24 February 2010

Halfway houses

Dr Grumble has been planning for some time to do a post on how to save money in the NHS. But the post would be too long for anybody to read. This does not mean that Dr Grumble thinks that the NHS is inefficient or that if it were privatised everything would be put right. In fact Dr Grumble takes the opposite view. But there are quite a lot of things that could be done to save money.

When Dr Grumble first started on the wards as a medical student there was something that immediately surprised him. What surprised him was that few of the patients on the wards looked ill. In those days we had many more hospital beds so perhaps that was not altogether surprising. With fewer beds and ever increasing numbers of elderly patients, has that changed? Not a bit. Walk around the average medical ward and the patients will mostly look reasonably well. So why are these patients in hospital? The answer is simple. They cannot go home.

It is a curious thing that managers think the patients are in hospital because they are ill. But many medical patients are in hospital because they cannot go home. It is important to understand the difference. There is no point in getting Dr Grumble to see his patients at weekends to try and discharge them as soon as they are well enough if they are not in hospital because they are ill. All this talk of care in the community and we cannot even return patients to the community early. Why is this?

There are all sorts of reasons why patients cannot go home. They may not have a home to go to. Relatives may be unable to take them back. And it is not uncommon for patients to lose their lodgings while they are in hospital. Surprisingly often patients lose their front door keys. Sorting out problems like this takes time. Meanwhile, every day that goes by a hospital bed day is lost. We do kick some out onto the streets if it looks as if they can manage. Dr Grumble does not like to do this but those are the rules. And there is little alternative. But most patients cannot go home because they cannot manage. They are not acutely ill but chronic problems and the ravages of time render them unable to look after themselves. They can be looked after at home but that is in the realm of social care. Over this Dr Grumble has scant if any control. The money comes from somewhere else. The prime concern of social workers are their clients in the community who are at risk. They never give priority to patients in hospital who are safe. The incentives to move them home are not strong.

When Dr Grumble was a young house surgeon he had access to halfway houses. The surgeons took well patients but after cutting them open they became unwell. They needed time to pick themselves up but not necessarily medical care. For these people we had houses in the country they could go to to recuperate. Over the years, one by one, all these places seem to have disappeared. In any case Dr Grumble's patients are not likely to get much better. But they don't need to be in hospital. What they need is a halfway house why they wait for a nursing home or other appropriate placement. And the bill needs to go the social services.


Pondering Practitioner said...

Whilst working on a care of the elderly ward as an SHO we looked after one elderly gentleman who became known as the ward mascot. He was there for over 6 months with no acute medical problems. His family did not want to fund a nursing home for him and so he remained with us whilst they took the PCT to court. He died before a decision was reached.

Anonymous said...

Your comment that social workers prioritise people in the community is strange as nearly all major hospitals do not refer to community social work teams, but have specialist hospital social work teams based on site that only deal with in patients and follow them up for a few weeks postdischarge, after whidht hey are passed to community based teams. Social services can get fined for delayed discharges, £100 a day so they are well motivated and hospital SWs are under neormous pressure to get people out. However it is true there can be shortages of specific kinds of social care eg. dementia nursing home beds which result in delays. I always found it interesting that certain middle class families were given far more leeway to keep mum and dad in hospital.

Nurse Anne said...

Anonymous we do not have hospital social workers. We rely on community social workers.

The few ward nurses in existance are made to work for the community social workers in order to make discharge happen. And community social services manage to get around the £100 a day fine by saying that "The ward nurse did not send us this section of paperwork on time blah blah blah".

The ward nurse often has 20 or 30 patients at once and cannot attend to all the social services forms etc so it gets left undone and the patient sits in hospital.

At least that is how it is in my trust. I don't think we are so unusual.

Dr Grumble said...

I recognise the picture painted by Nurse Anne. I would think it is common to most hospitals. It may be that the nurses are remiss in not filling in the forms on time (though we can all understand why) but I am also suspicious that the social workers use every trick in the book to try and bamboozle the nurses (and junior doctors) so that the right forms are not filled in, the fines go unpaid and delayed discharges go unlogged.

Anonymous said...

If you dont have a hospital SW team then I agree you have a problem. AT one point our wonderful senior managers considered getting rid of the hospital team, we were aghast. Luckily it didnt happen. Whe you are in a hospital SW team you work as part of the hospital towards the same goals, although I was always glad not to be dependent on patronage of consultants, as occasionally I had to challenge them. I and my colleagues worked hard and they still do, honestly to try and discharge people promptly do not try to bamboozle anybody.

You cannot really have hospital inpatients competing with urgent cases in the community, esp it teams are underesourced. Just as if you had someone lying in the street hit by a car bleeding you would always prioritise them over someone getting looked after already in A&E. Any acute hsopital without a dedicated on site social work team is going to be poorly served, but dont blame social workers.

As to halfway houses, or convalescence, it become known as the C word in our department in the mid 90s as social services decided they would no longer fund such a service. Nowadays it has to be called Intermediate Care then it is ok. However Ive a sneaky feeling it may make for a comeback. In our area we had a residential intermediate care unit a few years back, funded solely by social services - that was an error. It was heavily staffed with OTs, physios etc. The hospital looked on it as a (free to the NHS)community hospital for anyone who happened to live near it, it got lots of people it couldn't rehab dumped on it so it didnt meet the expectations placed on it - it was closed a few years down the line.

It is a shame that health and social care people have to be set at each other's throats like this, old people need time to get better, end of, and the state is going to have to pay for some of it one way or another.

BenefitScroungingScum said...

Blogged from another viewpoint http://benefitscroungingscum.blogspot.com/2010/02/where-have-all-flowers-gone.html


Anonymous said...

Bendy girl, I fear you are falling foul of the dreaded Fair Access To Care Criteria. You are oneof those people who struggles to just about manage everything themselves even though any fool can see you are genuinely in need of help. Have you tried your council's complaints procedure? Perhaps a silly question. Often people do get looked at more closely if reassessed in response to a complaint. A letter to your MP can work wonders too. You cant argue against the criteria so need to show that needs have not been taken into account, and pain should be a factor - if something hurts to do it, you should not be expected to.

Dr Grumble said...

I agree that we should not be squabbling with each other to solve these problems. It is the system that I was trying to criticise rather than social workers themselves. In fact more integration with everybody working for the common good is what I would like to see. A hospital social worker would seem to be a way forward with some ring-fenced provision for hospital patients so that urgent cases outside do not always trump the hospital patient.

As has been pointed out we have recurrent problems in hospitals when urgent admissions block elective cases - but these problems can be solved.

Nikita said...

At this end of the fiscal year, is it not the case that the SW coffers are nearly empty?

In my city, empty beds in nursing/residential homes are plentiful. We alays find it difficult at this time of year to fill them. There are no referals. We have been informed by social workers that the funds are not available to place those languishing in much needed hospital beds.

As with everything, it is all down to money.