Waiting to leave hospital

Unethical Procurement

Nick Kempe

Unethical procurement – the Scottish Government’s decision to fund 300 more care home places

On 10th January the Health Secretary, Humza Yousaf, announced in the Scottish Parliament  that the Scottish Government had made £8m available for Integrated Joint Boards to purchase a further 300 “interim care” beds in care homes.  In the same announcement Mr Yousaf revealed the Scottish Government was already funding 600 such places, a measure designed to free up hospital beds while people, predominantly frail and elderly, wait for a package of care in the community or a care home of their choice.  

The use of interim placements in care homes is not new.  The Scottish Government issued circulars about the use of interim placements for people in hospital waiting a place in their care home of choice in 2003 and then again in 2013.    It has never worked. It is well past time for a re-think of the whole system for dealing with “delayed discharges” which has dominated social care thinking for twenty years. 

The only time any Scottish Government has managed to clear “delayed discharges” out of hospital was at the start of the Covid pandemic.  This was achieved by removing all choice and control from people and their families and the protections that should have been afforded by social work with catastrophic results.  With flu rife in both care homes and hospitals, those mistakes – which led to the transfer of infections – are being repeated with no lessons learned.

What is new is that “interim placements” in care homes are now being used for people who are waiting for a package of care in the community. An illustration of the stupidity is from Edinburgh where in November the BBC revealed the Integrated Joint Board (EIJB) had been placing people in care homes due to a lack of community services .  One of the reasons for that was explained in the Systems Pressures Update paper presented to the EIJB in October: “a reduction in the number of staff within Homecare willing to use their cars for work purposes due to increased fuel costs.”  

What this means is the capacity of home care services to care for people in Edinburgh was reduced because staff were forced out of poverty to walk.  Despite representations from the Trade Unions, the EIJB’s management claimed they had no money to increase mileage rates. For the cost of a couple of “interim care home placements” they could have fixed the issues.

Similarly, instead of ensuring extra resources are invested in staff, most of whom are on the breadline, the Scottish Government apparently prefers to hand money over to care home providers who continue to make obscene amounts of money.

Unbelievably, the Scottish Government has increased the rate it is paying for these places.  Mr Yousaf stated that the Scottish Government would be paying 25% over the nationally agreed rate for the 300 places, currently £832.10 a week for nursing home care, i.e., £1,040.12 a week.  This will totally undermine the National Care Home Contract where rates are determined by what it costs care homes to provide care.

Mr Yousaf’s justification for this was “the increased costs of utilising those beds for a short time”.  Why those costs should be over £200 a week more than those negotiated to pay staff at the currently agreed rates has not been explained.  While admitting new people to care homes does require a little extra time – to draw up care plans, check medication and possessions etc – the cost to the provider of having an empty place far outweighs this.  Care home profitability is related to occupancy and by paying providers 25% more for 300 (or is it all 900 interim places) the Scottish Government is simply boosting profits and enabling more money to be sucked out of the care system.   Whether this is the result of corruption or incompetence is not clear.

For £1,000 a week the NHS could afford to provide interim care beds for people who no longer need medical treatment, but with nurses and care assistants who were properly paid and properly trained.  This would also provide more appropriate care for the large numbers of Adults with Incapacity, who are currently not counted as “delayed discharges” but nevertheless are languishing in acute medical beds.

For the last twenty years the focus of successive governments has been on “just in time healthcare” and getting people out of hospital as soon as treatment has ended.  This has ignored the fact that people who are old or who have long conditions often take significant periods of time to recover from hospital treatment, benefit from rehabilitative services and need time to make decisions about their future.  Instead of viewing the occupants of acute hospital beds as people, successive Scottish Governments have reduced the problem to one of “blocked beds”.

It was not a coincidence that the UK Government made a similar announcement about block booking care home places to get people out of hospital on 9th January .  The additional £8m may have been a consequence of the extra £200m being spent in England.  

But whereas local authorities and directors of social work in England expressed extreme disquiet about the plans, in Scotland they were silent.  Instead it has been left to the Care Home Relatives Group and Royal College of Physicians Edinburgh /British Geriatrics Society to question the consequences for older people and their families and to stress the need for proper investment (commissioning not purchasing).

To give an idea of the number of people who may be affected, £8m will pay for c7,700 weeks of care.  This means that if the average interim care home placement lasts 4 weeks, 1,925 additional older people may be moved from hospital to care homes. With the staffing crisis in care homes apparently even more severe than in the NHS or community services, a fact acknowledge by Scottish Care the organisation representing the interests of private care home providers, this makes no sense. At best this measure appears to be a very expensive form of warehousing and at worst will lead to yet more unnecessary deaths. 

Ethical commissioning needs to start with staff pay, expenses and training, not providers, and should be based on care provision, like health, being not for profit. Only then will the current crisis which is overwhelming both the NHS and the remnants of our care system be addressed. The Scottish Government’s announcement raises serious concerns about their commitment to develop ethical commissioning through the National Care Service bill.  It also reveals a woeful lack of understanding of people’s health and care needs and a capacity to re-think longstanding problems.

2 thoughts on “Unethical Procurement”

  1. I feel that the acquisition of 300 extra places in care homes is an appropriate short-term measure to reduce the alternative which is people dying waiting for ambulances to arrive because the ambulances are stacked outside hospitals due to being unable to discharge patients as a result of no bed being available, while a large proportion of beds are being used by patients who are ready to be discharged. Let’s look into the cause of this problem more deeply and consider what needs to be done.
    The first issue is to examine the reasons why patients remain in hospital once ready to be discharged. Three main reasons account for most of ‘delayed discharges’ – social work departments have not completed care assessments; social work departments have not put in place the necessary care packages required for patients to return to their own homes; families who are unwilling or unable to take elderly relatives to live with them also often refuse to agree to them moving into care home places that may be available. In all three of these causes, there is a financial incentive to delay discharge – councils avoid having to pick up care costs the longer they take to complete assessments and the longer they take to put arrangements in place; families avoid care costs the longer their elderly relatives remain in hospital rather than moving to a care home.
    Part of ending delayed discharges may involve removing or even reversing the financial incentives currently at play that have the effect of extending the time that some patients remain in hospital.

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