Adult social work at its most stretched but also at its best during hospital crisis

By Rob Mitchell and Elaine James

Looking back, there were warning signs well before the Christmas break that something was going wrong in the health service. Adult social workers are used to being on high alert at this time of year and being warned that winter is on its way, although, usually, the first warning we get to be ready comes around the beginning of July! At Christmas, whilst others celebrate the most wonderful time of the year, adult social workers experience the busiest time of their year. However, despite the usual six-month warnings, none of us were ready for the sheer weight of the pressure that hit us during the first week of the New Year as hospital after hospital tipped into crisis.

The first sign that things were going wrong was when the ambulance service went into high alert on Friday 19 December because that day all ambulances were committed and there was no further capacity to provide additional crews for additional ambulances. Ambulance crews were tired because they had been asked to work overtime to cover all shifts.

Meanwhile, the season’s flu outbreak was affecting community nursing services and tipping older people with chronic conditions into hospital. By New Year’s Day our local hospital started running out of medical beds and putting huge pressure on social care to move people out of hospital. Not out to the right place and right care, just out.

Dehumanising language

Under intense pressure, good people can behave badly and poor organisational culture, usually hidden, can be exposed. In the midst of heightened anxiety and genuine fear, consideration of human rights, issues of consent and evidence of compassion were the first things to go. Issues of choice and control, foremost in social work values, were often overridden and drowned out, replaced by the dehumanising language of the day: ‘patient flow’; ‘throughput’; ‘bed-blocking’; ‘units’ and even ‘creaking gates’. These have all been used in the last three weeks to describe those who became ill over Christmas and needed state help.

The resulting massive pressure transferred responsibility onto social care to shunt really ill people in need of medical care, therapy and compassionate nursing out of hospitals into care homes without any consideration of their capacity to be involved in decisions about how their care needs were met. The issue, of course, is not that people should be in hospital, it is that they should be moved to the right place in a way that gives them time and support to make the right choice. The impact of local government pressure on the social care market, however, has left it fragile and wary. None of our local care homes would accept the extreme high risk associated with this chaotic approach to hospital discharges. Many resisted the temptation of an income source in an effort to ensure that people remained safe and that discharges remained co-ordinated and appropriate. As a sector that is often maligned, they rose to the challenge.

Conviction and values

If ever there was a test of social workers’ conviction and values this has been the month. The pressure to discharge at all costs, with no real thought given to the long-term impact on the individual, has been immense. We have tried to co-ordinate, but it is genuinely scary to be faced with a hospital about to declare a major incident and to stand firm and insist on being given another 24 hours to clear a safe discharge pathway through services designed to get people home with support. Unfortunately, the cost of commissioning these services has wiped out any safety net we had reserved as we enter the most challenging financial year ever for social care.

The weeks since Christmas have highlighted social work at its most stretched but arguably also at its best. Social work, working alongside health colleagues but crucially operating outside of the health hierarchy, is able to provide the necessary challenge to ensure that even at times of crisis, human rights are upheld and that the most vulnerable of people experiencing the most uncertain of environments are afforded the same human rights as us all.

Rob Mitchell is principal social worker, adults, and Elaine James is service manager strategic commissioning at Calderdale Council