6 May 2014

What happens when the vulnerable leave hospital?

At first glance Rory MacKenna looked reasonably healthy.  Or at least as healthy as anyone can appear sitting on the grimy floor in the underpass leading to Charing Cross tube station in central London.

But within minutes of stopping to talk to him, he told me that he had not had a drink for four days ago because he had started to vomit bile.  He shrugged as if to say “that’s not a good thing” and who was I to disagree?

He said he was feeling OK but added it would be better if he was in prison because then he would be given some Librium which would help with the withdrawals.

And that was unutterably sad. Along with his story of abuse from a young age, of being in and out of care. Of moving around the country, of life on the streets or in hostels.

In fact, that is where Mr MacKenna, aged 60,  is currently living. In a hostel which he says is noisy. “So I don’t get much sleep.”

I was surprised at his openness – as well as being surprised at how matter of factly he described everything from the bile to the abuse.

But I had been introduced to him by Paul Wilson, who was once where Mr MacKenna is now. Without a house,  without warmth or comfort. Estranged from his family with a chronic alcohol problem.

How to survive on the streets

Indeed, he was literally where Mr MacKenna is. On and around the Strand. He knows all the nooks and crannies, all the places others like him will bed down. Where to find a toilet, how to get a shower. How to survive.

Mr Wilson, now aged 59,  is no longer homeless. Instead he acts as a consultant on homelessness, and we met because he is now helping with a ground-breaking inquiry into what happens when vulnerable people are discharged from hospital, a care home or a secure mental health setting. In other words, when the discharge is “unsafe”.

It is an inquiry set up by Healthwatch England. They are the organisation established under the government’s NHS reforms to represent the patient voice in health and social care services.

Their findings from this inquiry will be passed to the health secretary and anyone else who can make sure changes are made. And they have invited Channel 4 News to follow the inquiry over the next month, to make public the stories of what happens when the discharge is inappropriate.

Readmissions on the rise

What is already known is that between 2002-03 and 2011-12, emergency re-admissions to hospital within 28 days of discharge rose by 27.1 per cent.

The inference from that is that the discharge was unsafe: that it was too early or that not enough was done to ensure that the environment the patient was returning to was appropriate.

And the best way to find out if this was the case, Healthwatch England has concluded, is to ask the patients themselves.

To give those who are rarely heard a chance to talk about their experiences and to say what they believe should have happened.

To find these people, however, is not easy. The very nature of this problem is that these are people who live in the shadows, who are not only not heard but who do not know how to be heard, how to speak up for themselves.

An expert by experience

That is where the likes of Mr Wilson comes in. An expert by experience. A man who knows what it is like to be homeless and who knows what it is like to be inappropriately discharged from hospital.

Although it happened to him eight years ago, it is a story that is as relevant today and it was then. He had badly damaged his knee, “playing American football pissed”, he said.  He went to hospital, had the operation and, when the time came, was discharged with a bag of morphine.

He had no home and nobody asked him where he was going. So he walked through the door of the hospital, clutching his bag, his wound from the operation still fresh.

And that is why Mr MacKenna was willing to talk to me. Because he knew Paul Wilson and what he and gone through, and if Mr Wilson said it was OK to talk to me, then it was indeed OK.

In fact, their discharge stories were not dissimilar.  Mr MacKenna was beaten up while in a hostel and his ribs were broken and his lung was punctured. He was taken by ambulance to hospital.

An X-ray at midnight

He says due to the kindness of the doctor that he managed to stay in for a few extra days. They ordered, for instance, an X-ray at midnight, which meant the results did not come through immediately.

But in the end, even though he told them he was homeless, he had to leave. “I was in pain,” he said. “They had me on a morphine drip.”

What does he think should have happened? He should, he said, have been found some accommodation.

“They could have let me recuperate and recover until my ribs got better. Because if someone had whacked me, it could have killed me.”

Safe discharge is the duty of the hospital trust and most if not all trusts have  protocols in place. But the reality is, many do not operate them.

One man we spoke to said that the response when he told the doctor he was homeless was that they were “not housing officers”.

Needs for co-ordination

It is complex, too. There needs to be co-ordination between local authorities, social services, and the voluntary sector.

