In and Out of Hospital

In and out of hospital

Copyright © 2018 Any part of this publication may be cited, translated into other languages or adapted to meet the local needs without prior permission of the British Red Cross, provided that the source is clearly stated. Photo credits: Cover photo © Simon Rawles, page 4 © Simon Rawles, page 8 © Nick Strugnell, page 10 © Simon Rawles, page 14 © Patrick Harrison/British Red Cross. For media requests, please contact [email protected] For more information on the policy recommendations and research, please contact [email protected]

Contents Foreword 5 No more missed opportunities: our recommendations 6-7 Our research 8 Issues faced by the people we support 9-10 Mind the gap: views of health and social care professionals and Red Cross volunteers and staff 11-14 How the British Red Cross helps people home from hospital in 10 simple steps 15

4 In and out of hospital

In and out of hospital 5 Foreword he British Red Cross plays a unique once they are discharged. Hospitals are not role in health and social care in the UK. always noticing when somebody comes in and Our staff and volunteers are working out multiple times. Simple measures such as Twith emergency departments across establishing somebody’s mobility needs before the country, providing ambulance support, they return home are routinely missed. Nor are transporting patients to and from hospital and homes assessed for falls hazards, which may supporting tens of thousands of older and lead to a person returning to hospital far too vulnerable people in their homes. This gives us soon. Some of our service users even told us unique insight into every stage of a patient’s they feel unsafe in their own homes. journey, from home to hospital and back again. People are getting stuck in hospital, often Our privileged position allows us to bear because of a lack of care closer to home witness to the fantastic amount of good work – particularly those living on their own. The within the health and social care system. impact this has on people and the system is But we also see the stresses, many of them hard to overstate. Older people are estimated preventable, that these services are under. to lose up to five per cent of muscle strength Crucially, we also see where people are per day in hospital, ultimately reducing falling through the gaps. their ability to live independently at home once discharged.3 This report is the culmination of a programme of research that we have undertaken, It is also vital that the health system gets better which paints a bleak picture of the stress at admitting people only when it’s medically the system is under. All too often, we see necessary and is equipped to do so safely. vulnerable people having to reach a crisis Appropriate safeguards must also be in place point before they receive support. Others before vulnerable people are discharged. are caught in an endless cycle of avoidable Our research has broadened our understanding hospital readmissions, with too many missed of these issues from the perspective of people opportunities to rectify this. at the forefront of our system: whether that Latest figures show that emergency hospital be the person receiving care or the doctor or readmissions have risen by 22.8 per cent in nurse providing it. While a lack of resources the last five years.1 Worryingly, the number underpins most of the issues set out in the of people being readmitted to hospital within report, we have tried to identify some relatively 48 hours now accounts for one in five of all simple steps that we believe could improve emergency readmissions.2 patient flow. We hope these measures will go Today we see too many missed opportunities a long way towards ensuring that more people to prevent a person’s health from deteriorating go on to live healthy and fulfilling lives. or to stop their problems from reoccurring 1 This compares to a 9.3 per cent rise in overall admissions to hospitals during the same period. Healthwatch (October 2017). 2 Healthwatch (October 2017). 3 National Audit Office, Discharging older patients from hospital, (May 2016).

6 In and out of hospital No more missed opportunities: our recommendations We know that many hospitals are under serious Avoiding unnecessary pressure this winter and that, for many areas, hospital admission these pressures will continue all year round. The need for more resources, not least for adult > Invest in non-clinical personnel in social care and interventions to prevent people A&Es to help prevent people who are reaching a crisis point, underpins most of the medically OK but need support at home issues explored above. from being admitted. Non-clinical personnel have the time to Nonetheless, there are a number of practical, provide the flexible, person-centred support simple solutions that could make a big others in busy accident and emergency 4 difference both to people and ‘patient flow’, departments often do not have time for. at minimal cost to the health service. Importantly, they are able to take people The research we have conducted, including home safely who might need a little bit of insights from our own front line staff and service support but do not need to be in hospital. users, has informed our recommendations. > Ensure there are more multidisciplinary The key findings are laid out below. teams who work with people at risk of being admitted into hospital. These Helping people feel safe at home teams should be located in the same offices, > Automatic home assessments should have regular meetings and shared access be triggered for people who have come to care records. Voluntary and community in and out of hospital several times sector representatives should be fully within a few months. We encounter involved in these teams. people who have come in and out of Helping people home hospital with nobody questioning why their needs have spiralled into something much from hospital more complex. While people might appear > All discharge ‘checklists’ must include to be medically fit enough for discharge, a an assessment of equipment and regular cycle of readmission often signals medication needs, from wheelchairs that something is amiss at home. to blister packs. These should be arranged > The Government should seed-fund before leaving hospital. proactive falls prevention schemes, > At a minimum, transport home from ensuring people can access the simple hospital should be offered to all those home adaptations and mobility aids they who live alone, who are leaving need to live independently at home. hospital alone and have poor mobility. > People who live alone, have poor Anybody transported home should be mobility and have been in and assisted inside. Assisting patients inside out of hospital due to falls should their home provides an opportunity to check automatically have their home their home environment. assessed for falls hazards before they are discharged. 4 The movement of patients along a pathway of care, including in, through and out of hospitals.

