Critical Hospital Social Work Practice

Daniel Burrows

• Publisher: Routledge
• Year: 2020
• Print ISBN:
  9781032336374
• eBook ISBN:
  9780429536809
• Topic: Social Sciences
• Subtopic: Ethnic Studies
• Index: Social Sciences

Critical Hospital Social Work Practice sheds light on the fast-paced, high pressure role of the hospital social worker. At a time of public concern over the state of the NHS and the needs of a growing older population, the hospital social worker's job is more important than ever. Yet, it is poorly understood and often overlooked by policy makers, managers and other professionals.

Employing social theory to make sense of the contemporary context of health and social care, this book highlights the vital role played by social workers in planning complex hospital discharges. It provides an in-depth account of the activities of a typical hospital social work team in the UK, drawn from rigorous ethnographic fieldwork, and contrasts this with research evidence on hospital social work practices around the world. The author points towards exciting new directions for health-related social work and social work's potential to develop critical gerontological practice.

This book will be useful to social work students and practitioners working in hospital settings and with older people in general. It will also be of significant value to policy makers and academics who are interested in developing innovative approaches to meeting the needs of the ageing population.

Part I

Key issues in hospital social work

Preface

This book is concerned with statutory social work as it is practised by teams of hospital-based social workers employed by local authorities in hospitals all over the UK. Typically, these teams work almost exclusively with older people who are inpatients and who are unable to be discharged safely without social work services because of social care needs that have come to light since their admission. Hospital social workers are responsible for arranging services for such patients to be discharged as quickly as possible. This involves making an assessment of the patient’s needs, taking into account the views of the patient, clinicians and family members/carers, and producing a plan of services to enable the patient to be discharged safely from hospital. Typically, the care plan will arrange either for care services to come to the patient’s home or for the patient to go into residential care. The social care needs of patients usually arise from declining physical health, increasing physical disability and/or problems of cognition often related to dementia. Hospital social work is therefore characterised by short-term involvement with patients, whose cases are usually then passed on for review by community-based teams, and pressure from clinicians and hospital managers to deliver patient discharges as quickly as possible.

While I am concentrating exclusively on the mainstream statutory form of hospital social work, I fully acknowledge that there are other forms of social work that are practised by social workers based in hospitals around the UK. For example, as a practitioner, I spent six years working on a paediatric oncology unit, in a charitably funded post with the purpose of providing practical and emotional support for families while their children went through cancer treatment. While this niche role, and others similar to it, are of great merit and interest, they are so distinctive from the mainstream form of hospital social work as to be beyond the scope of this book.

Part I sets out the contemporary context of hospital social work and explores its historic development and current state, drawing comparisons with practices in other parts of the world. Part II explores an in-depth ethnographic study of a UK hospital social work team.

1 Hospital social work in context

Introduction

Since its foundation, health care has been the domain of the NHS, while responsibility for the provision of social care has resided with local authorities. Hospital social workers, who are usually employed by local authorities, therefore play a vital role in providing an interface between the health service and social provision, through discharge planning for those individuals who are in need of ongoing support in order to leave hospital (Moriarty et al., 2019). Primarily, hospital social work teams are occupied with discharge planning for elderly people whose medical and social needs are complex. This chapter examines the care of older people in hospitals, before going on to discuss social work with older people in the more broad sense, drawing especially on Bauman’s concept of ‘liquid modernity’ (Bauman, 2000a; Bauman, 2007) to explore the contemporary social context of ageing within which social work practice occurs.

The ageing population and the NHS

No society can legitimately call itself civilised if a sick person is denied medical aid because of a lack of means.

(Bevan, 1952, p. 100)

The UK’s National Health Service, established at the end of the Second World War, represents a bold and ambitious attempt by a state to provide a service to meet the needs and desires of all its citizens (Lowe, 2004). The vision of its founding secretary of state, Aneurin Bevan, was that it should provide all appropriate and necessary health care to both rich and poor, based on need, rather than means. In other words, the NHS was not to be merely a safety net for those who were unable to afford to make their own private arrangements, but a means of providing the best health care possible as a universal citizenship right (Rivett, 1998). This vision of the NHS was widely popular at its inception and continues to hold sway in the popular consciousness in the present day. Although a market in private health care and insurance flourishes for a small proportion of the population,¹ most of the UK population continue to expect the NHS to meet all their health needs without charge at the point of delivery (apart from dentistry and optometry). While expectations of the universality of NHS provision have not changed, however, both the needs of the population and the scope of medicine have evolved so far as to be completely transformed in the period since the NHS was established. The effects of these transformations on the care of older people are of great significance and must be understood by social workers who need to work with hospital systems, whether as part of hospital discharge teams or in community teams with responsibility for hospital patients.²

