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Unblocking 'bed-blocking'?

Are sanctions key to more efficient hospital discharge policies?

In January 2004, the government implemented a new law which allows the NHS to fine social services if they fail to act quickly enough in finding alternative arrangements for patients deemed ‘ready to be discharged’ from hospital into the community. The use of financial sanctions in England and Wales is, according to the government, explicitly modelled on a system which operates in Sweden.

Researchers aim to explore whether the new system in England and Wales is indeed comparable to the Swedish system and the institutional context in which fines are used. It will examine the impact of the incentive of financial sanctions on hospital productivity in Sweden, and in England and Wales. The study will also establish the number of fines levied by NHS trusts on local councils, how the money raised by fines is spent and how the use of sanctions affects intersectoral working between health and social care.

What the research means for policy makers and the wider community

Research methods

The project comprises an institutional analysis and a quantitative analysis. The institutional analysis will describe and explain the operation and implementation of the incentives regime in Sweden with its counterpart in England and Wales. The quantitative analysis will measure the impact of the incentives regime on hospital admissions among those aged 65 years and over. We will consider hospital admissions, mean length of stay, and numbers of readmissions among those aged 65 and over to hospitals in a large primary care trust in central London before and after the implementation of the policy. We will also measure numbers of fines levied by NHS trusts on local councils and how the money is pooled and used.

Further Information: Project Posters

Updated Project Poster 2009

Below is a summary of this project’s provisional findings. It was originally presented as a dissemination poster, which is available here as a pdf document. All figures can be found at the bottom of this poster summary as thumbnails, which one should click to view full-size images. Alternatively, where figures are reffered to in the text, click the linked text for a full-size version.




The shortage of UK hospital beds is well documented. Part of the problem is that some beds are ‘blocked’ by delayed discharge; in 2003, 4% of acute hospital beds were said to be occupied by patients deemed fit for discharge. A proportion of these are the result of Social Service Departments (SSDs) failing to arrange residential care or nursing home placements in time. To reduce blocked beds, the Community Care Act of 2003 gave hospitals in England and Wales the power to fine SSDs a daily tariff for delays in discharge caused by SSD failures, or to work collaboratively through special grants. The Act was followed by a decrease in delayed discharges, but we do not know how this was achieved. Did the hospitals adopt the carrot or the stick approach and did the focus on discharge compromise the overall quality of care?


We aimed to:

» To describe the implementation of the Act across the NHS and SSDs by analysing data on reimbursement and delays in discharge in England.

» To investigate the effect of the Act on overall care by comparing trends in admissions, readmissions and average length of stay in hospital over time, before and after the introduction of the policy.

» To explore the organisational and policy implications of the Act and the financial incentives for the NHS and local authorities.

What We Did

We used a ‘mixed-methods’ approach involving: a structured survey of all SSDs in England to determine levels of reimbursement and working relationships with hospitals; analysis of ‘Sitreps’ data to look at recorded delays in discharge and their causes; analysis of Hospital Episode Statistics data to look at trends in admissions, readmissions and average lengths of stay before and after the Act and a qualitative case study of the London Boroughs of Camden and Islington, comprised primarily of key informant interviews.

Provisional Findings

» Two thirds of hospitals chose the carrot rather than the stick approach, avoiding charges on SSDs and preferring to collaborate (using the delayed discharge grant to invest in community services).

» Reduction in delays in discharge may have been accompanied by negative impacts on SSDs, PCTs and patients in terms of cost and the quality of care » Rising readmission rates in England (Figure 3) were likely to have been caused in part by premature discharges.

» The decline in delayed discharge bed days was mainly due to reductions in delays attributed to SSDs (Figure 2), but was part of a longer trend (Figure 1), making the impact of the 2003 Act hard to assess.

» Gaps in the available data (caused by fragmenting care systems and the redrawing of definitions of what constitutes care) made it impossible to assess the impact of the Act on quality of care, and better data systems are needed to monitor the impact of policy changes on care quality.


Click on the figures to enlarge

pollockfig1.jpg pollockfig2.jpg pollockfig3.jpg

Other Project Outputs and Related Webpages

January 2009:  Godden S., McCoy D., Pollock AM., ‘Policy on the rebound: trends and causes of delayed discharges in the NHS’, Journal of the Royal Society of Medicine, 102(1) : 22-28.

2008: Godden S., McCoy D., Pollock AM., ‘Using SitReps performance data to monitor the delayed discharge process’ Health Services Management Research, 21:155-160

July 2007: Carrot and sticks? The Community Care Act (2003) and the effect of financial incentives on delays in discharge from hospitals in England, Journal of Public Health, 29(3): 281-287

This project currently has three Programme discussion papers, click on the links for abstracts, or if you would like to download the paper:

Research Team

Allyson Pollock

Allyson Pollock

Professor Allyson Pollock is Head of the Centre for International Public Health Policy at the University of Edinburgh. She trained in medicine and public health. She is a leading authority on the private finance initiative and the implications of market mechanisms and privatisation for public services. She has an international profile in public health and has made numerous interventions to the policy debate. She has given evidence to the Health, Transport, and Treasury select committees of the House of Commons, and to the Finance Committee of the Scottish Parliament.

Tel: 0131 651 3957

David McCoy

David McCoy

David McCoy is currently a specialist registrar in public health, and a member of the Health Care Evaluation Group in the Department of Epidemiology and Public Health. He graduated from Southampton University Medical School. After five years as a clinician, he began working in the field of public health. He has spent ten years working in South Africa and only recently returned to the UK . He has a doctorate in public health from the London School of Hygiene and Tropical Medicine. He is co-managing editor of the Global Health Watch, an alternative world health report.

Tel: +44 (0)20 7679 1805

Sylvia Godden

Sylvia Godden

Sylvia Godden has an honorary appointment with the Health Care Evaluation Group, Department of Epidemiology and Public Health. Her background is in Public Health information and research and she is on secondment from Sutton and Merton Primary Care Trust, where she has a role as an Epidemiologist/Public Health Information Specialist.

Tel: +44 (0)20 7679 8248