Winter – Part 3

Each year the headlines going into the NHS winter seem to forecast a bleaker outlook.  

Whilst the 1st October still feels very autumnal, the build up to this years NHS winter is underway.

Which is worrying if you are responsible for arranging services for people who will need some extra support from adult social care to help them home from hospital.  In adult social care we rely on so called winter monies to fund out of hours, home care, intermediate care and transitional beds, all of which get people out of hospital and back to their communities so they can complete their convalescence and recovery.  This winter however the signs are that these funds won’t reach social care.  The NHS winter is biting and hospitals are needing every penny health commissioners can find.

This is further destabilising fragile social care providers, many of which are small local businesses who are really struggling to make things stack up.  As reported by the Kings Fund & Nuffield Trust social care providers face huges pressures in terms of retaining staff, maintaining quality and staying in business.

social-care-for-older-people        Social Care for Older People (home truths)

Our experience is that small, local providers are full of caring, passionate people who are trying to make social care work despite the challenges.  People like Mark, whose story from 5.05 minutes into this video about what happened on Boxing Day 2015 when the River Calder broke its banks left me speachless when I first heard it.

Mark and his team faced the worst that winter could throw at them.   But driven by deeply held convictions that it was their job to care, they are made social care work in the most challenging of circumstances.

Going into this winter we are anxious, but we haven’t lost hope.  People have an incredible capacity for caring and to find humour and happiness in the bleakest of circumstances.

winter-okie-aged-80

So going into the social care winter 2016 here are our suggestions:

1.  Remember why you work in the social care sector.  You care.  If you didn’t you could earn more somewhere else.

2. Nevet forget you are a guest in people’s lives and this is a huge privilege.  The minute it stops feeling that way it is time to move on.

3. Create space with your friends and coworkers to talk about the people you are here to serve and support.  Every person is a bright spark of colour in your life.  Sharing those sparks might catch a fire to keep you and your colleagues warm during the darkest of days when the pressure is on.

Someone to Safeguard

The referral was pretty bog standard these days. The neighbours didn’t get Elsie’s permission for any of her details to be referred to Social Services. In truth it had never crossed their minds they’d be asked for this. When pushed by the call centre about the issue of consent they said that they didn’t think they needed her consent and that this was a matter that ‘the Council must take seriously for everyone’s sake’. And then behind the thinly veiled threat to act the neighbour stumbled upon four little words. Magic words. Words that suddenly change the meaning of everything and words that seemingly come with their own legislation, procedures, judges and juries. ‘It’s a safeguarding issue’. And boom, there it is. Elsie, aged 87, never known to the Council, never having failed to pay for council services or any other tax that propped up with welfare state that she didn’t really partake in, was known. Consent overridden. Case opened. Within moments Elsie had an electronic file. Elsie had a Reference Number. And Elsie would receive an automated letter thanking her for contacting the Council and she would receive a call within the next seven days. All done within five short minutes from the start of the phone conversation. Within ten minutes Elsie was on waiting list of other Reference numbers waiting to be allocated to a Social Worker and sat on the computer screen of the Manager. Whether Elsie used services or not, from that moment on to the day of her death, nothing was clearer – Elsie was a Service User and there was a record to prove it. There was, as far as everyone was concerned, someone to safeguard.

The social workers went in twos to the address. No-one was quite sure why. The referral mentioned that Elsie had got cats but there wasn’t any belief that the cats were dangerous. Perhaps the second social worker was there because social workers love cats. The referral said the house was ‘dirty’, ‘things everywhere’, ‘cluttered’, ‘soiled pads in the garden’ and Elsie, although not seen for some weeks, was wholeheartedly felt by the neighbours to be dirty herself. ‘She’s self neglecting’.

Having knocked at the door and getting no response the social workers pushed slightly at it and the door opened. A cat ran out and then back in again. No sign of Elsie in the hallway. The social workers called her name, walking gingerly through the hallway, past a sideboard with some framed pictures of a moustachioed man with the ‘Geraldo, King of Swing’ emblazoned on them. Calling out her name and holding out their ID badges the social workers continued inward.

Elsie was in the kitchen. She smiled when she saw the social workers and beckoned them in still further. The social workers introduced themselves and whilst doing so Elsie kept on smiling before raising her hand as if to stop the second social worker saying their name. Elsie bent forward and placed her right ear up against what looked like a radiogram from footage used to show listening to the broadcasts of Prime Minster Churchill telling them they wouldn’t surrender. Almost trance like Elsie’s smile remained fixed as she listened to the radio. Elsie probably listened to the radio for a full three minutes, to the social workers, observing the cats, the newspapers (one from May 1991 with a picture of Paul Gascoigne on) and moving their feet on the sticky floor tiles, the three minutes felt like a lifetime.

