The EconomistAugust 3rd 2019 Britain 191A
hospital wardis a great place to pick
up an infection, become depressed or
get out of shape. Unless you need urgent
care, it is not a great place to spend time. Of-
ficials in charge of the National Health Ser-
vice therefore keep a close eye on delayed
transfers of care, or dtocs, people some-
times known as bed-blockers, and official-
ly counted as those who remain in hospital
having been given the all clear to leave. To
much concern, numbers took off in 2014,
before peaking in 2017, when nearly 6,
people a day remained in hospital against
medical advice (see chart).
The measure represents a crucial fault-
line in the welfare state, where the compet-
ing incentives of the health and social care
systems rub against one another, says Jon
Glasby, a social-care expert at the Universi-
ty of Birmingham. Hospital managers need
to get patients out of their institutions, but
social workers are unwilling to take people
without the right care in place. Leaving
these people in hospital is not just a great
waste of money but also a failure of wel-
fare: nobody wants to be stuck in hospital
unnecessarily.
Helen Buckingham of the Nuffield
Trust, a think-tank, says the turnaround is
the result of “a burning platform and burn-
ing ambition”. With hospitals falling far
behind accident-and-emergency targets,
managers want to improve things at the
other end of the pipeline—those leaving
hospital—so doctors’ time is not wasted on
people who should be in social care. A re-
cent nhsmandate, by which the health
secretary sets priorities for nhsEngland,
instructed the health service to get on top
of the issue. More attention is now being
paid to the “super stranded”, who have been
in hospital for longer than three weeks.
The health service has been helped by a
dose of extra funding for adult social care,
which was hit hard by austerity. At the
spring budget in 2017, Phillip Hammond,
the then chancellor, announced £2bn
($2.6bn) more for such care, with strings
attached over how it was spent, forcing col-
laboration between local authorities and
health-care providers. Insiders admit re-
sults have been mixed, with some councils
using the money to boost their bottom line,
but say that it has supported innovation.
These days, people are more likely to be
discharged before their care needs are as-
sessed, rather than assessed before they are
sent home. That sounds like a ruthless way
of clearing wards, but once somebody is
home it is easier to work out whether they
need help with, say, making breakfast. In
Dorset patients are monitored at home
through “virtual wards”, in which a team of
social workers, doctors and nurses keep
tabs on patients, with visits when neces-
sary. In Somerset rehabilitative physio-
therapy is sometimes done in a care home
jointly run by a hospital and the council.
Blame for delays used to be contested, but
“we no longer wanted to distinguish be-
tween social care and health-care delays,”
says Tim Baverstock, who works for the lo-
cal council.
The Care Quality Commission, a regula-
tor, worries that the focus on dtocshas
moved attention from stopping people
reaching crisis point in the first place. Be-
cause thresholds have been frozen, ever
fewer people qualify for state help for their
social care, leaving more struggling to sort
things out for themselves. And despite the
improvement, things are worse than they
were five years ago. Yet the decline is still
rare good news for a health service that,
though loved, looks a little frayed. 7How the National Health Service got
better at freeing up beds
Health and social care
Beds unblocked
Off their trolleysSource: NHS EnglandEngland, average number of hospital
patients delayed per day, ’2010 12 14 16 18 1901234567Let’s get outta hereB
rexiteers, by and large, have nothing
but contempt for the Bank of England.
They think it behaved as a hired gun of the
Remain campaign in 2016. Its repeated
warnings since then of the dangers of a no-
deal Brexit have created further ill will. So
the government’s capture last week by
Brexiteers has injected an interesting ele-
ment of unpredictability into the race to re-
place Mark Carney, who vacates the gover-
norship in January.
Insiders such as Andrew Bailey, head of
the Financial Conduct Authority, and
Dame Minouche Shafik, the director of the
London School of Economics, have been
leading the field. But Boris Johnson is
thought to want his own person. That’s
why Gerard Lyons, a pro-Brexit economist
who advised Mr Johnson when he was
mayor of London, is now the fancied out-
sider. The pro-Johnson Daily Telegraph
newspaper reports that he “has already
been promised it”. Mr Lyons declines to
comment on the rumour. But even if he
doesn’t get the bank job, he’s likely to get a
big advisory role.
Mr Lyons’s euroscepticism goes back a
long way. At a recent event at the London
School of Economics he spoke glowingly of
politicians in the 1960s and 1970s who cam-
paigned against Britain’s membership of
the common market. Mr Lyons was an early
critic of the “exchange-rate mechanism”
(erm) of the early 1990s, in which the
pound was pegged to the Deutschmark.
“[S]omething will have to give: either the
government’s exchange-rate commitment
or the economy,” he wrote in the Observer
in 1992. He has called the euro “probably
the worst economic idea ever thought up
by anyone anywhere at any time”.
His language about Brexit is equally
passionate. Though he has shied away
from some of the Leave campaign’s wilder
claims—including Mr Johnson’s mislead-
ing statement that the nhs would get
£350m ($428m) a week of extra funding
after Brexit—he has compared the eu to the
Titanic. Theresa May’s withdrawal agree-
ment with the eu, meanwhile, is akin to
“allowing someone to put their hands
around your throat and to squeeze the life
out of your economy”, he told attendees at
an event organised by the Bruges Group, a
conservative outfit.
In “Clean Brexit”, a book written in 2017
with Liam Halligan, a journalist, Mr Lyons
explains how Britain can do much better. AWhat makes Boris Johnson’s favourite
economist tick?Gerard LyonsThe roar of the
outsider