Winter ‘blocking’

Looking back on the chaos last year, as hospital after hospital declared major incidents, this year all is quiet, almost eerily so. Have things really improved, or is it that:

• The weather has been mild so far….
• Tolerances are more flexible following changes to how Trusts are financially penalised for waiting times in A&E
• New ‘guidelines’ issued to Trusts on reporting on major incidents are controlling behaviours
• Managers are so distracted by the Junior Doctors Strike that the usual winter anxieties have been overshadowed

We will have to wait for the likes of @RichardatKF at the Kings Fund to tell us what is really going on however in the meantime, despite the lack of noise in the system, nothing feels to have changed on the ground.  If anything, the pressures seem to have increased.

Adult social workers are used to being on high alert at this time of year and being warned that winter is on its way, although, usually, the first warning we get to be ready comes around the beginning of July… At Christmas, whilst others celebrate, adult social workers experience their busiest time of their year.

Under intense pressure, good people can behave badly and poor organisational culture, usually hidden, can be exposed during winter. In the midst of heightened anxiety, consideration of human rights, issues of consent and evidence of compassion can be the first things to go. Issues of choice and control, foremost in social work values, are at risk of being overridden and drowned out, replaced by the dehumanising language of the day: ‘patient flow‘; ‘through-put’; ‘bed-blocking‘; ‘units’ and even ‘creaking gates’. These have all been used in the last three weeks to describe those who became ill over Christmas and needed help from our hospitals. Take these headlines which are typical of any particular month you want to put the phrase ‘bed-blocking’ into google….

• Bed-Blocking by elderly patients rises
• Bed blocking in Cornwall increases by 69% as new scheme fails
• Millions wasted on keeping healthy patients in Yorkshire hospital beds
• NHS bed blocking doubles, costing public purse £640M
• Rate of bed blocking ‘almost doubles’ in hospitals in England

The resulting massive pressure is transferred onto social workers and social care commissioners, to shunt poorly people in need of medical care, therapy and compassionate nursing, out of hospitals into care homes without any consideration of their capacity to be involved in decisions about how their care needs were met. The issue, of course, is not that people should be in hospital, it is that they should be moved to the right place in a way that gives them time and support to make the right choice. The impact of local government pressure on the social care market, however, has left it fragile and wary.  The market is at risk of a major failure this year facing pressures on all sides from squeezed public finances and raised thresholds of complexity as people who would previously convalesced in hospitals find themselves in ‘transitional’ or ‘intermediate care’ beds.

The dilemma of the care home setting is sensitively caught by Alan Bennett in the wonderful monologue he wrote for Thora Hird, The Last of the Sun. They are places where families hope for the best for their family members, whilst at the same time wanting to look the other way and not be made too aware of things that might upset them.  The decision to move into a care home is underplayed by hospitals under pressure to reduce lengths of stay and so called ‘delays to transfer of care’.  The reality is that the person is being made to choose to move from their home to the place where they will live out the rest of their life in a matter of a few short days.  This is a timescale that most of us would baulk at if told we had to move house and make the decision that afternoon ready to go the following day, never to see our homes or most of our possession again.  The best of our local care homes stand firm faced with the extreme high risk associated with this chaotic approach to hospital discharges. These homes resist the temptation of an income source in an effort to ensure that people remain safe and that discharges remain coordinated and appropriate. However, for the most financially challenged homes, those whose situation places the quality of care at the edge of acceptable levels of safety, it is a difficult temptation to resist, the offer of a new admission with the income the person would bring to fill a vacant bed and  delaying the decision of the home closing.

If ever there was a test of social workers and social care commissioners’ conviction and values, it happens during winter. The pressure to discharge at all costs, with no real thought given to the long-term impact on the individual, can feel immense. We try to stand firm and insist on being given another 24 hours to clear a safe discharge pathway through services designed to get people home with support.  But without genuine protection for social care the pathway for discharge will close down.

The weeks following Christmas always highlight social work at its most stretched but arguably also at its best. Social work, working alongside health colleagues but crucially operating outside of the health hierarchy, can provide the necessary challenge to ensure that even at times of crisis, human rights are upheld and that the most vulnerable of people experiencing the most uncertain of environments are afforded the same human rights as us all.

Edited from the original published in Community Care February 2015 http://www.communitycare.co.uk/2015/02/17/adult-social-work-stretched-also-best-hospital-crisis/