Covid-19 drive to clear hospital beds left some of those discharged with unmet needs and no support

Charity and watchdog say government guidance on discharge to assess not being fully followed with most people neither visited nor assessed once they return home

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The drive to rapidly clear hospital beds at the start of the pandemic left some of those discharged unsupported with unmet care needs, research has found.

More than four in five of those discharged between March and August 2020 (82%) did not receive a follow-up visit and assessment at home, with 18% of this group reporting an unmet care need, found a survey of 352 patients and 177 carers of people discharged during this time.

Almost half (45%) of disabled respondents to the survey by Healthwatch and the British Red Cross reported unmet needs following their discharge, as did 20% of those with long-term conditions. Issues reported by those with unmet needs included problems accessing aids and equipment, a lack of consideration of their home situation and being unsure how to manage their conditions.

Contrary to government guidance

The findings come despite government guidance published in March saying that patients with no or minimal support needs should have access to support from voluntary organisations if necessary within 48 hours, while those with care needs receiving an assessment from a lead professional on the day of discharge.

Healthwatch and the British Red Cross said their findings, which were also based on 47 in-depth interviews with health and care professionals involved in the discharge process, indicated “a real gap in the provision of post-discharge community health and social care services for those who are likely to need additional help”.

The organisations’ research examined the “discharge to assess” policy introduced in March to quickly free up 15,000 beds to provide capacity to tackle Covid-19, by assessing people’s ongoing support needs post-discharge, usually in the person’s home. To enable this, the government provided the NHS with £1.3bn to fund post-discharge support from March to August.

The report praised health and social care professionals’ efforts in rapidly discharging so many patients so quickly, highlighted the value of national policy and funding in reducing bureaucracy in the discharge process, and said there was evidence of better joint working between health and social care services as a result.

Lack of post-discharge support

However, the research found one-fifth of people felt unprepared for their discharge, while 35% did not receive the contact details of a health professional they could get in touch with if they needed further support or advice, again contrary to the government guidance.

Also, 30% of those tested for Covid-19 did not receive their results before they left hospital, creating barriers to managing people’s conditions post-discharge, which was particularly the case in care homes.

The research also found that 53% of unpaid carers felt that their caring responsibilities were not considered when they should have been, which included not being kept informed, being unclear about the patient’s transport arrangements and a lack of information about how to support their loved one after discharge. In addition, 54% of paid and unpaid carers felt they did not receive enough information to support their friend, relative or client after discharge.

The report also raised concerns about the government guidance allocating specific proportions of patients to each of four discharge pathways, with 50% able to go home with minimal or no additional support, 45% able to do so with a care package, 4% requiring rehabilitation and 1% nursing home care.

“We are concerned that the use of a single number as a national assumption might result in local systems using this as an informal “target” rather than developing their own assumptions,” said the report. “This appears counter-productive to ensuring that post-discharge support services are responsive to local needs.”

Social workers unable to assess capacity

The discharge to assess policy resulted in many hospital social workers being removed from wards so that they could assess and support people post-discharge. However, the report identified issues with there being a lack of social workers available to assess people’s mental capacity in hospital.

“Instead, some hospital staff had to conduct these assessments, when they reported lacking confidence in doing them or were not adequately trained to deliver them,” said the report. “This has been challenging for staff and caused delays for patients’ discharge.”

The British Association for Social Workers (BASW) said the report’s findings mirrored those of its own recent survey of social workers and people involved in hospital discharges, which also highlighted a lack of follow-up visits post-discharge and issues regarding capacity assessments.

Rush to discharge driving decisions

Liz Howard, professional officer at BASW England, said a rush to get people out of hospital was driving decisions, with social workers no longer involved in the initial decision making about discharge arrangements.

“Moreover, without access to care and health settings, social workers are struggling to comply with the Mental Capacity Act to obtain the person’s views and wishes, carry out mental capacity assessments, or advocate what is in a person’s best interests,” she said.

