Recovering at Home

Yesterday Mike Farrar, the Chief Executive of the NHS Confederation made the news by claiming that 1 in 4 patients in hospital beds could be cared for and could recover at home.

The difficulties of arranging appropriate discharges from hospitals is a matter that’s particularly close to my heart. Not least because I’ve been involved in the process for over a decade through my work. I’ve seen many changes (notably the Community Care (Delayed Discharge) Act 2003). Some steps forward. Some hefty leaps backwards.

And who are these ‘1 in 4’ that Farrar mentions. Well, unsurprisingly, he is referring to older adults.

The Guardian article says

One big issue is elderly care. Farrar said NHS leaders believed that at least 25% of patients in hospital beds could be better looked after in the community or could look after themselves at home rather than in the “outdated hospital model of care”.

With money short, there has been increasing concern that support for vulnerable patients from social care, paid for by councils, or from NHS-funded nursing in the community, has been cut back. The result is bed-blocking as patients face increasing delays in being discharged from hospital.

I have no doubt that better care could be potentially provided in the community but the block is very much services and more importantly access to appropriate services both from NHS primary care and from social care which are both being cut at the moment.

I have also over the years and in fact, quite topically, over this week, seen some appallingly rapid hospital discharges that have been rushed though purely on the basis of cost and pressure for beds. It is understandable when the pressure comes but the price that is paid for fewer hospital beds can be excessively high. A poor, rapid hospital discharge to the community with poorer and fewer resources available is a very costly one. The problem is that saving made by the NHS in the hospital bed being ‘freed’ is picked up by the local authority in terms of someone having an increased longer term need.

Yes, there are more quickfire ‘enabling’ home care packages intended to pick up the immediate hospital discharge but they tend to be focused on rehabilitation goals which are very much orientated towards physical care needs. My experiences have been that there are far fewer resources of a similar ilk available for people with dementias or those who have less ‘straightforward’ care needs.

I also find the tone of these discussions difficult. ‘Bed Blocking’ is an appalling term and I’m very disappointed that it is still used in the press and analysis because it implies there is a blame.

The blame for delays in being discharged from hospital is not usually on the patients themselves (although sometimes going home, especially if you are going home alone can be very frightening) or social services departments if the funding has been cut savagely or on the hospital which desperately needs the bed for more people coming in. There is a systemic failure in the way commissioning, care and health are disjointed and the eternal desire for one sector (health) to shift cost to another (social care) and vice versa.

And what good does charging local authorities for ‘delayed discharges’ do? It provides more cash for the hospitals.

The system currently almost aims to set up two competing demands of health and social care as separate. Until things work more cohesively, it is unlikely the best results will be met for patients.

As for providing more NHS care at home? That will need an increase in provisions rather than the decrease which I am seeing.

Of course not being in hospital is a good thing and receiving care at home instead of in an institution is a good thing but it has to be tied to

a) better access and availability of community health care as well as social care. District nurses as well as home carers.

b) better support for family (and friends) who are carers because I worry this will shift more responsibility to them without acknowledgement.

c) better planning of both health and social services and a greater vision to see these as two sides of the same coin rather than two separate budgets.

Unfortunately, I don’t see any of these as realistic due to the rush towards blind cost-cutting that we are seeing and worry that these kind of statements will have an increasingly negative impact on older people who are in hospital beds and who will be perceived as not ‘needing’ them as much as others – merely because as a society we haven’t been able to adequately meet their needs anywhere but hospital.

There’s a challenge for the government over the next year and while I’d like to start the new year on an optimistic strand, I can’t quite do it – but if I have one, smaller, more achievable aim, it will be to stop the use of ‘bed blockers’ as an acceptable phrase.

5 thoughts on “Recovering at Home

  1. Excellent post as always, have inefficient personal knowledge to comment except to say that my mother (91) has a justifiable morbid fear of dying in hospitals pierced by many needles and connected to machines and surrounded by malnourished incontinent drooling wrinklies – she’s seen too many go that way 😉

  2. I quite agree Ermintrude2 it is about time the ‘care’ services pooled budgets and provided ‘care’ not ‘services’ to people who need them most. We already know that most people want to be cared for at home and that there are around 6 million unpaid carers providing such care. How does the government propose to increase this ‘home care’ with staff who are often poorly paid and often poorly trained. It is not always about dying at home either which palliative care services are getting quite good at ( even if the ‘service’ is only available to people dying from cancer) but about living with dignity in familiar and safe surroundings so that people can still be a part of their local community. I have seen far too many people dumped in the community in complete isolation.

  3. I agree totally with every point made here. I think the limit has been reached with fast discharge. Jointly managed health and social care commissioning does NOT HELP because the aims of the Health service, being the larger and more powerful organsiation always take precedence. As a hospital social worker a few years back I could always stick my neck out and object to an unsafe discharge, but I wonder how safely I could do that today.

    Step down facilities such as community hospitals have been shut over the last decade, where sensible, careful assessments could be made with proper consideration of the views and rights of the older person and their families, giving time for recovery. Now the move is often from acute bed to possibly a nursing home – do we stop to think how horrible it must be to suddenly realise you will never go home again? Old people are being treated literally like homeless animals to be shunted to wherever can warehouse them.

    This announcement strikes as disengenuous at a time when Community Nurses are being cut and having their workloads increased. If we really want to treat older people at home, as opposed to purely denying them access to hospital, then a big increase in Community nursing resources will be essential with realistic caseloads.

    This could be done – but at a time when PCTs are being run into the ground, councils are having to find huge cuts, it seems unlikely.

    It would need:

    Re-provision of step down beds, whether in community hospitals, or in specialist units in nursing homes or local authority run residential homes with the necessary nursing, OT Physio and consultant geriatrician input.

    A vast increase in resources for domiciliary care, including a big increase in out of hours services of all kinds, doctors, community nurses, and care staff in partcicular.

    A substantial investment in project management

    I suggest an increase in the time scale to provision of free care from 6 weeks to 12

    For a safe transition you would need double provision for a while, increasing the communitys ervices before you cut the hospital beds. Does this seem likely under the present regime?

    • I agree entirely with Ermintrude, and also with Guiltycommissioner’s posts. Would some people be better off at home than in hospital? Yes. Are the resources needed to care for them at home being spared from the cuts? Nope.

  4. Pingback: Creating Solutions in Care for Older Adults « The Not So Big Society

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