Meet the social workers at the sharp end of an under-pressure NHS

As a social worker in one of the busiest A&E departments in the Midlands Maria Lole is never sure what problems she’ll face each day. She just knows she’s got 72 hours to solve them.

Her aim is to support people, wherever possible, to be able to leave hospital and live at home.

Most weeks she’ll have to consider safeguarding risks and search for temporary housing, but others bring more unusual challenges. One day it was nipping out to buy shoes for someone who couldn’t be discharged until they had a pair. On another, she removed a stove and chip pan from a woman’s home after a fire – the only items standing in the way of a safe discharge.

“We went through a whole range of services in order to achieve that – but for health and safety reasons no one was happy to remove those items,” she says.

“The lady wouldn’t sign a positive risk assessment, she wouldn’t pay for a trusted trader to remove them, she’d given verbal consent but that wasn’t in the presence of another person.

“So our practical difficulty was how can we actually go into the property and remove something. That’s really a typical day in hospital social work – our role is very analytical, it’s all about problem solving – what can we do to make this happen and how can we do it safely?”

It’s a snapshot of life in the hospital social care team at University hospital Coventry and Warwickshire, where Maria has worked for the past 25 years. The service handles an average of 50 referrals per week, a mix of safeguarding cases and complex discharges.

While Maria is assigned to A&E, other social workers in the team work on wards for longer-term conditions, and in a GP-led service that offers intensive community support to frail older people in a bid to prevent admissions.

‘Positive outcomes’

We meet on the last day of November. Temperatures are sub-zero. The NHS is in the headlines. Health bosses have warned that a failure of ambulance services to meet waiting time targets highlight a system-wide crisis. It’s the latest in a string of similar reports and statistics exposing the daunting winter facing the health service. A&E attendances are up on last year. Delayed transfers of care – cases where people are medically fit to leave hospital but can’t due to a lack of health or social care support – are at record levels.

In Coventry Maria’s team is braced for another tough winter. The hospital saw almost 12,000 patients come through its doors in December last year and at least the same is expected this time around. Delayed transfers of care figures are currently deemed a “high risk” issue and are a daily focus in team meetings across services.

While public and media attention surrounding these issues often lands on the vital work of doctors and nurses, social work teams are also a critical, yet often hidden, cog in keeping the system moving. A meeting held this morning to review recent cases shows exactly why.

The first case is from social worker Baderiah Lagadin. She worked against the clock to find temporary accommodation for a young man with autism. He’d been admitted to hospital after a head injury and was facing homelessness after his parents said they could no longer cope.

Baderiah teamed up with a local charity to find a short-term placement. The man is now happy and settled in his own tenancy. For Baderiah, the case showed the importance of making links with the third sector, especially as the team are increasingly dealing with homelessness cases.

I’m glad I held out for him and the outcome was positive. I am pleased he is doing well and I feel we have helped him to reach his goals.

‘Intervene and resolve’

A second case involved an elderly woman subject to safeguarding concerns after she made allegations that relatives were entering her bedroom in the night to move items around.

When the social worker, Bernice McCarthy, looked into the case, she discovered there had been a series of similar referrals made by other agencies over the last 10 years.

Bernice’s assessment found the woman was physically able and had no apparent cognitive impairments – but it later came to light she had mental health needs that had not been picked up. The allegations she had made were the result of a persecution complex, not actual events.

“She’d been through a mental health assessment but I think because at 80, people tend to focus on the cognitive abilities and don’t dig deeper, and so she was presenting as fine.”

Telecare was fitted in the woman’s bedroom, which confirmed that she was not being subjected to any abuse, and this was a reassurance for family members.

“But nothing would convince the lady that it wasn’t happening,” Bernice says.

“Another referral came in to say exactly the same as the last one did. Matters have since come to the attention of her GP and he has referred her for further “assessment.

We have done as much as we can as a hospital social care team, this is mental health.”

This case highlights the benefits and drawbacks of the unique hospital social work role. While social workers in hospital settings work to strict timescales and have to intervene and resolve problems quickly, those in the community have more time to see someone at home.

On the flipside – the hospital ward can help them to pick up on issues that would never be identified elsewhere. Bernice noticed that after she left the woman, she would start writing things down, something she says she would not have seen once the front door was shut.

“As much as time is an issue for us, we can actually go back several times to see a person.”

‘Urgent situation’

One thing’s for sure – the pace of hospital social work and the pressure from NHS services is markedly different to working in the community. Maria says there’s strict monitoring around delayed discharges and the social care staff are questioned about it every day.

What have you done, where is this person, why is this person still in hospital – and that’s about bed capacity and about the fact that the hospital needs to run successfully.

Sara Milne, one of the team managers who was previously a community social worker, says it was really challenging getting to grips with the pressures in the hospital.

“The amount of pressure that is on you from health colleagues to discharge somebody quickly…you’ve got to make sure they are safe and bring your social work values into it.

“Health says someone is medically stable, we go and see them and they are clearly not – that constantly goes on and there are a lot of social work v. medical model disputes.”

This is echoed by Jane Scoular, the third team manager, who says there can be a tension between the urgency of the situation in hospital and the needs of the patient.

“It can be tough. You don’t want to keep somebody in hospital, it’s not good for them long-term. It’s about working around that tension between health and social care, the needs of the person, and the needs of other people in the county who need to come into hospital.”

‘Empathy and understanding’

It’s only likely to get busier as the hospital juggles the increasing pressures of the winter months. Maria says it’s unusual to walk into the emergency department at this time of year and not see a lot of people on trolleys – “If you’re not used to it, it’s very busy and very noisy.”

“There’s always forward planning, bed capacity has been looked at, but the important part of that is the flow through. Where people are going into enablement services, we then need the services in the community to get them out the other end,” she adds.

“There’s a lot of work that goes into that.”

Maria Lole

While the vast majority of Maria and her colleagues’ time is spent trying to help people leave hospital, there are occasions where they have to work against that policy and bring them in.

She remembers a case where an elderly man with breathing difficulties was admitted to hospital 22 times in 30 days. With the man unwilling to engage with staff, care teams had historically struggled to get to the root of the problem.

“We all felt it had reached a point where we needed to bring him into hospital and understand what all of those admissions were about – we kept him in for just over a week,” she says.

Maria visited the man every day. She found out he was afraid of being alone and unable to breathe. “People treated him, but they didn’t listen and understand how frightening it was.”

She referred him to a housing with care facility and he’s only been back in hospital twice since.

“If you’re a doctor or nurse, your job is to treat and to heal people, you can’t really sit down and spend time with people going through issues and really understanding them.

“Although it’s restricted, social workers are able to do that. It means we can get to know someone and empathise and understand what it’s like for them – we should never lose that.”