In and out of hospital 7 > Frail patients whose transfer back to collect prescriptions and take people home the community has been delayed who need a little bit of support but do not should be encouraged and assisted to need to be in hospital. get dressed and walk around every day Outside hospitals, we carry out home they are in hospital so that their condition assessments. We check simple things like does not deteriorate.5 whether there are falls hazards, whether the Between home and hospital heating is on, if there's food in the fridge, with the British Red Cross whether the person has existing support networks or mobility needs and much more. The British Red Cross has been working We might help somebody for a few days or between home and hospital since before the a few months. NHS was established. Today our health and “ We try and get in [to the home] as soon as we social care services help over 200,000 people can because we don’t know what we’re going across the country continue to live safely to find when we get there.” and independently. Red Cross volunteer Across the UK, we help: Sometimes our services help people avoid hospital in the first place. We work in > 80,000 people to live independently multidisciplinary teams in some parts of the at home country, helping people with complex needs • 30,000 people through our avoid hospital. Some of our services have been A&E discharge support focussed on helping people who frequently • 50,000 people get attend hospital to seek the help they need to Home from Hospital live safely in their communities. One partnership with a mental health trust, for example, has > 125,000 through a combination of successfully reduced pressures on the system support including transport to and while helping people, some of whom had lost from hospital all hope, go on to live fulfilling lives. > 90,000 people with short-term access Indeed, so much of our work is about to mobility aids such as wheelchairs. spending time building relationships with the people using our services. We might learn, Our services have a simple idea at their heart: for example, that somebody won’t leave their preventing health problems from escalating house because they are afraid of falling. In into personal crises. At their best, they this case, something as simple as a ramp enable people to regain their confidence could make all the difference. Sometimes it’s a and independence. wheelchair, or help managing finances so that the heating is not cut off. It is this position, working within both the Again and again we find that by taking the time community and hospitals, which gives us a to get to know people, we learn just how big unique insight into where people are falling small interventions can be. So often, they prove through the gaps. the difference between living independently at Much of our operational work is focused on home and being admitted to a care home getting people home safely from both A&Es or hospital. and hospital wards. We work in hospitals across the country, providing the practical and emotional support others might not have time for. We might sit with disorientated patients, 5 Older people are estimated to lose 5 per cent of muscle strength per day in hospital, ultimately reducing their ability to live independently at home once discharged. National Audit Office Discharging older patients from hospital (May 2016).

8 In and out of hospital Our research We have gathered the insights and experiences of a range of people working within hospitals, in people’s homes and the space between – from nurses to our own independent living volunteers – as well as Red Cross service users themselves. Over the second half of 2017 we: > Carried out six focus groups across England with around 50 of our independent living staff and volunteers, exploring the problems and solutions in the health and social care system. > Commissioned five focus groups with health and social care professionals from across England, including: GPs, A&E nurses, social workers, occupational therapists, community nurses, discharge planning team members, paramedics, falls prevention team members and physiotherapists. > Commissioned a survey of just under 100 people using our independent living services and 10 in-depth interviews, which has given us further insight into everyday needs and experiences. This builds on a larger study The Crises Facing Our Independent Living Service Users, 6 that we published in 2016. This research combines to paint a bleak picture of the strain hospitals and social care services are under. We are seeing more and more people discharged without adequate attention being given to their home environment, while others are deteriorating in hospital while they wait for a care package to be put in place. 6 The 2017 survey and in-depth interviews were carried out by FACTS International and the external focus groups were carried out by Community Research. The 2016 research, The Crises Facing Our Independent Living Service Users, was based on a survey of 170 service users, 29 in-depth interviews with service users and 22 expert interviews with staff.

