Monday, 23 November 2015

Let's stop blaming patients for lack of care

'Bed-blocker!' This is the new, dangerous and pejorative stereotype in the NHS - elderly people with nowhere to go, occupying hospital beds. Sadly, it has become an accepted story.  It is a cover for the reality of a shortage of beds and an NHS in crisis.

In its simple form,  'bed-blocker' is an epithet used to suggest someone occupying a bed in a hospital unnecessarily,  preventing someone else receiving necessary treatment. It presupposes they are not ill and don't need treatment.  Yet evidence shows that many are sent home seriously ill.  Yet, 'Bed-blocker' has now entered our pejorative lexicon.

Earlier this year it was revealed that more than one million hospital bed days were lost because of 'delayed discharges' during the preceding 12 months.  Now, that is a lot of hospital bed time! It represented an increase of 20 per cent in a year, and it is now at a record level with a cost to the NHS of £287m.  Headline news.  So what is the reality behind this problem?

First we should ask how it could have risen by 20% in one year, given that the proportion of the population who are elderly didn't rise by that much.  Many are living longer, but we are not ageing any quicker! So what could have happened? It suggests it is an effect and not a cause of a deeper crisis.

Acute care is largely provided in 164 NHS hospitals, free at the point of use for patients and ultimately paid for through general taxation.  Long term care is provided in over 18,000 public or private care-homes and 60% of residents make at least some payment for this care, with means tested subsidies provided to poorer residents by their Local Authorities.  But long-term care is often also provided at home and at considerable cost to the patient and their families.  Shifting the criteria for discharge shifts the financial burden from the NHS to the family.  Shifting patients out too early has introduced a dangerous form of rationing in the NHS. 

Bournemouth Hospital thought the problem of 'bed-blocking' was so bad it threatened to take legal action against 'bed blockers', saying too many families are refusing to take elderly relatives home when they are 'fit to go'.  It is a blame-shifting  game. A dangerous game of musical beds where patients are discharged to make way for others in a lengthening queue. 

A spokesperson for Bournemouth Hospital said new patients, sometimes seriously ill, may have to wait in corridors or on trolleys in Accident and Emergency, while routine operations are cancelled because there are simply not enough beds.  Healthwatch Dorset, reported that many sick patients felt pressured to leave hospital before they were ready.

All this suggests that a cold calculation of cost and targets is taking over from care and compassion. - a quick fix for a squeezed NHS at the cost of patient care.

A report by Healthwatch England found that premature discharge creates a costly 'revolving door' with  one million patients readmitted to hospital within 30 days of being discharged. Readmission into A&E costs the NHS a staggering £2.4 bn a year.  It demonstrates that something isn't right about the 'bedblock' story.

There is little doubt that care is in crisis, with savage cuts making provision difficult. But we should be wary of a new narrative suggesting patients or families are wickedly occupying NHS bids - a division between the deserving 'genuinely' sick,  and the undeserving who are not really ill.  It is far too simplistic -  an assumption that the problems of the NHS are substantively due to lack of community-based or home care.  At best it is only part of the story.

We should consider that the burdens on care in the community or at home may also result from failure of an insufficiently resourced NHS - a game of pass the parcel of costs - a game of passing the patient from pillar to post. It is a political story, as much as a social one.  It is a story of political failure. Failure to invest in health and care, and failure to develop a joined up coherent health and care service.

Officially, bed-blocking occurs when hospital patients are ready to be discharged into long-term care but no place is available.  It raises two problems: 1) the decision on when a patient is 'ready to be discharged' and 2) where they are to be discharged to.  The first requires clear criteria on deciding when a patient should be discharged and it raises issues about how these criteria are applied in any given circumstance.  It should at the least consider the potential for effective nursing care at home compared to that provided by the hospital.

What is genuinely in the interest of the patient? Simply discharging a patient without consideration for how best care can be provided would a dereliction of a duty of care. It is the worst kind of rationing of health care when the service says one ill patient is less deserving than another.  The demands on a health service in crisis are being met by discharging patients too early.

Data from Healthwatch England suggest that the criteria for 'ready to be discharged'  is itself changing with the added pressure on a financially squeezed NHS.

Healthwatch England say many patients feel stigmatised during their care. Some of the most vulnerable people are being discharged with insufficient support. Consider the circumstance where an elderly relative is taken into hospital in a critical condition but there is little the doctors feel they can do and the family are then given just two days to arrange the 24 hour care needed at home - nursing care that will run into tens of thousands of pounds.

So what evidence is there that 'bed-blocking' is caused by a lack of residential care?

Study for the Centre for Health Economics showed that the problem is more acute in Local Authorities where there is a smaller supply of long-term care beds and where prices for these beds are higher. But the study also showed that although increases in the supply of long term care beds reduces delayed discharges, the effect is modest and concluded that an increase in the supply will not significantly reduce overall costs across hospital and social care sectors. 

The BMA Patient Liaison Group  in 2013 said it was aware of 'growing concerns' among patients about inappropriate discharges from hospital.  It concluded that the challenges posed by trying to co-ordinate services between hospital staff, transport providers, GPs and social care staff may be exacerbated by those involved not seeing the whole picture and not being aware of the impact that their contribution can have on other aspects of the process and on the patients and their families. 

If there is a problem with beds, it is only part of a broader picture.  It is not a cause but an effect of an NHS and social care crisis. That crisis stems from inadequate funding and a poorly joined up care service. Let's stop the pejorative language. Let's stop talking about 'bed blocking' and consider how best care and support can be given to vulnerable patients. 

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