When the NHS was founded, the practice of medicine was far less complex and less costly than today. Fewer diseases were treatable and fewer people lived into advanced old age, meaning that the treatment of the sick was a simpler (though less frequently successful) process (Porter, 1999). The developing ability of medicine to overcome disease, with the emergence of new sciences and vast improvements in surgical techniques, pharmacotherapies, diagnostics and technologies, and the efficient distribution of modern medicine to the people at large through the NHS, have supported developments in the demographic composition of the UK population that create a different range of needs to those which the NHS was founded to meet. Of particular consequence in this regard is the increase in the numbers of people living into old age and the increasing life expectancy of people at age 65.

Shortly after the introduction of the NHS, life expectancy at birth in England and Wales was around 66 years for men and 72 years for women. A steady increase in overall life expectancy followed over subsequent decades, such that by 2012, a new-born boy could expect to live 79 years, while a new-born girl’s life expectancy had lengthened to almost 83 years (Office for National Statistics, 2015). In 1997, around one in six people were aged 65 years and over; by 2017 that figure had increased to one in five people, and it is projected to reach around one in four people by 2037 (Office for National Statistics, 2018). For the NHS, a significant consequence of the growth of the ageing population is the increase in people living into advanced old age (i.e. 80+ years of age). In 1950–1952, a person who lived to the age of 80 would have a further life expectancy of around five years; by 2012 this had increased to nearly ten. As people progress through old age their health needs tend to become more complex and they are more likely to depend on assistance and support from others to manage daily living. The increase in the population of people in advanced old age has therefore given rise to a need for systems of complex health and social care provision, involving skilled and specialised clinicians³ with expertise specific to the multiple and various challenges of ageing.

It is ironic that the success of medicine in improving longevity is born of professional and institutional systems that are ill-equipped to look after the ageing population that they have helped to create. The nature of medicine as both a practice and an academic discipline rests on its continuing refinement and improvement (Porter, 1999), meaning that doctors keep up a career-long pursuit of both extending their own personal knowledge and of contributing to the generation of new knowledge in the field. Hospitals have become not only centres in which to treat the sick, but also hubs in which the boundaries of scientific knowledge are extended through experimentation and improvisation. Doctors tend to specialise, and their knowledge and interests become deeper yet narrower as they rise in seniority. While this drive for advancing knowledge should be celebrated for improving the treatments available for patients’ diseases, it must also be acknowledged that it creates a working climate in which both the self-esteem and prestige of doctors rests on the privileging of clinical, curative tasks over other forms of care that may be of equal or even greater importance to the patient (Latimer, 2000). As a result, elderly patients with complex co-morbidities become less attractive patients to treat, because a doctor’s ability to treat one disease successfully does not necessarily result in the restoration of health to the patient.

Hospital care, of course, does not depend on doctors alone. The majority of the direct care of patients is carried out by nurses and health care assistants (and, of course, the contribution of a range of allied health care professionals including physiotherapists, occupational therapists, speech therapists etc. should not be overlooked). Just as medicine has been transformed by the continuing pursuit and development of applied scientific knowledge, nursing has undergone a similar revolution through the project of professionalisation (Yam, 2004; Gunn et al., 2019). Professionalisation has led to nurses taking on additional responsibilities that formerly would have been the preserve of physicians alone, including the administration and prescription of medication, collection and recording of diagnostic information and the diagnosis and treatment of minor injuries and conditions (Westbrook et al., 2011). All of these tasks result in an increased administrative burden on nurses both for the recording and co-ordination of treatments. As a result, qualified nurses have less time to spend in direct contact with patients and vital aspects of patient care are held in lower esteem and are left to less qualified workers (Gillen and Graffin, 2010). This is particularly problematic for older patients when suffering from dementia or confusion. Caring for people in a confused state requires considerable skill underpinned by theoretical knowledge, yet this crucial relational work is not easily recognised or accounted for and standards of nursing practice in this regard are variable (Dewing and Dijk, 2016).

