Published: 20/05/2004, Volume II4, No. 5906 Page 18 19
Health and social care services are failing to provide mandatory assessments of older patients'needs before discharge.The unfortunate result is that many patients are placed in inappropriate accommodation
Today, the new philosophy is that hospital discharge 'is a process and not an isolated event'. It should involve the development and implementation of a plan to ease the transfer of an individual from hospital to an appropriate setting; and the individuals concerned and their carer(s) 'should be involved at all stages and kept fully informed by regular reviews and updates' (Discharge from hospital: pathway, process and practice, Department of Health, January 2003).
There are numerous goodpractice guidance documents and checklists to help NHS bodies speed up the hospital discharge process and, in doing so, help to deliver a personcentred care approach for older people (standard two, national service framework for older people). But my question is simply, why is the process still so often stressful and frustrating for a large proportion of frail older people leaving hospital and for their relatives and carers?
Counsel and Care provides advice and practical help to over 25,000 older people and their carers each year. The problems around hospital discharge for older people, although different in nature, are still as great today as they were 50 years ago, when the organisation was founded.
Fifty years ago we did not have the Community Care (Delayed Discharges, etc) Act, which requires authorities to carry out assessments of patients' needs before they are discharged.Yet, despite this new law and the reams of DoH guidance, callers to our advice line since January - when the law was introduced - have approached us with similar problems to those who contacted us before this date. Patients' rights are not being explained properly to them and their relatives at the point of discharge.
Our records show that both health and social services are often not in full knowledge of the right to a care assessment. Nor are they aware of the significance of such an assessment when a family is seeking appropriate accommodation for a relative, whether or not they are selffunding their care home fees.
One typical example involves Mrs Phillips, who contacted us in February this year.Her mother was in hospital, bed-bound with severe arthritis. At the time of contacting us, Mrs Phillips was getting conflicting messages from different hospital staff about her mother's discharge. She approached us because she was worried that the hospital could discharge her mother anywhere it chose in order to free up the bed, even if neither she nor her mother were happy with the choice.
When a person is in hospital, their needs may be complex. It is good practice for a care assessment to be multidisciplinary and informed by the principles of the single assessment process. Relatives and carers should be invited to be part of this process and can request a copy of the plan with the older person's permission.
Mrs Phillips was unaware of this.
We encouraged her to enquire further, and she discovered that although the hospital had started applying pressure on her mother to move on, her needs had not been assessed and no care plan existed. This was because Mrs Phillips'mother was believed to be a 'self-funder'. This is a decision that should only be made after a financial assessment has been carried out, which - in turn - should only follow a proper care assessment.
The consequences of assuming that a patient is able to self-fund can be serious. The expense of a care home means that, many clients may soon find that their savings have run down to the upper limit (currently£20,000).
When this happens, the local authority will not take over the care funding because the placement was based not on assessed needs but on preference.
The older person may then have to move again to a care home which the local authority can fund. If at the outset the selection of a care home is based on the care assessment, this often disruptive and disturbing game of musical beds would not be necessary.
There can be other financial advantages for the patient in receiving a needs assessment. For example, they may be entitled to financial help with nursing care. It is a good idea for the relative to request that a registered nurse, appointed by the relevant NHS body, assesses the patient's needs for a registered nurse care contribution. If the patient meets the criteria, they will be allocated funds from the health service determined by reference to one of three different funding bands. The consultant (or social worker) could set this assessment in motion.
The needs assessment, and registered nurse care contribution assessment, if relevant, would have allowed Mrs Phillips to set about finding the right care home for her mother at a much earlier stage.
Each month, callers contact us because they have heard that their relative may be eligible for full NHS continuing care funding. This is a complicated area where, once again, everything depends upon the right assessments being carried out.Many hospitals do not clearly inform patients and their relatives of their rights in this area and how the process works.
Conflicting information, long delays or lack of response to letters can lead to applicants losing confidence and questioning whether they are acting within their rights.
Each strategic health authority has a policy on eligibility for full continuing care funding and these vary considerably. In most cases, an older person would only be eligible for a continuing care funding assessment if they fell into the highest band for nurse care contribution funding.
Many people's expectations about their eligibility for full continuing care funding were raised by the Court of Appeal's Coughlan judgement in 1999, which found that the criteria for full continuing care funding in a particular health authority were too stringent. On the basis of this ruling, many other health authorities' criteria have been found to appear to be illegal.
A Mrs Benson contacted us during a dispute with the NHS about her mother's funding for full-time nursing care.Her mother, aged 78, had both nursing needs and dementia, and had been in a care home for seven years. She was a 'self-funder', but her family had been arguing that her placement should have been fully funded through continuing care payments since she entered the home.
The family went through the official review process, which found that the mother did not meet the criteria, so Mrs Benson requested an appeal. An appeal was refused, but only after Mrs Benson had waited almost two months for an acknowledgement to her letter: this should have been done in two days.
Mrs Benson has now taken her case to the health service ombudsman, who is currently dealing with a large number of similar cases.
Although fresh applicants may find it very difficult to succeed in securing continuing care funding beyond the top free nursing care band, a sizable number of people like Mrs Benson's mother have been able to gain continuing care funding for themselves or their relatives retrospectively.
There appears to be a long way still to go before hospital discharge can work as a process, rather than an event. The dwindling number of care home places is a concern, but I am hopeful that good practice will filter through the system and that timely assessments, with the appropriate involvement of relatives, will become the norm.
They are an individual's passport to being placed in a suitable and sustainable care setting. Only then does hospital discharge take its proper place in the therapeutic process, rather than disrupting or even undermining it.
Martin Green is chief executive of older people's advice charity Counsel and Care.