After hospital, where next?

The adult social care green paper envisaged services that put people in control of their lives and allowed them to maintain their independence, but this seems a long way off for a significant number of older people leaving hospital.

A new report from the Commission for Social Care Inspection charts the experience of 70 older people nine months after they were discharged from hospital in March 2004, and is a follow-up to an earlier study (news, page 10, 13 October). All needed social services support on discharge.

The first study found that up to one-third of the older people in some councils were moved directly into care homes on leaving hospital, and the follow-up shows that, once this happened, it was likely to be permanent.

This was seen as a good move by some people, but for others it was a “hurried decision that had come to be regretted”.

Annie Stevenson, senior policy adviser at Help the Aged, says the direct transfer of people from hospital to care homes is wrong and claims it is “unacceptable” for people to be asked to decide where they want to live while they are still in their hospital bed.

She argues that some form of intermediate care should be offered to all older people who need it on leaving hospital to give them time to make decisions about where they want to live. This can involve placing people in intermediate care beds, where they receive help from physiotherapists and occupational therapists on how to get themselves more mobile, or people living in their own homes but with a substantial care package that gradually becomes less intensive.

The report found that fear of errors, complaints and litigation had a “significant influence” on professionals when they were deciding whether to place people into residential care, and the CSCI says there needs to be more “responsible risk-taking” to help older people who want to stay at home to do so.

Penny Banks, a senior fellow at the King’s Fund, says putting people into care homes is a “quick, safe option” and there is a need for more “good supportive services” if people are to be placed back in their own homes.

“There’s a long way to go to transform services for people to be really flexible, not just to be either residential care or home care,” she adds.

She agrees that risk plays a part but argues that a lack of resources and fines for bed-blocking also influence decision-making.

The CSCI says a much more flexible role for residential care as part of a range of services to support recovery and improvement is “long overdue”.

Stevenson strongly supports this call and says care homes need to provide more rehabilitative services that prevent people becoming institutionalised and enable them to return home.

“There’s a desperate need for the Department of Health to reach out to the care home sector and challenge them and enable them to become centres of enablement,” she says.

She says this could involve therapists and nutritionists going into care homes and working with residents and staff to try to improve people’s quality of life.

The report also found that too many older people were being readmitted to hospital because of a crisis that could have been avoided.

Jo Webber, deputy policy director at the NHS Confederation, says it is likely that some of those being readmitted would have chronic conditions and that new developments in this field could reduce readmissions in the future.

She says the recently created role of community matron will help people with chronic conditions and their carers become more knowledgeable about their illnesses and more aware of the warning signs before a crisis occurs.

Many in the social care sector argue that services are becoming more person-centred but concerns have been raised over whether this approach will be subsumed by a more medical model in the forthcoming joint health and social care white paper.

Older people are arguably the client group for whom health and social care are required to work together most and any conflicting agendas could be highly damaging.

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