Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Rationing care by delaying decisions

BMJ 2019; 367 doi: (Published 27 November 2019) Cite this as: BMJ 2019;367:l6620
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter: @mancunianmedic

Practitioners at the interface between the NHS and adult social care can see in plain, daily sight a silent truth that’s often invisible to outsiders: care rationing, by delay, gaming, arbitrary rules, and bureaucracy. We need to speak its name and blow its cover to the wider public.

The officially reported data on the scale of delayed transfers of care from hospital make for grim reading about our under-resourced community health and social care services.1 But, as the National Audit Office reported in 2016, the real number of people waiting is often far higher.2

Here are some anecdotal examples I’ve seen. Patients are referred for social work assessment, and it may take a week or more for a social worker to be allocated. After assessment the social worker has to make repeated requests for more information from the ward team, such as night behavioural diaries or duplicated mental capacity assessments. Formal “best interests” meetings are organised to determine future care needs for patients whose mental capacity is impaired, but these take far too long to set up, even though they’re necessary in law and should happen. It can take longer still to source care agencies that can provide a personal care package, even when this has been agreed and funded.

Decisions on care provision and funding are then often subject (understandably) to panel discussions in local authorities, but this can take two weeks or more from receipt of referral. Even then, requests come back to the wards for further information or assessments, to help justify the spending on home care or a care home. Patients who are already in care homes that have been struggling to meet their needs for some time are admitted to hospital, ostensibly for a short lived illness, and then find the doors closed behind them, unable to return. The pressurised acute bed is now used as a holding bay and hotel to solve a longstanding community problem.

Delays and appeals

Then we have NHS Continuing Healthcare (CHC) funding.3 Just as with national social care eligibility,4 the criteria and thresholds for continuing care are set out in law and national guidance. Yet we know from NHS Benchmarking figures that time for assessment varies greatly, with long delays in some parts of the country.5 Initial CHC assessments are generally double checked and contested, and CHC funding is rejected or decisions are subject to long delays or appeals from families mindful of financial implications and their rights.

The adage that “the acute hospital runs on a stopwatch and community services run on a calendar”6 has never felt so real given the pace, pressure, turnover, and bed occupancy that we work with and the daily imperative to get more patients back home sooner.

I’m painfully aware of the impact of sustained government cuts on local authorities, which are forcing social care managers to do everything they can to use what money they still have left wisely, in nigh impossible circumstances, and ensure that any money spent is used for people with the most need.7

I know that social workers face a workforce and workload crisis and have to follow due process in completing assessments, and I don’t think that anyone’s acting in bad faith. Clinical commissioning groups are under pressure from NHS England to limit their spending on CHC funding.8

Stranded in hospital

The effect of all of this is to ration care by delaying decisions. And, while people wait, they’re stranded in hospital, where their physical health and emotional wellbeing are at risk, and they may deteriorate or die.

Such treatment of vulnerable older people flies in the face of platitudinous organisational values on person centred care. Procedure, bureaucracy, and money come first—not people. And this forces caring health and social care professionals to make decisions that they know full well aren’t always driven by the best course of action for the patient or family.

We’re in the middle of a general election campaign, so we must blow the whistle loudly on rationing by delay, and we must make politicians and national service leaders listen.



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