Streetmed is a London-based charity which works with homeless people to improve their access to healthcare. The nurse-led team told us  they can try and persuade hospitals to delay discharge for a while while they try and sort out accommodation but if social services refuses to help there is often little they can do.

Or that by the time they have appealed it is far too late.  In fact, through Streetmed we were expecting to meet a man due to be discharged from hospital that day.

He had had cardiac surgery caused by sepsis from a rat bite.

The hospital had delayed the discharge because the man is Polish and had not been able to prove his entitlement to housing.

Should be housed

Quite patently, the last place this man needs to be sent to is back on the streets. Technically, too, the housing act says he should be temporarily housed while his situation is investigated.

But what is meant to happen and what will happen are two different things. As I write this, a week later, his situation remains that the local authority will not help, the hospital does not want to let him go and Streetmed are frantically trying to find somewhere safe for him.

And into this Kafkaesque nightmare of bureaucratic buck-passing, there falls another element.

If a person is not admitted on to a ward but is instead kept within A&E or put on to an observation ward, the trust is not obliged to check that the person is being safely discharged.

It used to be – maybe 15 years ago – that hospitals had social services departments within the hospital.   Now, that is less common and instead they are relying on hard-pressed charities like Streetmed to take up the slack.

Thin and bedraggled

As we continued our journey down the Strand, we met Antonio Goncalves, aged 47. In fact, he did not know Mr Wilson but a quick chat between the two men and he was willing to talk to us.

Unlike Mr MacKenna, Mr Goncalves really did not look well. He was thin and bedraggled. He needed a wash. He looked beaten down by his life.

He told us he has HIV and  hepatitis C. He goes, he says, to a clinic every two months for his medication.

He was, after we had finished filming,  going to walk to Elephant and Castle, a couple of miles from the Strand, for the  methadone he takes to deal with his heroin addiction.

As Mr Wilson and I knelt down beside him on the dirty pavement, Mr Goncalves, who is originally from Portugal, told us that he had had an operation on his groin in 2008.

Should he be back on the streets?

But that after a week he was discharged back on to the streets.

It could be argued that his case was some time ago. But as the readmission figures show, the situation is getting worse not better.

So there is nothing to suggest it would have been any different. And there remains the concern about his treatment for HIV and Hepatitis C.

If, as he says, he is being given medication for this, is it appropriate to let him back out on to the streets, where he has now been for three years?

As with Mr MacKenna, when asked what he thinks should have happened when he was discharged from hospital, he said they should have found him some accommodation. “Even a room would do,” he said.

But should they? Is that the role of doctors and nurses?

Responsibility on others

It is easy to argue that they have a duty to ensure that the hard work of bringing the person back to health is not undone by their dismissal back on to the streets or to an inappropriate hostel.

It is equally easy to argue that this is the responsibility of others: social services, for instances, and housing departments.

All this, of course, against a background of cutbacks, certainly. But more, there is the seemingly intransigent problem of getting one part of the system to talk to another, of persuading health and social care services that they actually do need to talk to each other.

It is not as if there haven’t been attempts to do this. In fact, it is probably one of the biggest discussions going on within the health sector at the moment.

The word integration is rarely absent from the lips of the relevant think-tanks, commentators and ministers.

This is also a question the Healthwatch England inquiry will have to address – the fundamental need to better co-ordinate services. Yet to do this with the voice of the patient – be they homeless, elderly, with mental health issues – at the heart of their final report.

‘People fall down the cracks’

Anna Bradley, chair of Healthwatch England, said that the key to this was making people see that health and social care services are not operating in silos. “They are there to provide a set of services which need to be joined up otherwise people fall down the cracks, and when they fall down the cracks some very terrible things happen to lots people,” she said. “We need to find out more about that so we can prevent it.”

I had thought initially they had set themselves an almost impossible task. Yet this may not be the case.

We had set aside hours to find homeless people who would not only talk to us on the very specific topic of being discharged from hospital but would agree to be filmed. In the end, it took just two hours before we had as many cases as we could deal with.

All of them seemed, in the end, astonished that anybody out there wanted to know what had happened.

Channel 4 News will be following the inquiry as it goes through to the end some time in September. If anybody would like to have their stories told they can either tell us and we will pass them on or they can contact Healthwatch directly.