The effect of both the ongoing development of medicine and the professionalisation of nursing is that wards and clinics have become spaces in which the emphasis is upon cure rather than care. This occupational and institutional culture can create difficulties for older people, since their medical presentations are often resistant to the linear trajectory of cure, due to the complexity of co-morbidities so frequently present in the ageing body. Older patients may find that their illnesses fall among a range of medical specialities, leaving the rightful location of their treatment within the hospital disputed (Tadd et al., 2011). In summary, because it is often so difficult to cure older people’s diseases, responsibility for the care of individual older people within hospitals can be shunned instead of embraced both by individual practitioners and whole specialist teams or wards.

In addition to the unattractiveness to clinicians of treating older people whose bodies are resistant to straightforward cure, the development of risk management practices within contemporary health care has resulted in the prioritisation of a rational response to patients’ bodily needs over holistic approaches that incorporate emotional and psychological needs (Hillman et al., 2013). For example, as a response to the risk of elderly patients having falls, ward staff sometimes encourage continent individuals to soil pads rather than help them to the toilet, and the risk of the spread of infection results in patients being left isolated in side rooms (Calnan et al., 2013). Such measures make sense in terms of risk management, but can be detrimental to older people’s sense of dignity and emotional well-being. These issues do not arise in the main because hospital staff set out deliberately to treat older people badly (though abuse by professionals of all backgrounds must be guarded against), but the end result is that the incompatibility of older people’s needs with institutional cultures leads to both tacit and overt ageism within hospitals. Even the physical environment of the hospital can be hostile for older people. The burgeoning complexity of health care, with its myriad departments, clinics and technological installations, has resulted in confusing layouts, poor signage, lack of storage space and lack of day rooms – problems that impact especially on older people (Tadd et al., 2011).

Hospitals represent institutions in which ageist practices can flourish, not necessarily because of a wilful disregard for the feelings, rights and well-being of older people, but because the professional and organisational cultures within hospitals have developed from a model in which narrow tracts of expertise are deliberately cultivated. The cultivation of disease-specific expertise is advantageous to advancing the overall efficacy of clinical practices, but can engender an approach to patient care that is highly rationalised and instrumental, and which is not well adapted for patients who present with complex co-morbidities and additional emotional, psychological and social needs. This is not to deny the outstanding commitment, compassion and hard work of staff within the NHS, or the existence of many wards and hospitals in which older people do receive excellent care. Rather, I am suggesting that, where the rational scientific approach of modern medicine meets the messy and uncertain realities of elderly people in failing health, age-related discrimination is too often an unintended and unforeseen consequence.

‘Bed blocking’ and ‘patient flow’

Forms of institutional and professional ageism within hospitals are crystallised in the discourse of ‘bed blocking’. The term ‘bed blocking’ describes the occupation of an inpatient bed by a person who does not need the care that can be provided on the ward in which the bed is situated. It is taken by clinicians and hospital managers to be an illegitimate use of hospital resources that deprives other patients of access to the services that can be provided to the occupier of the bed. Though the term is not linguistically ageist, its underlying assumptions are rooted in the institutional cultures described above, which emphasise cure over care, to which elderly people’s bodies may be unable to conform. Frequently, elderly hospital inpatients reach a point at which they no longer require the expertise of specialised clinicians, but cannot manage to return to their lives outside the hospital without additional support. It is at this point that hospital systems demand that they must be transferred to social care providers, with any delay in this transfer of care and responsibility regarded as an unwelcome interruption of the hospital’s flow of patients. Contemporary management systems within hospitals define and record any delayed transfers of care, with power to define a patient’s readiness for discharge regarded as the exclusive preserve of clinicians (Manzano-Santaella, 2010). Legitimacy of bed occupation rests on medical need alone, therefore.

The patient-blaming tone of the phrase ‘bed blocking’ has widely been replaced within health organisations with the term ‘delayed transfer of care’ (DTOC), which will be used in this book. Underlying the discourse, whether ‘bed-blocking’ or ‘DTOC’ is the preferred term, is a shared understanding among clinicians and hospital managers that each hospital bed’s essence is as a tool in the treatment and management of a particular medical condition, rather than as the rightful temporary preserve of an individual person. Individual patients are expected by hospitals to ‘flow’ through their various compartments, in which differing clinical tasks can be undertaken. For example, a patient is a legitimate occupant of a bed on a surgical ward only for the purpose of preparation for, and recovery from, surgery. If a different medical need hinders the patient’s discharge from hospital following recovery from surgery (for example an individual who contracts a serious respiratory infection following orthopaedic surgery), it would be expected that a bed on a different ward should be found (Benson et al., 2006). Thus, patients are treated as objects transferable to different centres of care, depending on the needs they present.

