The government shot itself in the foot last November when it announced figures showing an unexpected rise in delayed discharges from hospital in England for the year from 2005-6 to 2006-7. In fact the figures showed an overall decline in delayed bed days from 776,101 to about 733,000 leading to a hasty apology from care services minister Ivan Lewis.
But figures from The Information Centre for Health and Social Care released in May show that while delayed discharges are being reduced, emergency readmissions to hospital in England are on the increase, rising from 203,095 in 2004-5 to 221, 847 in 2005-6, leading some to ask whether the two are linked.
After years of mistrust joint working between health and social care professionals is generally improving but in some hospitals in England it is a different story. The pressure on bed space, driven by hospital targets on patient throughput, is putting this relationship under huge strain in some areas.
Social workers are concerned with the whole person and the consequences if they are discharged too early. They argue that hospital staff see patients simply as bodies to be fixed and once this is done they think they are ready to leave with little regard for what goes on outside the hospital. Health staff on the other hand state that infections such as MRSA and C difficile and the potential delay to rehabilitation means once someone is “medically fit for discharge” they should be on their way.
Ruth Cartwright, professional officer for England at the British Association of Social Workers, used to manage a hospital social work team and keeps in regular contact with her former colleagues. She says medical staff have a different perspective from social workers. “When I joined the team I was struck by the way the medics had a very narrow definition of when somebody was ‘medically fit for discharge’. People have no time to come to terms with the fact they have had, say, a stroke,” she says.
Regardless of their physical condition, when asked many older people say they don’t want to leave hospital purely because they are scared of what lies outside and how they will manage. Cartwright says she is not advocating that people can stay in hospital for as long as they want, but that they need to be gently eased out.
While critical of health professionals, she says the pressure on them to free up beds has to be recognised and that delayed discharge fines have increased this further.
David,* who manages an older people’s team in a council in the north of England, says this is evident in his area: “There is a problem with older people and the pressure being put on them to be discharged from hospital quickly and that’s the pressure put on the ward staff by the consultants and, most probably, the executives of the hospital are on their back.
“We are fighting for the client. For the NHS it’s just ‘get them out of hospital as quickly as possible’ and we are saying you can’t do this. This individual has their rights if they choose not to go to a nursing home.”
Such situations echo Cartwright’s experience. “Really, if you are going into hospital social work a flak jacket is a requirement,” she says.
But Jo Webber, deputy director of policy at the NHS Confederation, says health staff’s perspective must also be considered. She agrees that pressure on beds does play a part but says that for many people hospital is not the correct place for them.
“There is an issue about people receiving care in the right environment. I think the last thing you want to do is to keep somebody in hospital for longer than is absolutely necessary. You don’t want to expose people to the risk of infection. You don’t want people to be in an environment where they are not being rehabilitated quite as quickly as they should be.
“Hospital is probably not the right place for people to be once they have been medically stabilised.”
Step-down or long-term re-ablement wards give older people the space to get to grips with what has happened to them and social workers the time to carry out full assessments – getting to know individuals and families rather than just ticking boxes.
Alongside such wards, intensive home care services which “re-able” people to live independently also help to stop emergency readmissions. A recent Department of Health-commissioned report found such services could help to prevent people needing further home care for at least two years.
Both the wards and intensive home care services are now widely recognised as best practice. All but 20 of 150 English councils have either implemented or decided to introduce a re-ablement service, but some areas are starting from a low base, meaning provision is patchy.
David says that, where re-ablement wards are not available, the speed of discharges is leading to poor assessments and support.
“A lot of those long-term rehab wards have closed [in his area] so people sit in acute beds which cost a fortune and there are others leaving hospital without proper assessment in the community. There are quite a significant number of unsafe discharges going on,” he says.
One result of the ageing population is the frailty of older people once they start to receive social services. In this context the term “older people” is more likely to refer to people aged 85-plus rather than those in their seventies – making premature discharges more likely to have a negative effect.
“By the time they get to us they are elderly. We have clients who are 100 living in the community,” says David.
Government research has found that having services within walking distance is one of the public’s key priorities for the NHS. People report wanting services in their communities, as near to their homes as possible – only wishing to go to hospital for major operations. This, coupled with a drive for resources to be moved out of secondary into primary care, has resulted in many hospital social work teams being disbanded with general teams, such as those serving older people, picking up hospital cases instead.
Cartwright’s team was hospital-based. She feels that moving social workers out of hospitals is wrong and increases tension on the ground. “They should be in the hospital in the discharge team with nursing colleagues and consultants. That brings more understanding of the issues for each group. My experience was that this improved working relations and defused some of the adversarial situations that were going on.”
The hospital social work team in David’s area has been moved out and disbanded. He says that, since the move, social workers’ relationships with hospital staff has worsened and the group has to juggle hospital clients and community work.
Logistical problems such as parking and wasting time in driving to and from hospital, or unexpected overlaps in appointments are other issues raised by former hospital social workers.
“You could turn up and the occupational therapist is with the person you’ve come to see. If you are based in the hospital you can just check back in 10 minutes,” says Cartwright.
Webber acknowledges that face-to-face corridor conversations are less likely where hospital teams have been disbanded, but says personal relationships are important rather than where people are based. “The relationship between social workers, nurses and doctors is key to all of this,” she adds.
* Not his real name
The impact of delayed discharge fees
● The Information Centre for Health and Social Care, Compendium of Clinical and Health Indicators/Clinical and Health Outcomes Knowledge Base, Emergency Readmission to Hospital within 28 days of Discharge from Hospital: Adults of Ages 16+
● Department of Health, Homecare Re-ablement Workstream, Retrospective Longitudinal Study, November 2007
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This article appeared in the 13 December issue under the headline “The war on the wards”
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