Cutting hospital patients 'will not cut costs'
The £3.8bn Better Care Fund, due to be launched in 2015, is the latest government proposal to save money and make the health and social care sectors work better together in England.
But in this week's Scrubbing Up, Nigel Edwards, chief executive of the Nuffield Trust think tank, says it's a risky plan, with little chance of delivering big savings - and more emphasis is needed on cutting the length of hospital stays:
Moving around pots of money to reshape health services is a tool beloved of policy-makers across the globe.
The government's Better Care Fund - a plan to take a large slice of the NHS budget and pool it with local government funds - is the latest and most ambitious attempt to do this in England.
But it's a risky plan and is based on very optimistic assumptions about the savings it will yield in the short to medium term.
The theory is sound: people have both health and social care needs.
All too often, health services are used when they needn't be. People are admitted to hospital, nursing homes or residential care when they might have been better-off at home.
But the practical application is the issue.
The plan is built around reducing the numbers of patients admitted to hospital. And doing this at speed.
On one level this looks attractive. There are around 15% of admissions where better primary care services, such as GPs and community nursing, have the potential to prevent the admission.
There are even more cases where alternatives to hospital can be used instead of an admission.
But attempts to prevent admissions have not been very successful.
It's hard work, the interventions are complex and they need to take effect rapidly.
Only in some cases is social care the answer and where it is available, it may have difficulty responding to new cases in time.
Even where admissions can be prevented it cannot be assumed that this saves money or that any money saved can be easily re-used for other things.
About a third of people admitted for non-surgical emergency procedures stay less than one day and another one in five people may be sent home within two days.
The costs of assessing, diagnosing and treating these patients may not change that much if their admission is prevented.
Making the decision not to admit patients may still require significant resources, expert opinion, specialist labs and imaging.
Making these decisions in the community may be more expensive because the expensive infrastructure to support this will be less intensively used.
What's more, the cost of alternative care needs to be very much cheaper if there are any savings to be made. But this is not the case.
Costs do not fall very much if 15% of the activity is removed - around 80% of hospital costs remain unchanged with relatively small changes in activity as most of these costs are tied up in staffing and infrastructure.
Care at home is often better, it's preferred by patients and it prevents the risk that they become institutionalised.
But the direct costs of care may be similar to or greater than those of the hospital.
Paradoxically, a focus on preventing admission to reduce costs runs a significant risk of increasing them, at least in the short to medium term.
The type of intensive support that is provided to patients seems to find new problems that may need treatment.
This may prevent further problems later but some of these might well have resolved themselves without help from the NHS.
Moreover, while reducing hospital admissions is in itself a good objective, it may not greatly reduce the pressure on hospital beds.
Most beds are occupied by a relatively small numbers of patients who stay a long time. In fact, in medical wards 10% of the patients that stay over seven days account for nearly 71% of the beds.
More can be done quickly by reducing patients' length of stay.
A large proportion of patients could be more effectively cared for elsewhere.
This will require better social care, community services and new types of care.
Reducing the time patients stay in hospital is not easy either.
However, it can be done more quickly and effectively than reducing admissions.
Realistically it has to be done, because without this the NHS will need nearly 15,000 more beds over the next seven years.
And that really is impossible.