Friday, 13 January 2017

It's not an NHS crisis, it's a social care disaster



You've probably all noticed that I haven't been writing much lately. Well, not on this site, anyway, though I have been doing rather a lot elsewhere.

In the last couple of months, my life has been upended. I suppose I should have seen this coming - the signs have been there for a long time - but the speed at which this has happened has shocked me.

At the end of October, my father suffered a fall at his home on Sheppey, where he has lived alone since my mother went into a nursing home in August 2014.  He was found - after several hours - by the taxi driver he had booked to take him to see her. I didn't find out for another two days that he had been taken into hospital.

When I went to see him, I was horrified. He couldn't talk, and when I spoke to him he just stared at me. I thought he had had a stroke. But the hospital thought otherwise. They decided it was his heart, fitted him with a pacemaker (for which he had previously been recommended, but no-one had got round to fitting it), and discharged him. Unable to talk and unsteady on his feet, he went back to his home, to live alone with no support.

He tried to carry on as before. The day after his discharge, I had a phone call from his taxi driver saying that he had just taken my father to see my mother. "He shouldn't be living alone", he said. "He's not well".

How right he was. A few days later, my father was back in hospital after a fall in the street. This time, the doctors decided that he had post-stroke seizures, though they didn't know exactly when the stroke had been. They gave him epilepsy medicine. He stopped falling over, though he still had frequent small ("petit mal") seizures during which he temporarily lost the power of speech and purposeful movement. They didn't have a solution for the small seizures, so they referred him to Kings College Hospital in London, and discharged him. Yes, you got it - discharged him back to his home to live alone without support.

Both my father and I resisted his discharge on the grounds that as his epilepsy is clearly not under control and he has a number of additional health problems, it is unsafe for him to live alone and we needed time to arrange accommodation and care. The doctors told us that there would be a care package for 6 weeks consisting of visits twice a day to ensure his safety, and the ward nurses said that he would not be discharged until the care package was in place. The discharge nurse amended this slightly - she said the care package would not kick in "for a few days". So I - rashly - agreed to cover.

Two weeks later, there had not been a single visit. Clearly, something had gone wrong. I didn't know whether the failure was at the hospital, which requests care, or in the local council, which provides it. Fortunately, I was able to enlist a spy.

About ten days after his discharge, my father had been telephoned by a community occupational therapist. Telephone calls are difficult for my father, since he often loses the power of speech during the call - this is one of his (so far unresolved) care needs. So, as my father was unable to speak, the occupational therapist decided to make a personal visit to assess his care needs.

I was not present for that visit. Later that day, when I arrived to help my father with his shopping, he said "They can't help me". The occupational therapist had concluded that since my father doesn't need help with personal care, he doesn't need any help. I spoke to the occupational therapist the following day, and he confirmed that the decision was to provide no care. I pointed out that the hospital had promised 6 weeks of twice-daily visits to ensure my father's safety, and that the NHS was paying for these visits. He said he didn't think any such request had ever been received, but he agreed to find out what care had actually been requested.

A few days later, he rang me. No care request had ever been received. All that had been requested was district nurse support for my father's permanent catheter, and follow-up by the GP regarding routine EEG as part of epilepsy management.

I am not one to take such hospital malpractice lying down. We had only agreed to my father's discharge on the basis that a care package would be provided. Had we been told the truth, my father would not have left hospital until I had been able to organise private sector support for him, which could have taken quite some time. So I registered a formal complaint with Medway NHS Trust and copied it to mine and my father's MPs.

That stirred things up nicely. Within a few days, I was contacted by the sister of my father's ward at Medway Hospital. She investigated what had happened, and discovered that somewhere in the labyrinthine administrative nightmare that is the NHS's relationship with community care providers, the doctors' request had disappeared. Despite the assurances the ward staff and discharge nurse had given us, my father had in fact been discharged  to live on his own with no support.

The hospital apologised, of course. But there is still no care. And this time, it is not the hospital's fault. It is the fault of the local council.

The occupational therapist said that even had the care request from the hospital been received, Kent Social Services would still have provided no care. This was confirmed by a social worker a few days later. "We don't do safety visits," she said.

So the local authority will provide absolutely nothing for my father. No care in his own home. Nothing to ensure his safety apart from assistive technology which requires him to be able to speak - which he cannot, when he is having a seizure. No sheltered housing (he fails the means tests). Apparently the local authority has no duty of care whatsoever to an 83-year old frail elderly man with multiple health problems who is living on his own. What kind of society have we become?