Follow @vsmcdonald on Twitter

Tweets by @vsmacdonald

16 reader comments

  1. paul wilson says:

    Wow the truth may come out now it is about time the trith really was shown well done Victoria.

  2. Jane says:

    What happened to hospital almoners/social workers who had to make sure there was a home and someone to care before a patient was allowed to leave hospital?

  3. john nunn says:

    Dig deeper than what this government says rather than what they say they do. They always have an excuse for what is happening about the caring of our peoples’. This government cares for “conservatism” of those which are affluent in their income. and couldn’t care a toss of a coin about the real people of the real foundation of our country….the ones who have toiled their bodies to build this country, NOT the ones who have been the exploiters, Look and see that conservatism is to preserve what THEY have got and to leave the others to fend for themselves. This is conservatism, an accumulated form of dictatorship control using their deceit of the people to achieve their aims to keep control of their political aims.

  4. chris says:

    Dear channel four

    Everytime l have said about my health concerns to social services, they have said it wasn’t their problem.still trying to recover from a foot operation that took place 18 months ago.

  5. christine says:

    I work for a drug and alcohol service and come into contact with many individuals that become homeless. In a lot of homeless situations the reason can be that they have been evicted from a hostel due to their behaviou, drug or alcohol use etc.r. The reason. could be due to violence towards another This would result in no one else willing to take them. Yes most of these individuals have mental health issues ,drug problems.Yes i do feel sad to know that a client of mine is on the street or,any other individual. A lot of the people that are on the streent in my area i will know, There is very little we can do in a crisis.Even to get somebody ito a hostel they have to be assessed and accepted which could take up to 2 weeks We need to look at the prison system. Prisoners are released without any accomadation, They are also at risk of overdose if they are drug users. Prisonors are also released back into the community without any supervision as well as being homeless.

  6. Dr Helen Zeitlin says:

    Twenty five or so years ago we would never have discharged a patient without making quite sure of the home circumstances and no-one would have been discharged to the street. The hospital social work department would liaise with services in the community. And once upon a time we had convalescent homes which took the pressure off acute beds. But these were sold off. The NHS has been gradually dismantled over this period to make way for privatisation, a process initiated by Kenneth Clark. Market vocabulary quite simply does not include the word ‘care’. Doctors and nurses are left holding the baby without the facilities to properly practise or the means to effect change – they have been stripped of authority and gagged. And so the public and media only find out at a very late stage, as in this case of hospital discharge, just how much we have lost of our NHS.

  7. Mr Gerard Walsh says:

    Dear Ms Mcdonald,

    The simple fact is. That the way the NHS & Councils are managed/monitored & governed. IS. Corrupt !

    Failures/abuses/dishonesty/falsifying & destroying of medical records. IS. Systemic.

    Simply because local management/local complaints management. And separatly the CQC/PHSO/LGO. Actively cover it all up full stop. Let alone to protect their or their boss’s bonus’s/their department or organisation’s funding. Which is directly affected by competence & complaint statistics, Ie: Polititians. Knowly quote fraudulent Healthcare statistics
    based on the way statistics are distanced from “How many complaints were actually made by victims/the public. Before the multiple levels of cover uqs a complaint has to survive before being included as a official statistic by a governing body & by default a polititian”???

    The problem is. The 3 main political parties are all at it. Hence why. Anything & everything. Can & will happen to the public/the vunerable?

    I have been official in the mental health/social care system since 1993. Multiple hospital stays up to 40 days at a time. 2×6 sessions of Electro Cunvulsive Treatments (ECT). ALL without signed consent forms or being under a section 3 to make it legal??

    They did not even do/record a first diagnosis for the first 10 years. They did not even diagnose bipolar untill 14 years later. All of which was under a Enhanced CPA???

    Yet No actual social care services given? After a complaint was made and then covered up by all. No improvements made. Instead i war removed from the CPA process. And left since May 2007 with just a repeat monthly prescription of meds??

    Even now. No one. Including the CQC/PHSO & LGO. Will explain why no social care assessment has been since or services provided.

    While my MP (Mr Gardiner) decides not to comment. Even when factually challanged over the complaint fraud/cover ups occuring !

    The same corrupt formula is used with the Police/Banks/Schools & others that would cause embarresment !

    Yet political parties/individual polititians. Get elected/re-elected based on competence/statistics???