In and out of hospital 9 Issues faced by the people we support “ It is to do with my walking ability, increases to 50 per cent for those aged over 7 I can stagger, I am not steady.” 80. All too often an avoidable fall can be the Female, 35-49 start of a downwards spiral. “ She has to get out of the chair, into her “ If I want to post a letter at the end of the wheelchair, to get to the commode the other street, I would just love to be able to just do side of the room, and that is quite a struggle, it. My balance has been poor since I had my in fact, she’s had a number of falls this week.” falls and I now I need an arm to balance.” Male, 75-84 Female, over 85 Our survey of just under 100 of our The overriding impression given by this independent living service users provides a research is just how scary everyday activities unique insight into the lives of those who rely can be to people who struggle with their on our health and social care system. mobility. People are effectively afraid of their The participants were a range of ages and own front door, the shower, going to the post used a range of Red Cross services, from A&E office, changing the lightbulbs, the staircase, assisted discharge and transport, to our home and so on. from hospital and support at home services. “ I’ve got a shower over the bath. That is a little Over 90 per cent of those surveyed were bit of a difficulty, even now. I have to sort of limited by a health problem or disability get my legs cocked over the bath, to get expected to last at least 12 months. The even into the bath to get my shower.” majority were limited by a mobility issue or Female, 75-84 by stamina or breathing difficulty. They also We believe that that there are usually relatively often had more than one long-term issue and simple solutions to these well-founded fears: 38 per cent had three or more conditions. the provision of mobility aids, exercise classes Feeling unsafe to build up strength, checking for falls hazards at home. It’s estimated that addressing falls Over half the people we spoke to did not feel hazards in the home could save the NHS in England £435m a year.8 completely safe in their own home. People who are ‘limited a lot’ by a long-term health disability were, perhaps unsurprisingly, more likely to say Struggling with everyday tasks they feel less safe in and outside their home. On average, our service users reported having The most common reason people felt unsafe difficulty with seven out of 15 everyday tasks: was around falling outside the home (68 per ranging from doing work around the house, cent) and inside the home (57 per cent). These getting dressed, managing finances and fears are not unfounded: 30 per cent of people washing to preparing a hot meal. aged over 65 will fall at least once a year; this 7 Public Health England. 8 Public Health England Falls and fracture consensus statement Supporting commissioning for prevention (January 2017).

10 In and out of hospital The top three activities most struggled with are: What they would like to do doing work around their house or garden but can’t (87 per cent), walking 100 yards (71 per cent) and climbing one flight of stairs without resting Many of our service users told us that there are (70 per cent). many things they would like to do but cannot – which, in turn, affects their sense of freedom Our 2016 study of 170 Red Cross service and confidence. users found that many struggled to take out the rubbish. Indeed, what was perceived as “ To be able to get up in the morning and get hoarding was often down to poor mobility – washed or showered and dressed and then not being able to tidy up, move things the same at night, but without planning. I around or pick things up. Living in an untidy worry about undoing all the good work that environment can lead to somebody’s condition has been done on my hip, if I were to fall.” worsening, as well as heightening somebody’s Female, 75-84 risk of falling. “ I would like to be able to transfer myself from Almost 60 per cent struggled with bathing the wheelchair on to the sofa. I can’t do that or showering, a third with walking across the at the moment.” room and getting in and out of bed and 23 per Anonymous cent struggled with taking their medicine. Living alone Many of our service users live alone – almost 70 per cent of those surveyed. Despite struggling with everyday tasks such as bathing and dressing themselves, we found that those living alone were less likely to access both informal support from family and friends and formal support from local authorities and charities. Just 47 per cent received regular help from a friend or loved one, compared to 90 per cent of people living with others. Similarly, only 30 per cent of those living alone were receiving help from the local authority with personal care compared to 47 per cent of those living with others. With older people increasingly living alone, we believe that targeting support at those living without support networks is vital to prevent a continuous cycle of preventable hospital admissions. Struggling but caring for others A significant minority were caring for someone else while contending with their own conditions. “ I would like to go out more but my partner is also disabled, we look after each other and have to be together twenty-four seven.” Anonymous

