Care homes are not NHS dumping grounds

Today the Scottish Tories are proposing a policy whereby spare capacity in care homes could be used to free up hospital beds where there is delayed discharge. This proposal has merit in principle but also fails to lean the lessons of the pandemic or to reflect on the bigger issue it raises.

Delayed discharge is the term used for people who are deemed medically fit to leave hospital but for whom the living arrangements needed to enable them to return home have not been put in place. This is the source of so-called 'bed blocking' and it is estimated to cost the NHS £262 million each year.

Setting aside the fact that most 'costs' talked about in the NHS are derived from notional internal market pricing and so are not reliable in themselves, it is undoubtedly true that there is significant pressure on acute care beds in hospitals and that these are expensive to maintain because of the levels of staffing needed to monitor patients.

These are patients who are assessed as no longer needing acute care in hospital and that capacity is much needed so people absorbing that capacity unnecessarily puts real pressure on the NHS. But from there we believe there are some misconceptions.

First of all, when people cannot be released to their homes because home circumstances have not been adapted, that is not a limitation in the health service in but in the care service. Enabling people to adapt to living at home is about care support and is a stark reminder that the broad political disinterest in funding care is one of the reasons there is so much pressure on the NHS.

Second, while those awaiting discharge from hospital may no longer be in need of acute care, that does not mean they are at the end of the need for care or necessarily that they are able to or are served best by returning home. Cost saving pushes in the NHS have encouraged a practice of returning people to their homes as quickly as possible, but this may not be the best healthcare outcome.

Many patients benefit from a period of aftercare and rest which may not be best served by returning people home as fast as possible. Recent thinking on health has again emphasised the importance of recuperation for long-term outcomes. Rest is essential to healing.

And the approach suggested has another troubling component; it once again sees care as being something like a 'dumping ground' to be used first and foremost to reduce pressure on the NHS. Care is such a degraded service in Scotland that politicians are not held to account over it in the way they are over the NHS, so they have a political incentive to prioritise the NHS.

In the late stages of the Scottish Government's attempts to get its badly flawed National Care Service plans passed in some form it had become clear that the objective of learning the lessons from Covid and creating a strong, humane care service had been relegated and it was now being seen primarily as a cheap way of clearing out hospitals.

That is, at heart, what is proposed in this plan. But it also fails to learn the lessons of Covid in other ways. As we pointed out in our report The Predictable Crisis, when you move people into enclosed communities like care homes and when those in the care homes are among societies most vulnerable, the need to screen for transmittable illness is higher still.

Care homes are long-term centres of care and support and not designed for fast-turnaround 'dumping' of spare NHS capacity. There is minimal healthcare support in modern care homes and it is in any case focussed on personal care for people with age-related problems like dementia. It is not clear that is the best place for recuperating patients.

But this proposal does have merit in what it identifies; that we have a care-related problem in delayed discharge and that we have insufficient (going on no) recuperation capacity in Scotland. We set out the solution to this in Sorted – a proper care service that can respond to issues like this and much more non-acute bed provision in the NHS.

The former needs a politician who understands what care really is to relaunch National Care Service legislation that is fit for purpose. And we propose that the latter is best met by creating a network of inexpensive, community-based recuperation wards to act as a bridge between acute care and returning home (for those that need it). It also creates a new era of accessible local capacity.

With the NHS the conversation always seems to be about either reorganising the furniture or having less furniture. The possibility it is simply being used wrongly is seldom considered.