    Mr Walsh (just another victim/covered up statistic)

  8. Dr. John Hopkins says:

    The report on Tuesday night Channel 4 news was confused and, consequently, misguided.
    Is the status of a homeless person recorded when they enter a hospital ? Absolutely,
    it is. Once the homeless person is discharged, it is up to Social Services to pick
    up the slack, not the hospital/ NHS.

  9. Alan says:

    The article reads as a revelation? There are many that understand you can’t be poor and ill in callous Britain.

  10. MaSHUD hAQUE says:

    I am wondering why we are talking about this eight years old episode at a time when the election is coming.

    Why child mortality rate in UK is so high would be a better topic to probe.

  11. H Statton says:

    It’s a heap of soil-smelling clothes with what appear to be feet poking out from an otherwise indiscernible pile of rubbish. On further inspection, I can see it’s a person underneath last week’s newspapers, carrier bags, coats and an old Manchester United football scarf.

    On closer inspection I can see this person is alive, and although something human registers when our eyes meet, that’s where mine and their understanding of one-an-others worlds ends, mine in confusion and feebleness theirs in resignation. Both of us are powerless. How and where do they get help, how and where can I get help for them?

    I go home and complain that the house is not quite as warm as it should be and that I’ve broken another light bulb. They assess with much practicality having to spend the night in this semi-floodlit place as opposed to their usual spot which is more comfortable and sheltered, more private and peaceful. It also provides storage for some very basic requirements such as cardboard and newspapers which are good insulators, and if extremely lucky, an old mattress.

    The only time they might get to sleep in a normal bed is if they get given a chance through one of the available charities; there they might be able to get a wash and some new clothes.

    It is only when a passer-by spots them lying on the pavement unmoving and possibly exuding blood that they may end up getting the bed and vital health check they need, but ironically they may already be ‘in extremis’ following an unprovoked attack by a drunken mob, or gang.

    An ambulance is called and the patient is rushed to A&E. The immediate problems are dealt with e.g. Head trauma, knife-wound, heart-arrhythmias, diabetic-coma etc. The patient is put on an Acute Assessment Unit (AAU) for ~ 24hrs to monitor their intensive/urgent condition. If they need surgery, they go under the knife. If they need more conventional treatment e.g. hyperthermia, malnutrition, de-hydration, skin-infections, HIV etc. they go to a general ward. After the hospital has done its bit, what happens? The patient gets sent back to their non-home. And the circle starts again….?

    What happens if a homeless person arrives via ambulance at A&E, spends a few hours in the operating theatre, is monitored for a few hours in an Intensive Care Unit then dies suddenly? Does this person simply get incinerated along with the other hospital clinical waste? Is this the undignified reminder what we dignified people need to wake us up? After all, in a recent report, it was found that certain ‘failed’ pregnancies were dealt with in a similar fashion. Some families were misled into believing cremation of the babies’ bodies would occur, but in actual fact some of the babies’ bodies were simply destroyed with other clinical waste in the hospital incinerator. Hardly respectful!

    Thinking of all the above on my way home I give someone my cup of tea and sandwich, make wretched conversation and walk slowly home. I wonder where the cheques to charity are sent and on what they are spent? How is it that the ‘life-savers’ link up with the ‘carers’? I wonder how the ‘carers’ link up with the ‘welfare’. Are not all these links supposed to put people back into society and not merely help them hang on to it by their fingernails?

  12. H Statton says:

    With an already imploding NHS budget things are not going to change in their current mode. The Medical services are doing what they can but they are being increasingly squeezed.

    After a patient is discharged, inappropriately or not, the NHS is not a housing service, and I’m sure many working within it wish they could facilitate some guidance in that area. They don’t have the resources. No member of medical staff wants to see a patient discharged early only to see them re-admitted the following week with new preventable problems.

    I’ve seen people that are still ill discharged simply because there is someone deemed ‘more ill’ on the way in. Dilemma: Two people and one bed. It’s not difficult to work out who gets it. It’s a sad case of picking ‘the lesser of two evils’.

    There are too many ‘patients’ in limbo. Even those with families are struggling. Relatives are not a sure safety net to catch all the fallout from inappropriate or no treatment. They require help and advice also.

    In practice there is no holistic approach to healthcare. There are pockets of ‘care’ dealing with specific issues that for one reason or another can’t seem to link up. Money and investment are never usually far away from the problems they face.