When Elsie moved away from the radio she asked the social workers ‘who are you again, love?’. The social workers explained who they were and said that they were there to see if ‘she was alright, you know, see how things are’. Elsie said she was fine and asked if the neighbour had asked for them to visit. ‘She’s lovely, like that. Looks out for me’. Elsie explained that she had lived in the house all her life. Her parents, who she said ‘died recently, in 1971 and 1975’ had left the house to her. The social workers listened. They wanted to be respectful, they had questions of course (and they had lots of boxes to tick) and had already decided that things ‘weren’t right’ but they listened nevertheless. Half way through talking Elsie’s eyes suddenly lit up. ‘John!’ she said. Within moments Elsie was back to the other side of the kitchen, head propped up against the radio, same expression on her face, which now to the social workers seemed almost rapturous. This time a longer a wait. Five minutes. Elsie broke her concentration just once, to beckon the social workers to sit down. Neither did. Elsie didn’t notice or care.

Elsie said that John worked for the radio. He was in his late forties and his job was a ‘broadcaster’ and that each day John ‘either announced the news or introduced big bands… sometimes both’. Elsie said that John was based in London and he still lived there. She said John sometimes slept in the radio station and sometimes broadcast during the night, but not usually. The social workers continued to listen but really wanted to talk about the cats and Elsie’s ‘daily routine and keeping clean’. More in an effort to wrap the conversation up about John and move on to the matters at hand, the self neglect, one of the social workers asked a question. ‘John sounds lovely. Is he someone you have actually met and know’? And with that the tone of the conversation changed. Elsie explained that John had spoken to her on the radio for over 60 years. He was her man friend and he was engaged to marry her. Her betrothed. John had promised Elsie that one day he would drive up from London in a white Bentley car and marry her. Their plan was to live in London and take Elsie away from all this, including the cats. Elsie said the social workers could have the cats if they wanted them.

On walking to the door with the social workers Elsie thanked them for coming but they had to go now as John liked to ‘talk to her alone’. Elsie smiled as she shut the door behind them. The last thing the social workers heard Elsie say as the door closed was that John was her man and ‘was not for sharing, goodbye’.

The social workers weren’t inexperienced. One had just become an Approved Mental Health Professional and the other had worked with older people for years. But as they walked to their cars and drove back to the office the silence between them spoke more than any words of completed boxes on the safeguarding form. ‘What was all that about?’
Safeguarding referrals can be complex. The social workers knew that. They also knew that to ‘help’ Elsie they had to get to know her, build up trust etc. So the visits continued throughout the next week. On each occasion Elsie spoke to the social workers but continued to ignore any questions about her health, her wellbeing, her cats and the state of her house. Most questions were met with ‘I know love. John’ll see to it’. All conversations were interspersed with long periods of Elsie listening to the radio and smiling with occasional, knowing nods and some ‘ah’s’ aimed at the social workers as if ‘John’ was further confirming plans that would need to be relayed to the social workers. For the most part the social workers just heard the hiss of the untuned radio. For them there was no voice, no programme and without doubt there was no John. However what bothered the social workers more than this was that there was no progress. No getting Elsie to see what state she was in. No getting Elsie to consent to sorting the house. No getting Elsie to realise the safeguarding issue. The self neglect. The abuse.

Safeguarding doesn’t allow for stalemate or for someone to continue to be abused. It identifies the abuse and through a list of ‘outcomes’ it makes the social workers do something. For the social workers things needed fixing for Elsie. She had a choice. Either Elsie worked with them to ‘improve the situation’ or they would ‘Refer to other agencies’. The case notes were clear. Elsie wouldn’t engage. She lacked capacity to make the decision. It was all in her best interests. The risks were unmanageable. The hoarding was a fire risk. The cats were underfed and the RSPCA would be cross. She needed safeguarding. If only she could see it! She was a problem. The problem needed fixing.

The social workers didn’t seek Elsie’s consent to refer to other agencies. In Elsie’s case the ‘other agencies’ was the Mental Health Team. Elsie was visited by a Community Psychiatric Nurse, who within hours visited again but this time with the Psychiatrist. The social workers received a call ‘How has this gone on so long? and ‘she’s in a terrible way, totally delusional, paranoid ideation’ and is ‘refusing all treatment because of this bloody John thing’. The next call was to the AMHP. Pink papers in the bag, the Mental Health Act Assessment was to take place that evening.

The Ambulance couldn’t stay and eventually the police were called. 87 year old Elsie was escorted out of her property by two young police officers. One of the police officers had to switch the radio off during ‘the incident’ in the house. He at least had the foresight to give the radio to Elsie and reassured her that she ‘could hold it’ in the back of the car. It was the only bit of humanity Elsie ever witnessed either that evening or throughout her entire dealings with the ‘support’ agencies.  Section 2 completed. Safeguarding outcome achieved. No more self neglect. Someone had been safeguarded.

The first thing Elsie did on the ward was to find a plug for the radio. John was there. Reassuring her and helping her to stop crying. And that’s how things stayed for a number of weeks. The medication was taken, Elsie complied. The nurses moved on to the next person, Elsie listened to John. There was no more worry about Elsie from the neighbours, the problem had been fixed. No more self neglect, no more self to neglect. Elsie’s care plan said ‘needs all cares’. And that’s what she had. All cares attended to and a continued love affair with John.