Association of Directors of Adult Social Services (ADASS) immediate past president Julie Ogley said directors were particularly concerned that follow-up calls and assessments had not always happened, and that good information and advice were not readily available post discharge.

“At times, it required greater staffing support across social and community services that were simply not available,” she said. “If we are going to avoid repeating those mistakes this winter, we must learn the lessons of this report.”

From September, the government amended its policy to limit NHS-funded care to six weeks post-discharge, backed by £588m to last until March 2021, though has continued with the discharge to assess approach.

Ogley said more funding was needed to “allow us to properly remunerate and expand our committed and valued workforce, and to make effective post-discharge care a reality”

Recommendations

Her call for extra investment in post-discharge services was echoed by Healthwatch and British Red Cross, who said it should be a medium-term objective to improve the discharge process, amid a resurgence in coronavirus cases and  anticipated winter pressures across the health and social care system. This should include ensuring community services can operate seven days a week and tackling workforce shortages, it said.

The report added that, immediately, everyone leaving hospital should be given a follow-up contact for further support, with carers and family members also given this information. In the short-term, the Department of Health and Social Care and NHS England should assess and tackle the low level of follow-up visits post-discharge, which should then be monitored locally and nationally, by local leaders and the Care Quality Commission respectively.

It also said policy should be amended to ensure everyone is given a follow-up visit, even if they are anticipated not to need post-discharge support, and that the allocation of national proportions to each post-discharge pathway should be reconsidered.

11 Responses to Covid-19 drive to clear hospital beds left some of those discharged with unmet needs and no support

  1. Bernardine November 4, 2020 at 10:56 pm #

    Apparently social workers and their managers are powerless to assert a role for themselves in both ends of this process. Self imposed impotence is not a particularly good excuse though is it? As for BASW, the usual laughable blaming statement with no ownership, leadership at it’s best.

  2. Liane November 5, 2020 at 9:14 am #

    Re “Social workers unable to assess capacity” … I would like to challenge the underlying assumption that it’s a social worker role to undertake mental capacity assessments. Instead, it is my understanding that mental capacity should be assessed by the decision maker, which can be a social worker but – especially regarding health treatment decisions – will often be a healthcare professional. Whilst it’s sadly very true that other professionals don’t seem to receive adequate training in undertaking mental capacity assessments and often express lacking confidence, the critique should address this underlying issue rather than seeing the flaw in the availability of social workers.

  3. Anita November 5, 2020 at 11:49 am #

    What’s the evidence that other professionals don’t receive adequate training to undertake mental capacity assessments? It’s this arrogance and unfounded belief in the superior competence of social workers which lead to the abuse and deprivation of liberty of so many vulnerable people. Social workers have a lot to be humble about and not much to crow about. I have observed BIA assessments which have made me ashamed to be a social worker, and capacity assessments that have filled me with wonder and joy at the skills and compassion of my nursing colleagues.

    • A Man Called Horse November 6, 2020 at 11:29 am #

      The deprivation of Liberty issue of vulnerable older adults is a complex issue. Recently I moved someone out of a Nursing Home who had been placed there because they had Covid19. Mr X reported he had not been able to return home to supported living because of the infection and the NHS wanted and needed the bed for other patients. He remained at a Nursing Home for more than six months with no review and no attempt to listen to his wishes. The supported living scheme he was living at opposed his return because they said his care needs paticularly at night could not be met. After consultation with Mr X I planned his discharge back to his home and he told me very clearly he wanted to leave the Nursing home because he was unhappy there and felt life wasn’t worth living if he had to stay where he was. I arranged his discharge and he returned to his home, correcting a breach of his human rights to self-determination and recognising he is entitled to make an unwise decision if he has capacity. I am a Social Worker I don’t have any arrogance about my superior competence and I hold the principle of self determination and the right to family life as important principles. Assessing Capacity is not always easy so I understand anyone’ who feels that perhaps they have not had enough training on the issue being a little anxious. We don’t always get it right and professionals don’t always agree on what constitutes best interest. The major abuse of deprivation of Liberty occurs with families who don’t have LPAs on Health making decisions to put their family member into care through coercive behaviour often overriding their loved ones views thinking they know best. Deprivation Of Liberty Assessments eventually get completed and it ends up with Social Workers having to confront family who often think they know what’s best for their relative and give any challenge to that view by a Social Worker a hostile reception.

