 206
....................................................
Figure 7.11: CMOs for Case Study 11: Mr Kingsley 210
................................................
Figure 7.12: CMOs for Case 12: Mrs Leachman 213
.......................................................
Figure 7.13: CMOs for Case Study 13: Mr Marshall 216
................................................
Figure 7.14: CMOs for Case Study 14: Mrs Naylor 219
..................................................
Chapter 8:
Table 8.1: Reasons for Inclusion
Exclusion from Reimbursement Scheme
or the and
Cases Delayed
whether 228
were
.....................................................................................
Table 8.2: Relationship between Social Services Participation in Discharge Decisions
Programme Eligibility Criteria
and 231
............................................................................
Table 8.3: Relationship between
Choice Promotion Independence in Se lf-
the
and of
funders
233
........................................................................................................................
ix
ABBREVIATIONS
CRAM: Capacity Risk Assessment Meeting
FACS: Fair Access to Care Services
GP: General Practitioner
Team Meeting
MDT: Multidisciplinary
NHS: National Health Service
OT: Occupational Therapist
PbR: Payment by Results
PCT: Primary Care Trust
RNCC: Registered Nursing Care Contribution
SDD: Social Services Department
SitReps: Situational Report
UK: United Kingdom
X
`Hospitals have
to
are places where you
in for long if
time,
stay a even you are a
Time doesn't in
to the
visitor. seem pass
in hospitals it does in
same way as other
Time to in
places. seems almost not exist
it does in
the
same way as other places'.
Pedro Almodovar
'A hospital bed is
taxi the
a parked with
Groucho Marx
meter running'.