The NHS is insatiable. In the last financial year it racked up a £2.45 billion deficit in England alone. Its funding challenges are described as “colossal”, this despite the fact that it will be allocated an additional £8.4 billion (above inflation) by 2020-21. And all compounded by profound demographic changes, with a projected 106 per cent increase in the number of over 85-year-olds between 2012 and 2032. If the NHS behemoth is to prove financially viable, it is going to have to box clever in its provision of care to the elderly. Below is a genuine case (with names changed) from Scotland, which shows the vastness of the potential for inefficiency within the present system.
Jane is in her eighties and has a diagnosis of mild dementia. She cannot walk and has achondroplasia (she’s a dwarf). She lives alone and is now refusing to cooperate with home carers. Her situation is no longer tenable. As a result she is admitted to an NHS dementia ward.
Upon admission, it is obvious that Jane will require ongoing nursing home care, and within two weeks she is declared ‘fit for discharge [to a nursing home]’. The relevant social work referral is made so that the process of identifying a suitable placement can start.
Six weeks elapse, during which time no significant changes are made to Jane’s treatment plan. The discharge process is halted as it becomes apparent that Jane doesn’t want to go to a nursing home. A guardianship order will have to be sought from court, allowing Jane’s family to make welfare decisions on her behalf.
Another eighteen days pass. The necessary guardianship application has still to be initiated by the family. They have “issues” with the process. To put all of this into a financial context, Jane’s psychiatric hospital bed costs about £300 a day to fund.
Four more weeks pass. The family finally launch the guardianship application. Fourteen weeks have now elapsed since admission.
Another six weeks pass. At this point, all of Jane’s medicines are discontinued; her concordance with them has been non-existent. She will not receive any further psychiatric treatment throughout her stay in hospital.
Another six weeks pass. The guardianship process remains ongoing. It is decided to move Jane sideways to a long-term NHS ward. This is surprising. These beds are normally occupied by those patients who pose such management problems that they cannot be discharged. Also, Jane has the financial means to fund her future care. To place her in an NHS bed would be for the State to assume this financial burden. The consultant then abandons this plan.
Another eight weeks pass. It is decided by the increasingly frustrated consultant that a further meeting must be arranged with social work to discuss discharge plans. At this point the case-notes record that “social work can’t attend any dates in September”. Around this time, the doctors complete their guardianship reports.
Eight more weeks pass. The family are to start viewing nursing homes.
Three more weeks pass. Jane’s family have not yet begun viewing nursing homes as the list of suitable placements was sent by social work to the wrong address. The social worker has still not completed his paperwork for the guardianship process. As the (already completed) medical reports are over thirty days old, they become invalid and must be re-done.
Three months later, and social work inform ward staff that all of the guardianship papers have now been lodged. The family have still to nominate a nursing home. It is now nineteen months since the patient was first admitted.
Three more weeks pass and Jane is finally assessed by a nursing home (nursing home ‘A’), who accept her, pending guardianship being granted. They have beds available. An attempt is made to obtain ‘interim guardianship powers’ from the court, so as to be able to discharge Jane sooner. The sheriff (judge) rejects this, stating that he requires further reports on the patient’s ‘aggression’ (she has in the past scratched people, like a little, angry gerbil). Another week passes. Nursing home ‘A’ are still holding a bed open for Jane.
Three more weeks pass. The guardianship hearing takes place, and guardianship is granted!
Nursing home ‘A’ immediately informs social work that they no longer have any beds available. Jane is now assessed by a nursing home ‘B’, who refuse to accept her. The family state that they want Jane to go to a nursing home ‘C’. However, they have no beds available. Jane is then assessed by nursing home ‘D’, who do accept her, however, the family do not want this option. Then comes ‘E’, who accept Jane. The family agree that Jane should go to ‘E’.
Three days later Jane is finally discharged from hospital. 636 days have elapsed since first admission, at an estimated cost of £190,000.
Here we have the slow, agonised scream of public bodies grinding against each other. The good news is that there are large savings to be made; the bad news: we are dealing with public bodies. Throughout this whole epic process, one brief comment made by my ward’s erstwhile registrar nailed the problem. As he had looked grimly down the ward’s list of patients, counting up all of those who had been waiting weeks and months for guardianship orders, he had turned to me and murmured, “I can’t believe that if we were a private company things would be allowed to drag on like this”.