Not only has the local authority refused to provide care of any kind, it won't even help us to find self-funded private sector support. The best the social worker could offer was a referral to Age UK. Age UK say they can probably provide someone to accompany my father on trips out of the house, but they don't do safety visits, and nor can they provide an on-call service as backup to the assistive line to avoid unnecessarily calling out the emergency services. So it is now left entirely to me to find a private sector care agency that can meet these needs. Until I do, my father is on his own, and I am his sole carer despite working full-time and living 30 miles away. We have been comprehensively dropped in it.

By failing to provide care, the hospital and the local council between them have effectively forced me to become my father's carer, without my agreement and - more importantly - without any respect for my own needs. I am not in a position to give up work to become my father's carer. I still have a dependent child, whom I must feed and house (though thankfully I don't have to clothe her any more - she pays for that herself). So I am now trying to manage my father's needs in addition to working full time and looking after my own family. There are only 24 hours in a day, and they are not enough. Sleep is for wimps.

Whoever failed to organise care for my father clearly didn't give a stuff. All they cared about was getting him out of hospital. Such is the pressure on beds these days that hospitals will discharge frail elderly people into unsafe environments with no attempt to ensure that appropriate care is in place. And they will also wilfully mislead the families of frail elderly people to get their agreement to an inappropriate discharge.

But the bigger issue here is the comprehensive failure of the local authority safety net. Local authorities have cut social services to the bone. Even for those who are poor enough, or needy enough, to qualify for social support, the provision is dangerously overstretched, with inadequate care homes and carers who are poorly trained, poorly paid, insufficiently supervised and seriously overloaded. And for those who can afford to pay for their care, or whose care needs simply don't meet the extremely narrow criteria to which local authorities have restricted their care provision, there is very little provision at all.

Importantly, it is not just the public sector that is desperately short of capacity. I was advised not even to try to contact private sector care agencies over Christmas because they were so overstretched. As I have said previously, this is a massive market failure. Neither the public sector nor the private sector are able to provide the care that elderly people living in the community increasingly need.

Ring-fencing the NHS budget protected it from the worst of the cutbacks in recent years, but because the NHS was protected, other areas were cut even more heavily. Local authority budgets have been cut repeatedly: many local authorities are struggling to provide even basic services. No wonder they interpret their remit so narrowly that many vulnerable people are left without care. But I don't understand why they won't act as an enabler for people who are able and willing to use private sector care support, but need help finding providers. Surely it doesn't cost much to provide a signposting service?

The really stupid thing is that the NHS ends up paying anyway. Elderly people remain in hospital far longer than they need to, because there is nowhere safe for them to go. Or, worse, elderly people are discharged from hospital into unsafe environments with no care in place, and quickly end up back in hospital after emergency services are called out by family, neighbours, assistive line call centres or voluntary services. The NHS then has to treat them for wholly unnecessary injuries, hypothermia, dehydration, and the consequences of failing to take medication.

And it's not just elderly social care that has been cut. There are widespread cuts to other social services, such as community mental health. These local authority cutbacks don't really save any money, they simply push the cost somewhere else, increasing it along the way because of the distress this causes to those affected. And when the music stops, the cost inevitably falls on NHS Accident & Emergency departments. No surprise, then, that NHS A&E is in crisis.

When social services fail, it is the NHS that picks up the tab. This, not underfunding of the NHS itself, is the main cause of the crisis in the NHS.

Like all crises, this one has been visible on the horizon for years. There have been repeated warnings about the effect on social services of severe cuts to local authority budgets. But of course now the crisis is here, everyone will say "why didn't we see this coming?" There is none so blind as those who only see money, and none so deaf as those for whom listening is more than their political job is worth.

Related reading:

Market failure
The sandwich generation
Broken windows, broken lives









14 comments:

  1. While I agree with your post in principle, I think the "not an NHS crisis" line is misguided. Mainly because it could be used in the wrong way - to say that there actually is no crisis.

    IMHO, the current situation has been wholly contrived by the Tories, and also their New Labour bag carriers. The task is the dismemberment of the care system (wrt the NHS forget any banal talk about "free at the point of use") via institutional crisis, which can only be cured by more bad medicine (sorry).

    In that sense, targeting the care system is entirely deliberate - as it's run by local authorities and the private sector, it allows plausible deniability, behind which they can hide. But the target is the NHS. The care system is just a means to an end.