In and out of hospital 11 Mind the gap: views of health and social care professionals and Red Cross volunteers and staff Delayed discharge “ The pots of money for the packages of care “ A patient medically fit for discharge stayed in and all that's been whittled down. If that's the hospital for two weeks waiting for a social gone and your nursing home bed's gone, well care package. That happened so many times that's just going to create crisis in other areas. It's hospitals that are feeling it because we when I was working in the wards… They can't get the patients out, because there's would then pick up other problems. Then they nowhere to get them out to.” would not be medically fit. Then they would Occupational therapist, Manchester go to the back of the queue for the social care because they’re not ready to go – get out Inappropriate discharge of hospital – then they’d be waiting another few weeks for another package of care and “ Sometimes like this 84 year old and they'll exactly the same thing would happen.” go, 'Right, they're medically fit,' and I'd go, Social Worker, Birmingham 'Actually they need their package of care restarting, which might take 24/48 hours.' While over half of delays in discharge in I know the hospital is not always the best October 2017 were attributable to the NHS, environment for people, but for some people 9 just an extra 24/48 hours is enough for with many waiting for ‘non-acute NHS care’ , we know that the lack of available adult social them to go home, be fine, and actually have care is a growing major factor in delaying not come back in. Sometimes even just hospital discharge. In fact, delayed transfers holding them on for 24 hours makes a huge from hospitals due to social care have risen difference, even when you're chocka.” Occupational therapist, Manchester 10 by 65 per cent since 2011. Over a third of delayed transfers are attributable to social The Red Cross volunteers and staff, and care: the main reason for social care delays the health care professionals we spoke to, in October 2017 was “Patients Awaiting Care expressed concern not only about delayed Package in their Own Home”. transfers of care and the impact on people, For older patients in particular, each day in but also about inappropriate discharge. They hospital risks reducing their mobility. Some point to a number of cases where patients have studies have found a reduction in muscle been sent home from hospital before adequate 11 support is available or arranged. strength of as much as 5 per cent per day. Health and social care practitioners raised the “ They've got no family, they've got no one issue of reduced community and intermediate and there's no care package in place for them care services, a corollary of which is patients coming home. They [the discharge team] just staying in hospital longer than they medically ask us to go in, and we go in and we find need to. them, they've either had a fall, they're on the floor and it's because they've been sent back out too soon and they get readmitted again.” Red Cross team member 9 NHS England, Statistical Press Notice Monthly Delayed Transfers of Care Data, England (October 2017). 10 House of Commons Library briefing paper, NHS Indicators; England, (February 2017). 11 National Audit Office, Discharging older patients from hospital, (May 2016).

12 In and out of hospital Time and again they are seeing inadequate In-home assessments consideration given to what will greet a patient “ Often it's about getting them well enough to when they get home as a result of the pressure be able to go home but actually in the home to free up beds. is often what’s causing the decline in health “They let her home, she didn't have any food. because of the way that they are living and She'd been in there for two months, so all the the lack of support at home. So if [only] you food in the fridge had all gone mouldy, there could see what they’re like at home and was no food there. She'd got home, nobody assess them.” to help her.” Community nurse, Bradford Red Cross team member In-home assessments were frequently Red Cross volunteers and staff also spoke mentioned by the Red Cross staff and about people being transported home from volunteers as well as health and social care hospital, only to be left in their car park, unable professionals we spoke to as being crucial to make their way inside. to ending a continuous cycle of hospital “ He’d actually been sent home eleven o’clock readmissions. at night. The ambulance had dropped “ And people we see have just come into him in his car park on his crutches, and hospital because they've had a fall and driven away.” broken their hip, and then we turn up after they've been discharged… there's no gas, Red Cross team member there's no electric, they're living in a messy Assisting patients inside their home provides an house; they've not really been coping getting opportunity to check their home environment. their food, they've just been getting by. ” Checking their home is safe would likely help Red Cross volunteer reduce the number of emergency readmissions within 48 hours of discharge, reported to make All too often, the professionals and Red Cross 12 volunteers and staff we spoke to saw scenarios up more than one in five readmissions. Others pointed out that pressure to free up where older or vulnerable patients were sent beds could sometimes result in qualified home without the right care in place, only to nursing or occupational therapists being return to emergency departments. diverted away from their substantive roles to “ When she went into hospital, they kept do discharge planning. sending her home the same day, but she was Sometimes care packages have been still living in the same squalor, nobody was organised, but due to pressures in social care, there to support her. The final thing we know they are not adequately implemented: is that, she had one more fall…” Red Cross team member “ A lot of the time, the care agencies are so stretched that they can't actually meet the There was a sense among some professionals needs that are required on the actual referral, that there are now fewer in-home assessments so the ward might say she needs – or the because of financial and capacity issues. social worker might say she needs four times a day carers, but actually the care agencies “ Five or ten years ago, this kind of patient we can't provide it, so carers don't show up, or would have probably have done an access they might need a double visit but only one visit, where we go out and look at that [their carer can go – it's constantly happening, home]. We don't do them as much now constantly happening. ” because we just don't have the time.” Falls prevention team nurse, London Occupational therapist, Manchester 12 Healthwatch, What do the numbers say about emergency readmissions to hospital? (October 2017).

