Tarun Solanki FRCP is a Consultant Geriatrician at Somerset NHS Foundation Trust.
I write this blog at a time when the NHS and social care crisis is again in the headlines. In my 28 years as a consultant geriatrician, I have not encountered such a crisis before.
There have been many reports and calls to action by successive governments over the last 10-15 years, but none has had the courage to address the thorny issue of social care. Indeed, in 2019, when Boris Johnson was elected Prime Minister with an overwhelming majority, he stood outside Downing Street and proudly proclaimed that he had a solution to the social care crisis. Despite all the rhetoric, the reality is that social care has continued to decline. The King’s Fund and Nuffield Trust estimated in 2016 that 500,000 fewer people were in receipt of care than at the start of the decade. Considering the growing older population, the situation in 2023 is likely to be worse than 2016. I would like to discuss the human cost of this lack of action from successive governments.
Let me introduce you to Sam and Pam, a couple in their 80s. They do not have any children and until early 2021 managed well in their own home. Despite his age, Sam was very tech-savvy and had all the latest gadgets. Indeed, during the Covid lockdown, he not only did their shopping online but also helped their neighbours. The couple were active prior to the pandemic and did their 10,000 steps on their pedometer daily. Sam had a history of mental breakdown in 2016, when he was ably supported by Pam at home as there were no mental health beds available for admission. The stress of looking after Sam took its toll on Pam. Pam also suffered from type 2 diabetes and her cognitive function was progressively declining. During lockdown neither of them had any outside input and by the time lockdown ended, it was apparent that Sam had been increasingly responsible for all Pam’s care and for all household chores. She was referred to the local memory service for assessment and support.
While awaiting an assessment, Sam became unwell with a recurrence of his mental breakdown. There were no mental health beds and both Sam and Pam were admitted to an acute hospital. After an initial assessment and an inpatient stay of 2 weeks, both were deemed suitable for discharge with a Discharge 2 Assess (D2A) package of care at home, despite concerns raised about the ability of the couple to manage. As expected, within 48 hours at home Sam’s condition worsened, with him running into the street shouting for help as he felt he was dying. As a consequence, both were readmitted to an acute hospital. After a further inpatient stay of 3 weeks, it was decided that Pam should be temporarily placed in a dementia care home, thus allowing Sam to recover from his illness without having to care for his wife.
Sam was once again discharged home with support from D2A. Unfortunately, due to insufficient staffing, there was little rehabilitation at home and Sam spent his days sitting in a chair, resulting in significant deconditioning. As a result of being separated from his wife, his nutritional intake declined. After about 2 months he was readmitted to an acute hospital with a fall. As a result of his deconditioning, on this occasion it was felt that he would benefit from rehabilitation in a community hospital. After 4 weeks in an acute facility, he was transferred to a rehabilitation unit where he spent 12 weeks without much progress, primarily due to the fact that rehabilitation was patchy due to staffing issues. At this stage, it was finally agreed that Sam would be eligible for a placement in a care home. He was transferred to a residential home which was 15 miles from the care home in which Pam was residing. Within a month of his transfer to the care home, Sam was sadly found dead in bed. By this time, Pam’s dementia had progressed and having not had contact with Sam for 9 months, she was unable to process the fact that Sam had died. Pam then had a fall in her care home which resulted in a large subdural haematoma, and she died 3 weeks after Sam.
This real-life story of one couple is likely to be happening hundreds of times over in the UK, particularly with older people who may not have anyone advocating for them. If we had a properly funded and working social care system, it is unlikely that this couple would have been separated for the last 9 months of their lives. Furthermore, due to the lack of funding in social care, they spent a significant period of time in an acute hospital and by the time Sam was sent to a rehabilitation facility, it was apparent that he would eventually require a care home placement. Despite this, the system required demonstration that efforts had been made to return him to his own home. We consider ourselves to be a humane and compassionate society. But where is the humanity and compassion when, for the sake of expediency and the lack of political will to address difficult issues, we allow frail, vulnerable individuals to be shunted from one place to another? Also, even when it is apparent to all involved in the care of these individuals that they will not be able to manage in their own home, the system requires that they go through a lengthy assessment process just to demonstrate that everything has been done to try and return the person to their own residence. As geriatricians working within the multidisciplinary team, we need to regain our role and voice in the discharge planning process and to be better advocates for such people who we know will not manage again in their own homes despite a prolonged period of rehabilitation.
The Government has just announced an additional £250 million to block-buy care home places for older people living with frailty who have been stranded in hospital due to a lack of an adequately resourced social care system. In my view, this is a profligate use of resources which will do little to improve the outcomes of the people who are transferred there from an acute unit simply to make room for acutely unwell patients. As the President of the BGS has already highlighted, there are concerns around this policy, which may result in further deconditioning of older people who are living with frailty. Also, if there were proactive planning and sustainable funding, then the £250 million could have been used for recruitment and better remuneration and therefore retention of social care staff. As it stands, a significant amount of this money will go to larger corporate care homes and line the pockets of its shareholders. If we are to have a safe and cost-effective social care system in place, then we must start planning prospectively and not rely on the crisis management which appears to be the order of the day.
