Healthcare delivery dependency5 , poorer mobility prior to admission
and confusion at the time of admission.6 Patients in old age psychiatry wards with greater cognitive impairment have also been shown to be more likely to be delayed than those with less cognitive impairment.7 One aspect of packages of home care which
were seen to be particularly difficult, and the reason for delays, were when people needed two care workers to visit at the same time, as there are shortages of staff in the domiciliary care field. People’s needs are becoming more complex and two care workers are needed more than in the past. The number of people needing multiple visits daily is also increasing, which introduces inflexibility into the system and creates pinch points for the providers.
Lack of capacity Not only are there shortages in the provision of domiciliary care but also in the numbers of residential and care homes available. Delays are constantly attributed to a mismatch between the types of placements available in the system and the requirements of people being discharged. In some areas of the country, there is a dearth of nursing placements for people with complex needs and challenging behaviour. There may be residential care places for those with signs or active dementia but not those with other comorbidities requiring nursing care. Residential care homes are reluctant to take such patients and do not have staff with sufficient abilities to care for them. They therefore languish in hospital waiting for a place to become vacant. It is known that, since the pandemic, many homes – both nursing and residential – have beds closed, as they are unable to recruit staff. This is down to a multitude of issues, including Brexit, but largely due to pay and conditions. Many staff, after heroic behaviour during COVID, have left and are working in retail or hospitality where they can gain greater wages and suffer far less stress. Some delays are placed firmly at the foot of
families or the patient themselves where they had been made a “reasonable offer of care” – i.e. a short-term care home placement, but have refused to accept this. One of the reasons for refusing the residential placement, either temporary or longer term, was the geographical location of the home. If it was hard for the family to reach or was unfamiliar to the person, it might well be refused. Similarly, if a local home was chosen, but had no vacancies, a long wait might ensue – an example is given of a wait of six months in hospital due to a wait for a place in a chosen home, especially if they are self-funding.
Structures for discharge The guidance for local organisations on how best to manage the process of discharge bases the planning on collaboration, by having a ‘transfer of care’ hub.8
The hub involves all
relevant sectors – such as the NHS, social care, housing and voluntary services. The transfer of care hub should coordinate care for people who require formal care and support after discharge
The key component of any reforms is: do they address the central problem? The cap on lifetime costs is a start but is an ungenerous offer. Equally, the reforms do not address the issues that are central to comprehensive provision, which are the workforce issues, and also wider unmet needs of those being discharged into the community.
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from hospital, and any support for unpaid carers providing care. Hubs should be staffed by a small team, dedicated to ensuring people are discharged from hospital on the right pathways, with the right discharge information, and they should get the right onward care and support (if needed). Staff based in the transfer of care hub may also be the care givers and rehabilitation professionals for an individual. Decisions about what long-term support package is needed should not be taken on the hospital ward. Changes to the structure and governance
of local health and social care was constituted by the Health and Care Act 2022, which enables Integrated Care Systems to be the primary organisation taking responsibility for health and social care needs of the local population. It heralds the biggest reforms to the NHS in nearly a decade, laying the foundations to improve health outcomes by joining up NHS, social care and public health services at a local level, and tackling growing health inequalities and pooling their budgets. It is too early in the process of building these new organisations and their new relationships to see whether they have resolved some of the discharge problems.
Social Care changes The Government has also signalled extensive changes to the social care system but, instead of the changes being relevant from October 2023, they have been postponed until 2025. The social care systems in the UK are subject to devolution and are becoming increasingly divergent, as the current discharge difficulties are most acute in England. This article will focus on reforms planned here. In December 2021, the Government
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