      • Another one November 20, 2020 at 5:15 pm #

        As a family whose parents were separately miserably failed by the same London borough, some of what you state is met with a ” thank God’ someone in social work is actually at work. And we say that as an NHS family staggered at the way social services saw the NHS emptying beds as some sort of opportunity to dump the most vulnerable..At home or in a care home miles away from loved ones.

        So, where have all the social workers been? Why can they STILL not go see and assess the needs of those unable to be supported remotely? You suddenly expect other professionals to become capacity experts in tne most confusing legal framework ever drafted?

        And what do social workers think us as NHS staff have been doing since February? Those of us not on frontline were redeployed to it. Including a fair number being pulled from MH Trusts ( but mone sent the other way of course).

        NHS community staff continued to see people. The councils own trades people can. Just not social workers apparently . And case law allowed individual’s needs to be considered when decisions were made to stop entry in to care homes.So, no excuse really unless you have a personal exemption.

        This local authority, like so many, de facto cancelled care packages for so many. Even today we are told it is our job to look after our parents, despite us having our own serious health and care issues. We have been unsupported carers since childhood. And here very notably the MH Trust has literally closed it’s doors to all community support inc even crisis care for a few weeks.

        One of our parents is STILL dumped in a care home hundred miles from home and when of working age because of apparent internal politics. And not a single social worker has bothered to go do the assessment the care home have stated they cant do.

        During this time every single council funded service, including advocacy, has been told they cant open.

        So, when social workers meet family resistance maybe it’s because we see no evidence that what was meant to have been a temp position whereby our most loved ones were dumped out of hospital at 2 hrs notice, has had any plans in place to resolve.

        In the meantime both our working age parents health have severely deteriorated. They will die preventable collateral deaths. Because social workers were willing to agree to dumping vulnerable pts out of NHS wards instead of pausing and actually arguing corners as you have here.

        But someone tell us why our lives as a family have less value than the professionals? Our risk somehow less? Some of us were separated months from family working on the front line. And in one of our parents case were told we would have to move in with and care for 68 hrs a week on top of our 14 hr a day 7 days a week hospital shifts with no days off for up to 78 days for one of us.

        As a family with co roles we have had to immerse ourselves in legislation that doesnt seem to EVER place the vulnerable person at the centre if the local authority doesnt want to. Both parents believe this is planned culling. But speak to the council duty team and the human cost to all just doesn’t register for us.

        And as for feeling like social workers are our colleagues- not a chance when they dont have to actually see anyone too vulnerable to be assessed remotely.

        If I can work in ICU then a social worker can get on the train to the care home THEY dumped our parent in to assess. Let alone walk tbe 10 mins to pre arranged socially distanced assessments in someones home.

        10 months on. STILL not working according to tbe duty team unless it is an emergency. The threshold of which is unacceptable

    • Chris November 8, 2020 at 12:59 pm #

      Anita, you’re right there is good and bad in both health and social care in terms of capacity assessments. However, as an IMCA working across both social and health care, there is a woeful disparity between the quality of MCAs completed by health professionals compared to that of social care workers. I have also come across health professionals who profess to neither know of or understand the main principles of the MCA, However, I have never had the experience of a social worker saying the same. That to me points to a lack of adequate training and resources for health care workers.