    1. Helen Zeitlin says:

      Good, sensitive writing. The trouble is we did once have a holistic approach to healthcare. The NHS has been purposely dismantled along with the shrinking of other parts of the welfare state. The conditions in which the poor and the sick are living, so well described by yourself and Victoria, must remain on the front page as a hot political issue. What else can we do?

  13. Daisy says:

    I think this is a good thing to be highlighted as people’s life’s are valuable .
    However , there is always another view .
    I work as a Health Care Assistant and see many patient s with many needs .
    I have one patient on the Ward at the moment who is homeless and is waiting to be housed before he leaves , therefor taking up a valuable bed . I agree that he should have a room and a roof over his head when he leaves .
    However, he is a drug user and says he will return to it as soon as he leaves . He spends his whole day watching his tv which costs him five pound a day . Many of our patient s cannot afford this , as they have worked hard all their lives , and now living on a pension .
    So while I sympathise with those who are homeless I also think that there are other problems in other areas . The person who is homeless was homeless before they went into hospital , so why then does this become the hospital s responsibility ?

  14. john nunn says:

    Thank you daisy for your very relevant comment to your situation.
    People who are using drugs will be indifferent to the use of any help from others.
    You are being used as a caring individual by this uncaring government who has not taken into consideration any application of care for people who need help.

    It boils down to drugs (which this government chooses to ignore because it would cost too much to rectify the situation).

    I really do not know which party of government will have the guts to rectify the drugs situation.

    It seems the Devils drugs and the evil politicians are in cahoots, and we have to suffer for their greedy surrender to the evil.

  15. Richard Lohman says:

    I’ve worked with people experiencing homelessness for 14 years and the reality is it’s a very complex issue and not just about a roof over someone’s head. Homelessness is ultimately symbolic of how we relate to each other. It is a reality that as long as our society continues to abuse some of the abused will refuse to take part in that society. Homeless people are stripped of their dignity in many ways and yet lots of them seem more able to accept the kindness of strangers than some of us with four walls around us.

    If we are focussing on the particular issue of a roof and especially after hospital discharge then shared discharge protocols between local authorities, hospitals and commissioners are the solution – Greater Manchester has tis in place and the situation there is better than elsewhere in England.

    We need to shake up our politicians though so they amend the legislation around council housing, housing ownership responsibilities and Housing Benefit. Councils who pay Housing Benefit should be paying it to themselves and thereby buying up properties to add to their stock rather than making landlords wealthier.

    The owner of any residential property that is empty should have to pay council tax, this should double after 4 months and double again after 8 months. If the property remains empty for more than 2 years it’s ownership should transfer to that local authority who then should have a duty to use such properties for the vulnerable and disadvantaged.

    Social workers and local authority housing officers often have their hands tied due to low availability of housing stock and too much demand and yet there are literally hundreds of thousands of empty properties dotted around England. If the owners don’t accept their social responsibility then Parliament as the body with overall responsibility should make them and we elect our government so ultimately it is down to each of us.

    Oh and by the way I’m an ex injecting drug user . Drugs are not a problem if used responsibly. If I take a chair and bash you over the head with it are chairs a problem? If someone takes a drug including alcohol when they feel bad to feel better then it’ll probably lead to a problem for them. If someone takes a drug including alcohol when they’re ok in themselves and are celebrating life with friends, say at a wedding, then it’s likely that getting out of it won’t go on and lead to a problem. Getting drunk every three months or so is probably good for the soul.

    Homeless people are not all drug users or alcoholics. 1 in 9 adults in England has experienced homelessness at some point in their lives! People finding themselves homeless who are admitted to hospital should be discharged to some kind of safe bed but we need to care enough to make this happen. We need to take responsibility and elect members of parliament who belong to political parties who’ll address the issue. Britain is not great because it raped and pillaged a third of the known world it is great because it has one of the best safety nets for vulnerable people in the world. This has been severely eroded over the past few decades and we need to strengthen it again but responsibility is mutual. Just like any relationship. If the drug user misuses the relationship there has to be consequences. The person leaving prison has done their time, they should not be further punished by being assessed as intentionally homeless. We do have enough houses, we do have enough to go around.

Comments are closed.