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  2. It is very sad to read your personal story, and indeed there is a social care disaster, but there is also a NHS disaster too, the one does not exclude the other.

    «Local authority budgets have been cut repeatedly»

    Also, try to imagine the care situation in the north, where most council budget cuts have been targeted, and they have often been of 30-40%.

    The government policy is based on a simple premise: that people should take personal responsibility for their care in old age, and become rich if they want to be able to afford good care. If they fail at becoming rich enough, that's their personal failure, and taxes on those who succeed should not be used to reward the others for their failure.
    It is an old and well popular attitude.

    «market failure. Neither the public sector nor the private sector are able to provide the care that elderly people living in the community increasingly need.»

    Obviously the market is not able to pay sufficiently large fees to satisfy notional demand or the market limited to people able to pay enough is too small to support enough care businesses in small towns or even in general. Not every small town has a Waitrose or a M&S either: is that a market failure too?

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    Replies
    1. Don't start with the Waitrose comments again. They were stupid last time, and they are stupid now.

      Park your ideology and address the issue.

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    2. I talk about my situation because that is what I know. I do not deny that the same or worse problems exist elsewhere in the country. My comments are general.

      The NHS crisis is in large part because it ultimately bears the costs of failures elsewhere. There is probably also an underlying crisis in the NHS itself, but it is not possible even to see its dimensions unless the failures elsewhere are addressed. Throwing more money at the NHS while social care remains in crisis is like giving a patient who is bleeding heavily a blood transfusion. It is necessary in the short term to keep the patient alive, but you also need to stop the bleeding and repair the tissue damage that is causing it. Only when you have done all that can you see the underlying cancer. While social care remains in crisis, the NHS will continue to bleed out, however much money is thrown at it.

      You miss the point about market failure. You missed it last time, too. I'm not going to explain it again.

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  3. It will always be thus, as long as the two entities are funded from separate sources. The logical, though politically unfeasible, solution is to fund the NHS and social care from the same pot, either through local government or Central Government. Or, better still, charge the NHS with social care responsibility (and fund it of course) then it can make responsible and humane decisions on a case by case basis.
    With life expectancy increasing with very passing year, this problem is only going to get worse unless action is taken to address it now, but I can't think of a single politician with the metaphorical balls to grasp the nettle.
    Dave Hardy

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  4. Sheppey? Just up the road. My wife, late 70's, fractured a hip mid 2014. Hospital was OK apart from them being unable to feed her. On coming home a couple of chaps turned up with support frames for delivery, then two visits by physio's and that's your lot. Nothing since and nobody's business.

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  5. This is not the first time i have heard reports of aged people being discharged under blatantly cynical circumstances.

    On the one hand the NHS's raison d'etre is preservation of life, yet by its actions it seems to want to deliberately accelerate the loss of it.

    With austerity still being the electorate's preferred choice of economic policy, it's not surprising that the Tories wish to be seen to be the party delivering it.....if it keeps them in power, then why not milk it for all it's worth?

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  6. Frances,
    Any indication of level of NI contributions vs NHS + LA health expenditure as I understand the former just included in tax pot rather than ring fenced?

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  7. "We don't do safety visits"! Good grief. What a dreadful story - and happening in different forms, I'm sure, in thousands of houses like your father's up and down the country.

    Somehow the government's been allowed to get away with cutting funding to local councils below the level where they can provide a minimum level of services, while letting each individual council take the blame for the inevitable consequences of the cuts they have to make.

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    1. Yes as the Press have an agenda and it does not include accountability for the Cabinet...

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  8. "So it is now left entirely to me to find a private sector care agency that can meet these needs."

    My family has had a good experience with Bluebird Care, both when they helped us with my Dad (aged 76-79) and currently with my mother (aged 80). Different office to the one local to your father so I can't offer a direct recommendation for that office.

    http://www.bluebirdcare.co.uk/about-us/our-offices

    Thank you for writing this post. I feel that ordinary British people have been swindled as we've seen our public services wither during decades of near continuous economic growth. Where's the money gone?

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    1. It's "gone" to pay interest on government debt. Difficult to believe but we spend more on interest on government debt than the cost of our entire armed forces combined.

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    2. If you look at comparative economies, rather than trolling about "government debt", it's gone on tax cuts.

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    3. It's a really awful situation to be in. I've written about how we are misled about NHS and Social Care affordability, with reference to the King's Fund Commission Report. See http://www.futureeconomics.org/2017/01/explaining-the-nhs-crisis-lies-damn-lies-and-health-spending/

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