In and out of hospital 13 A lack of resources The Red Cross volunteers and staff we spoke “ [T]hey call it bed nine and three quarters, like to are increasingly seeing referrals of people Harry Potter. So you’ve got three beds in with more complex and higher-level needs. a row, they’ll squidge them all up and stick Our own staff and volunteers have told us another one in between. So, one person about increased difficulty signposting people won’t even have a curtain, a call bell, oxygen to appropriate support. if they need it, and that’s the situation we’re “ Our staff and volunteers are not bedside- facing at the moment and that’s going to befriending, tea-and-sympathy any more, happen this winter again, easily.” it’s really… quite high level stuff these days.” A&E nurse, Bradford Red Cross team member Our focus groups with health and social care Our volunteers and staff are seeing people professionals revealed the ripple effect the deteriorate because of restrictive criteria pressures on adult social care services are in accessing support. People can receive having on the whole system. A lack of differential care based not only on where they capacity in the community is piling pressure live but also on their age or condition. on to hospitals, resulting in a lack of available Red Cross staff and volunteers also reflected beds and ultimately affecting patient flow in the lack of services available to people aged its entirety. between 40-60 years old with lower to Faced with such pressures they also report moderate levels of needs. being less and less able to provide the “ Sometimes, those that don't quite fit in, it person-centred care their patients require. seems as if they get passed around the “ I think it [person-centred care] pays off in the houses. By the time they show up at your long run from the community worker’s point service, they have already been to three or of view that, even though it does take a bit four others that haven't been appropriate.” longer doing it this way, hopefully they won’t Red Cross team member bounce back and reuse the service over and over again because you’ve empowered them A greater focus on preventing and taught them how to self-manage.” people reaching crisis point Community nurse, Bradford Health and care professionals would like to They also spoke about how patients are see a greater focus on prevention and believe routinely falling through the gaps that exist that the system currently only responds when between hospital departments, and between someone has reached crisis point. hospitals and social care services. “ We often find so many times that we are “ It's responsibility tennis, isn't it, a lot of the literally having to let it get to the worst point time. Interdepartmental within the hospital, in somebody’s life for somebody to actively it's over to you, responsibility, back to you, intervene or do something.” back – that's what it is, isn't it? People think Community nurse, London and work insularly. All they're interested in is their bit, once their bit's done they can sit Our health and care professionals also back in their chair and think okay, I've done mentioned how pressure on social care staff my bit. Everything works by link. It's like Lego, and facilities mean that there is no effective everything works by putting things together.” strategy for ensuring existing conditions do Paramedic, Manchester not worsen.

14 In and out of hospital “ In adult social care… the waiting list can be three months and what happens then is you only deal with crises rather than dealing with all the preventative work that would stop that from happening… I think the threshold criteria goes up because, if it's something that can wait, if it's not an emergency, it will just be put to one side until they’ve dealt with all the crises.” Social worker, Bradford Lack of resources is seen to be a key barrier and, because of budget constraints, people get help only when they reach crisis point. “ Our organisation does nothing [in relation to prevention], our resources have been scaled back so much. I think we’ve had so many cuts to staff, now it appears to be the sole focus from a Trust perspective is to get people out of the beds.” Physiotherapist, Warmley Participants from almost all groups spoke positively about falls prevention initiatives, such as hospital-based physiotherapists asking out- patients over 60 to routinely complete a falls questionnaire; routine falls assessments in A&E, exercise classes, proactive falls hazards checks and so on. However, they also noticed falls prevention schemes in the community being cut, most typically due to stretched adult social care budgets.

We believe the involvement of non-clinical personnel in supporting patients and the system is crucial. How the British Red Cross helps get people home from hospital in 10 simple steps 1. The patient is signposted to our services by hospital staff. 2. We ensure the person has suitable clothes to wear to keep warm. 3. We check they have their medication and know how to and when to take it. 4. We transport a person home, either via assisted public transport or car/ambulance. 5. We ensure a person has their keys and can get into their home OK. 6. We check whether people can move around their homes OK, do they need a mobility aid like a wheelchair, walking frame or commode 7. We check whether the home is habitable, are there trip hazards or any other safety concerns. 8. We check that the power is working and the heating is on. 9. We ensure there are enough supplies, such as whether there is food in the fridge to eat. 10. Next steps – check in with people, connect them with local services, accompany them on shopping trips or appointments and help build confidence and recovery.

British Red Cross 44 Moorfields London EC2Y 9AL The British Red Cross Society, incorporated by Royal Charter 1908, is a charity registered in England and Wales (220949), Scotland (SC037738) and Isle of Man (0752). redcross.org.uk