Hospital discharge and its impact on patient flow through hospitals
The British Association of Social Workers is the professional membership organisation for social work. With a membership of over 22000 we are the independent voice of social work that champions social work and helps members to achieve the highest professional standards.
Our five-year Vision from 2020 - 2025 is that “Social work will be a thriving, influential, respected profession, improving lives and upholding people’s rights across the UK.”
Our organisation Mission clarifies what we do, why we do it and who for:
BASW acts…
- For social workers: Supporting, protecting, and inspiring social workers in all roles, and the next generations of professionals.
- For social work: Developing professional ethics, practice, knowledge, research, and learning.
- For a better society: Speaking out for social work and social workers on social justice, equality, poverty, human rights, oppression, and other vital social issues in the UK and internationally.
The scale of the current situation with delayed transfers of care from hospital?
The chart below represents a snapshot of the delays to transfer of care to both recovery pathways and those by-passing recovery pathways between 10/07/2020 and 30/11/2021. https://statswales.gov.wales/catalogue/health-and-social-care/nhs-performance/delayed-transfers-of-care
Table 1
|
Date |
Type 1
People awaiting transfer from hospital to recovery pathways
|
Type 2
People awaiting transfer out of recovery pathways and on to longer-term care
|
Type 3
People awaiting transfer from hospital to longer-term care, bypassing recovery pathways
|
Total Delays
|
|
10/07/2020 |
327 |
289 |
26 |
642 |
|
30/11/2021 |
328 |
527 |
213 |
1,068 |
It's important to note that the numbers in each category have decreased and increased over the salient timeframe. In November 2021 the numbers awaiting transfer from hospital to recovery pathway remains almost the same. The numbers awaiting transfer out of recovery pathways and on to longer-term care, or awaiting transfer from hospital to longer-term care, bypassing recovery pathways have however, increased significantly. These delays to longer term care and will include people who have complex non-acute health conditions and sadly, those who should be on a palliative care pathway and who should be receiving end of life care.
Each delayed transfer represents a real person who is not receiving care and support in the right place and whose potential to benefit from a recovery pathway, to return home, or to settle into a long-term care placement becomes compromised in direct proportion to the amount of time they spend in an acute hospital setting.Antonio Rojas-Garcia et al research in 2018 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5750749/ suggests that the ‘adverse effects of delayed discharge are both direct (through increased opportunities for patients to acquire avoidable ill health) and indirect, secondary to the pressures placed on staff.’ This is amplified for older people where every extra day in hospital adds risks of functional decline.We already know that large number of hospital patients developed hospital acquired Covid 19 infection, amounting to 1% of all Covid 19 infections and the Welsh Government has committed 4.5 million to investigate and learn from hospital acquired infection. https://media.service.gov.wales/news/more-than-gbp-4-5m-to-investigate-and-learn-from-hospital-acquired-covid-19-infections-in-wales We are also all too aware of the pressure that has been placed upon on front-line NHS staff throughout the pandemic.
A hospital is not the right environment for people to make long-term decisions about their ongoing care and support needs, assessments should be at home with families, carers or advocates, after reablement or rehabilitation if required.
Our members are reporting delayed transfers of care at a scale not experienced by them previously, which is supported by the data in Table 1.
The impact of delays in hospital discharge, both on the individual and the patient flow through hospitals and service pressures?
One of our members recently told us that the current situation is the worse it’s been in 30 years of them being a social worker. When assessments are undertaken there is a lack of care home places or no availability of domiciliary care. One member remarked that domiciliary care agencies are handing back referrals as they have no staffing capacity to meet the demand. These factors increase the risk of institutionalisation, loss of confidence and motivation to move on, which in turn, increases the pressure on unpaid carers to step in.
Delayed transfer from a care setting to home, once assessment has been completed, means less care home places available for transfer to assess, or for long term care, from a hospital setting.
Our members have told us that there have been times when social workers have not been able to access wards during the pandemic due to not being ‘clinical’ staff. Particularly during lockdowns, our members have felt that their essential role in supporting ethical transition from a hospital to a more appropriate setting, was not always fully integrated into cross-infection guidance. Social workers are an essential element of the multi-disciplinary workforce.
Sickness amongst social workers in some hospital social work teams has impacted clearly on the timeliness of assessments being undertaken.
The impact of home working on being able to undertake assessments consistently and robustly has been a source of concern for some of our members. Some of this relates to the availability of devices for patients, the availability up of nursing staff and support staff to support these remote assessments and the lack of private spaces for patients to talk about confidential and family matters. Undertaking remote assessments is challenging at the best of times and this is amplified when a patient being assessed has cognitive or sensory impairment, especially when family or advocates have been unable to support the process due to Covid restrictions. Social workers are concerned that the rights of such patients are being compromised, because their ability to fully participate is not always able to be realised, despite the best intentions of social workers and health staff trying to support the process. People need choice and control so support is built around their strengths, own networks of support, and resources (assets) that can be mobilised from the local community.
The variations in hospital discharge practices throughout Wales and cross-border, and how they are meeting the care and support needs of individuals?
A consistent approach which is co-produced, and rights based, is essential. Our members feel, that at times, these approaches and values have been a casualty of the pandemic, with patient choice being a primary concern.
Approached like ‘Discharge to Assess’ can build more consistency and reduces local variation but will not achieve its fundamental aim until capacity and workforce issues are addressed.
The support, help and advice that is in place for family and unpaid carers during the process?
Our members have experienced an increased pressure on unpaid carers to accept the care of family members. This can result in carer burnout and breakdown of the caring arrangement risking the cared for person potentially returning to hospital, as no other alternatives available. It could also potentially result in lead to safeguarding concerns through carer stress. We know that through Carers Wales Track the Acthttp://www.lukeclements.co.uk/track-the-act/ that the implementation of the Social Services and Wellbeing (Wales) Act 2014 has not improved the life of unpaid carers in Wales and not led to an increase in carers assessments, this was pre-covid, the situation for unpaid carers has not improved during the pandemic. Attention must be paid to the ongoing needs and support offered to unpaid carers to ensure viability and sustainability.
What is needed to enable people to return home at the right time, with the right care and support in place, including access to Reablement services and consideration of housing needs?
The recruitment and retention crisis in the social work and the social care workforce must be addressed along with ongoing support for the wellbeing of a workforce which is under unprecedented stress and pressure.
Unhelpful distinctions between clinical and non-clinical staff need to be removed if patients are to benefit from an integrated health and social care workforce, working jointly to support timely and ethical transfer from hospital.
Family and/or professional advocates need to be accepted as a vital part of the multi-disciplinary team and their essential role in supporting patient voice and choice understood.
Where patients live outside of bricks and mortar housing, for example Gypsies and Travellers living in trailers, more creative and flexible approaches to adapting trailers for those wanting to return to their homes, living in a way which is consistent with identity and ethnicity. The danger is that Gypsies and Travellers may be forced into bricks and mortar accommodation with devastating consequences for their identity and mental health.
Care home providers concerns about viability and rising costs must be addressed, as do concerns about contractual obligations for staffing levels and activities, contingency planning and how to share risk with commissioners.
Allison Hulmes
National Director for Wales
BASW Cymru