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