The discharge planning never once considered home. Home was where the ‘multi-disciplinary team’ had felt that the bad thing happened. Home was where the cats had had to be removed and where the social workers had found Elsie’s love letters to John, which had ensured merriment on the ward due to the details that she went into about her feelings for him. The self-neglect would re-start at home and why risk things? Elsie was happy enough. Everything was fixed, apart from the John thing.

The Care Home never fully read the care plan about Elsie and the new social worker had not really written much up about John and what had happened at home. The radio didn’t go with Elsie to the Care Home. Elsie noticed this on her first day at the home. However instead of asking for the radio Elsie screamed for 8 hours. In the end she was given medication. The Care Home didn’t call the hospital or speak to the psychiatrist about how distressed Elsie was. They made one phone call that day, which was to the social worker requesting more funding ‘due to the screaming’ and the impact this was having on other patients and staff.

Over the next 3 months Elsie moved into two different care homes and was returned to hospital following a fall. The radio was never switched back on.

Elsie died in a care home. It was four months, five days and 6 hours after the phone call from the neighbour.

Lord Justice Munby stated ‘what is the point in making someone safe if it merely makes them miserable’. In ensuring Elsie was miserable, we were unfit to even ensure her safety. John did exist for Elsie and we never saw that. John was the risk management plan. John stopped Elsie self neglecting, not the other way around. Elsie was the expert in her own situation and had an 87 year start on the rest of us who tried to study her and fix her within weeks. John was her flickering light of hope which we extinguished in the name of safeguarding people from themselves. I hope she saw John again somehow.

Winter ‘blocking’

Looking back on the chaos last year, as hospital after hospital declared major incidents, this year all is quiet, almost eerily so. Have things really improved, or is it that:

We will have to wait for the likes of @RichardatKF at the Kings Fund to tell us what is really going on however in the meantime, despite the lack of noise in the system, nothing feels to have changed on the ground.  If anything, the pressures seem to have increased.

Adult social workers are used to being on high alert at this time of year and being warned that winter is on its way, although, usually, the first warning we get to be ready comes around the beginning of July… At Christmas, whilst others celebrate, adult social workers experience their busiest time of their year.

Under intense pressure, good people can behave badly and poor organisational culture, usually hidden, can be exposed during winter. In the midst of heightened anxiety, consideration of human rights, issues of consent and evidence of compassion can be the first things to go. Issues of choice and control, foremost in social work values, are at risk of being overridden and drowned out, replaced by the dehumanising language of the day: ‘patient flow‘; ‘through-put’; ‘bed-blocking‘; ‘units’ and even ‘creaking gates’. These have all been used in the last three weeks to describe those who became ill over Christmas and needed help from our hospitals. Take these headlines which are typical of any particular month you want to put the phrase ‘bed-blocking’ into google….

The resulting massive pressure is transferred onto social workers and social care commissioners, to shunt poorly people in need of medical care, therapy and compassionate nursing, out of hospitals into care homes without any consideration of their capacity to be involved in decisions about how their care needs were met. The issue, of course, is not that people should be in hospital, it is that they should be moved to the right place in a way that gives them time and support to make the right choice. The impact of local government pressure on the social care market, however, has left it fragile and wary.  The market is at risk of a major failure this year facing pressures on all sides from squeezed public finances and raised thresholds of complexity as people who would previously convalesced in hospitals find themselves in ‘transitional’ or ‘intermediate care’ beds.

The dilemma of the care home setting is sensitively caught by Alan Bennett in the wonderful monologue he wrote for Thora Hird, The Last of the Sun. They are places where families hope for the best for their family members, whilst at the same time wanting to look the other way and not be made too aware of things that might upset them.  The decision to move into a care home is underplayed by hospitals under pressure to reduce lengths of stay and so called ‘delays to transfer of care’.  The reality is that the person is being made to choose to move from their home to the place where they will live out the rest of their life in a matter of a few short days.  This is a timescale that most of us would baulk at if told we had to move house and make the decision that afternoon ready to go the following day, never to see our homes or most of our possession again.  The best of our local care homes stand firm faced with the extreme high risk associated with this chaotic approach to hospital discharges. These homes resist the temptation of an income source in an effort to ensure that people remain safe and that discharges remain coordinated and appropriate. However, for the most financially challenged homes, those whose situation places the quality of care at the edge of acceptable levels of safety, it is a difficult temptation to resist, the offer of a new admission with the income the person would bring to fill a vacant bed and  delaying the decision of the home closing.

If ever there was a test of social workers and social care commissioners’ conviction and values, it happens during winter. The pressure to discharge at all costs, with no real thought given to the long-term impact on the individual, can feel immense. We try to stand firm and insist on being given another 24 hours to clear a safe discharge pathway through services designed to get people home with support.  But without genuine protection for social care the pathway for discharge will close down.

The weeks following Christmas always highlight social work at its most stretched but arguably also at its best. Social work, working alongside health colleagues but crucially operating outside of the health hierarchy, can provide the necessary challenge to ensure that even at times of crisis, human rights are upheld and that the most vulnerable of people experiencing the most uncertain of environments are afforded the same human rights as us all.

Edited from the original published in Community Care February 2015 http://www.communitycare.co.uk/2015/02/17/adult-social-work-stretched-also-best-hospital-crisis/