The system is not designed in this way deliberately to be inhumane. It represents a highly efficient way of organising and distributing expert clinical knowledge, with the purpose of ensuring that each individual person who is treated in hospital receives the best possible care and has the best chance of a satisfactory outcome. Indeed, it has long been acknowledged that prolonged stays in hospital are associated with a wide range of additional troubles for the patient, including increased risk of infections, pressure sores, deep vein thrombosis and loss of muscle condition leading to decreased mobility (Hirsch et al., 1990). Maintaining patients’ ‘flow’ through the hospital is therefore important both to ensure that each hospital department can provide services as efficiently as possible and to ensure the best outcome for patients. The problem for older people is that often they cannot ‘flow’ through the hospital in the desired way because of the medical complexities their bodies present, and the social needs that arise from age-associated deteriorations of body and mind.

Clinicians make clear distinctions between medical needs, which are legitimate claimants of their time and resources, and social needs, which are held to be the preserve of other organisations and professionals (Latimer, 2000). Responsibility for delays caused by social needs is therefore, naturally, held by clinicians to be the responsibility of those other organisations. Since the 1990s, the medical profession, with its powerful voice in shaping public opinion and political discourse, has developed a narrative in which the dominant explanation for the occurrence of delayed transfers of care is that local authorities fail to provide the social care services for which they are responsible (Gill and Ingman, 1994). This is an incomplete understanding of the reasons for delayed transfers of care. Though variables related to social care have been shown to be strong predictors for delays (Challis et al., 2014), internal hospital factors (e.g. waiting on a specialist ward for services from another medical discipline) and an undersupply of rehabilitation services are also important factors (Glasby and Lester, 2004). For the period of 2018–2019, NHS England (2019) found that 28.9% of delayed transfers of care could be attributed to social care alone, with 9.2% attributable to both the NHS and social care services, and 61.9% attributable to the NHS alone. The evidence for the numbers of delayed transfers of care attributable to social care services is regularly a matter for dispute. During the fieldwork undertaken for this book, I observed daily meetings between social workers and a patient flow manager in which social workers corrected wrongly attributed records of delayed patient discharges on the hospital database. Attributing blame for a delayed transfer of care to an organisation outside the NHS appears helpful to ward managers’ presentation of performance indicators, since length of patient stay is widely taken as a proxy measure for the efficiency of hospitals (Manzano-Santaella, 2010).

Despite the fact that the majority of delayed transfers of care are caused by internal factors within the NHS, the narrative of blame upon social care services became so widely accepted that, in 2003, the UK government passed the Community Care (Delayed Discharge) Act, which legislated for hospitals to be able to charge local authorities if they failed to provide services required for a discharge within forty eight hours of notification. Pitching services against each other in this way supports a false dichotomy between health and social care services when often both are of equal importance in meeting the needs of older people in ill health (Glasby, 2003). Though charging of local authorities has subsequently been made optional, local authorities in England and Wales nonetheless retain delayed transfers of care as an important key performance indicator for their social services. This embeds within social services departments an acceptance of the legitimacy of the ‘patient flow’ model and affirms that discharge planning must be the primary role for hospital social workers. It also discourages a holistic approach to older people as hospital inpatients that might be more appropriate where their physiological, psychological and social needs cannot be disaggregated.

The ‘patient flow’ model represents an efficient way to manage scarce resources and distribute expert clinical knowledge and skill, but can result in experiences of hospital for older people that are disorientating, disempowering and even humiliating. Older patients who cannot ‘flow’ through the hospital in the way the system demands may find that they are moved in and out of wards, and in and out of bays within wards, at all hours of the day and night (Tadd et al., 2011). As I observed during the fieldwork for this book, they may experience pressure from hospital staff to accept permanent placement in a residential care setting before they are emotionally ready to take such a significant life transition, or may be discharged to their homes reliant upon outdated formal care plans that are not adequate for their new needs, or upon informal carers wh...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Acknowledgements
• PART I: Key issues in hospital social work
• PART II: An ethnographic account of hospital social work
• References
• Index