  4. Anita November 9, 2020 at 8:53 am #

    Social workers are good at generalising from anecdotes, that’s the curse of a “profession” that can’t decide what its educational and knowledge base should be. Inconsistent and poor training somtimes makes an incompetent social worker doesn’t it? I have yet to meet or work with a social worker who wasn’t an instant expert in any discussion, we have an aversion to admitting we might not know or that we can’t do. Applause to those health workers who admit not knowing. The average social worker has little to no understanding of mental capacity though they would all be excellent in filling in a pro forma and glow in their assumed expertise. We know that the quality of many IMCA’s assessments are poor also. Most reflect next to nothing about the person being assessed but no doubt ‘comply’ with the law. Social workers shouldn’t be let any where near a person whose liberty is at stake. We pretend to be look at the person but what we are really doing is covering our backs given we work in organisations that offer next to no support. I speak as an AMHP, and most of us are nor as brilliant and highly skilled and competent as we think we are. Social workers need to learn humility and listen to what service users tell us about their experinces of us. Believing that we are unique doesn’t make us so.

  5. Constance November 9, 2020 at 1:50 pm #

    I very much agree with Anita. It’s interesting to me how most social workers while being critical of health staff, retreat from confronting doctors. Is this somehow about social workers seeing their status on a par with doctors and above that of nurses? Not one social worker would survive a 12 hour A&E shift not just because of the physical demands of nursing but also because nurses make hourly decisions, including whether their patients understand treatment options, without the endless and often pointless discussions social workers indulge in before making the most basic decisions. By the way not all IMCA’s are as independent as they should be. In the end we are all just workers and should treat each other as such rather than scoring imaginary points about who is the more competent. The average hospital ward, nursing home hospice and the like would be a lesser place without social worker input but they could function without being graced by them. Not many health and social care plans would deliver without the skills of nursing and medical staff.

  6. Suzanna November 10, 2020 at 12:53 am #

    Strange that the immediate past president of ADASS advocates better pay for “our valued workforce” now. I remember the silence of ADASS over pay and more clearly their complicity in driving through austerity. Some of us have very long memories I am afraid.

  7. Christopher D November 25, 2020 at 9:08 am #

    Reading these replies actually makes me cringe. Its about time the NHS and Social Care stopped blaming each other and pointing out failings to come together and celebrate the achievements of successful discharges and learn from the failed ones – this bickering over who is best does not help the people and their families that we all should be focussing on getting it right for.. together. Just saying..

    • Experto Crede November 27, 2020 at 7:23 am #

      Its not bickering. Its challenging professionals to do their jobs and act lawfully. And it is right to ask why social workers cannot now see clients THEY dumped ( albeit under huge pressure) hundreds miles away when colleagues in the NHS can and do.

      And the words THEY are used because the template letter email sent to ppl affected was all about how as social workers THEY had decided to make decisions without consultation. What we and others were sent was a heavily worded quite threatening letter about how we nor our loved ones had any choice.

      The collateral harm by staying silent as NHS professionals or as family ,and doing NOTHING would be shameful. Whose job is it to advocate for client’s needs? In whose job descriptions?

      De facto blocking and removing home care packages of the most vulnerable without going through due legal process has had a horrific impact on carers AND their loved ones.

      Telling carers to take on 24 hr 7 days a week care for now 10 mnths should be called out. Not doing so and not speaking up for the rights of those who cant themselves when no advocacy agencies are open non remotely, is already cringe worthy and anger making.

      Social Workers agreeing to dump NHS pts in to care homes with covid , with NO exit strategy, is wrong. As an NHS worker I get 2 hrs level one online mental capacity training 3 yrly. Our immersion into the pit of the DOLs world as a family has only been supported by our intimate knowledge of the god awful use of the MHA with a different parent.

      We are in the not so unique position of being NHS frontline AND having 2 working age parents with significant care needs.
      And the word ‘bickering’ diminishes the impact not speaking out has.
      And mdt does mot mean co working, in our experience silo mentalities are worse mow than pre pandemic

      If community social workers stopped telling us they are not seeing people we wouldn’t be writing here.

      And as for undertaking DOLs the NHS does not have capacity is the real reason and now , even if skilled individuals wanted to, we wont for a very long time even when the mess of a legislation is changed.

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