Timely Discharge Series: Right care, right time, right pathway

Anne Hendry is Deputy Honorary Secretary of the BGS. She tweets at @AnneIFICScot.

This is the ninth blog in the BGS’s ‘Timely Discharge’ series. We aim to raise awareness of the detrimental effects on older people of being stuck in hospital when they are 'medically fit for discharge'. Our blog series explores the causes of delayed discharges, the knock-on effects to the wider health and social care system, and what needs to change.

The series of blogs about discharge from hospital, published by BGS over the last two weeks, shines a light on a system that is truly broken. Older people stranded in hospital with no carers to support their return home. An acute lack of available hospital beds caused by the knock-on effects compounding the impact of Covid. Soaring waiting times for A&E and for planned care, and patients being moved to the next available bed instead of the right bed and the right specialty team. Professionals worn down trying to source the right care in the right place at the right time. The root cause for this gridlocked system is the long-term underfunding of social care and a critical shortage of carers. Our eight blogs expose the harms experienced by older people, carers and professionals alike throughout the system. The stories reflect experience in England but I know this is mirrored across the UK.

Tom Gentry from Age UK tells the moving story of 93 year old Sylvia returning home alone from hospital following a stroke. Sadly the themes are all too familiar to those who work with older people: deconditioned from bed rest; isolated from social contact; frustrated and confused by misinformation and poor coordination. Then Sylvia was placed on the wrong pathway and missed out on the much-anticipated rehabilitation. Thanks to practical support from Red Cross, the Stroke Association and her own helper, Sylvia recovered. Despite the system.

I believe there is no better place to assess the capability and support needs of an older person than in the familiar surroundings of their own home alongside their family and social network. But Discharge to Assess at home (Pathway 1 of the national Discharge Service Policy and Operating Model in England)¹ should never be Discharge to Abandon at home without the right care. Home First principles, allowing people to recover, re-able, rehabilitate or die in their own home, are only appropriate when home is safe, supported and where the person wishes to be. And discharge to assess in a community hospital or care home bed (Pathway 2) should be closer to home and providing the right care and support the person needs, if it is to add value.

Transferring to a community bed was of little value for Emily and even less for her husband Lammy. David Attwood, BGS Honorary Secretary, shares their heart-breaking experience of care following Emily’s hip fracture. As she steadily deteriorated towards end of life care, David and his colleagues battled to secure a care package so Emily could die at home, with her husband at her side. All the escalation protocols and traffic light scores proved futile. There were simply no carers in the area. Sadly, neither the community healthcare services nor the local hospice could step in to grant Emily and Lammy’s wish to be at home together.

Katie Kennerell, Rapid Transfer Service Operational Manager, describes the feelings of guilt and failure experienced by staff when they are unable to source the right care and support for patients who are ready for discharge from hospital. Every day they face challenging conversations with families and strained professional relationships within hospital or with community providers. Too often, these pressures lead to older people receiving suboptimal care on the wrong pathway, increasing dependency and further increasing demand.

Liz Jones, Policy Director for the National Care Forum, unpacks the root cause of this crisis. She highlights a depleted and exhausted social care workforce whose experience and skills are undervalued and underpaid, and whose sickness rates have doubled² with very high levels of burnout and stress from the unrelenting pressures of the last 18 months. Her words are echoed by Prof Martin Green, CEO Care England. Both call for solutions that deliver parity of esteem, reward and career development opportunities for the amazing carers who work in many different roles to help people who need support to live their best lives. Graham Livingston, Managing Director for the homecare provider Caremark (Plymouth), describes the perfect storm resulting from chronic low funding for the sector, an ageing workforce, the impact of Brexit, Covid-19 and a policy of enforced vaccinations. Without radical action, he predicts a downward spiral from higher employer costs, lower income and lower wages exacerbating the extreme recruitment and retention challenges.

This is not only a social care workforce crisis. Just read the Care Quality Commission’s State of Care report³ and our BGS Through the Visor reports.⁴ Sara Hazzard, co-chair of the Community Rehabilitation Alliance, also highlights chronic underfunding of rehabilitation services, further deprioritised during the pandemic. This has created greater levels of dependency in those awaiting rehabilitation, generating further demand for health and care services. Yet we know reablement, rehabilitation and intermediate care enable independence and better outcomes for patients and carers.⁵ They should be viewed as critical ‘invest to save’ services that can reduce early readmissions to hospital and reduce demand for long term support.⁶

Adrian Hayter, National Clinical Director for Older People and Integrated Person-Centred Care, NHS England and NHS Improvement, points to additional government funding for hospital discharge and community support and to new models of integrated discharge hubs and multidisciplinary teams that combine technology-enabled remote monitoring with in-person support. The money may be too little too late - but let’s spend it wisely and invest in care at home rather than opening or purchasing additional community beds that have insufficient multidisciplinary support.

The introduction of Integrated Care Systems (ICS) presents an ideal opportunity to develop creative integrated workforce plans supported by pooled budgets and joint accountabilities for population health, better care and better value.⁷ Going forward, ICSs should position a Right to Social Care and a Right to Rehab at the heart of their workforce plans, drawing on the collective assets of housing and voluntary sector partners as well as statutory and independent providers.

System transformation and integrated workforce planning are the long game. Right now across the UK we face a social care emergency that is failing our most vulnerable citizens, leaving unpaid carers and families struggling, and exacerbating the current unsustainable pressures on healthcare. Right now we need courageous national and local leadership with urgent action on some key solutions. To enable more people to receive their care and rehabilitation at home, healthcare staff must be prepared to work more flexibly between hospital and community.⁸ Commissioners and managers must create the right capacity and skill mix together and invest in the required social care support. All governments must guarantee decent pay and conditions for social care workers if we are to stop the drift towards other better-paid sectors. The UK government should increase access to Skilled Worker visas for social care workers, at least for a defined period. Their skills are essential if we are to sustain our NHS and reform our care system.

The consequences of failing to act now are entirely predictable and the headlines will make grim reading this winter.