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

by
Frances Coppola
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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.

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