Hospital social work and discharge planning for older people: challenges of working in a clinical setting

Abstract

Across the world acute hospitals are under unprecedented pressures due to shrinking budgets and increasing demand, against this backdrop they are also experiencing record levels of activity in Accident & Emergency and delayed transfers of care. Reducing pressure on hospitals by avoiding unnecessary admissions and delayed discharges has risen up the global policy agenda. However, reviews of strategies and policies have rarely involved discussions about the role that hospital social workers play in achieving timely hospital discharge. Yet discharge planning has become a, if not the, central function of these professionals. This paper presents the results of a small-scale exploratory study of hospital social work in an acute hospital in Northern Ireland. The findings reveal that the work of hospital social workers is characterised by increased bureaucracy, an emphasis on targets and a decrease in the time afforded to forming relationships with older people. Hospital social workers highlight concerns that the emphasis on discharge planning and pressures associated with the austerity agenda limits their capacity to provide other more traditional roles such as advocacy and counselling. It is argued that hospital social work should not be narrowly defined as ‘simply’ co-ordinating discharge plans. The tension that arises between expediting hospital discharge and advocating for older people and their families is also discussed.

Introduction

Timely and effective discharge planning can ensure continuity in the care of older adults, improve the transition from hospital for both older people and their families, and reduce hospital readmissions and associated financial and personal costs (Bull and Roberts, 2001; Durocher et al., 2017). Unnecessary and avoidable delays in discharging older people from hospital is a longstanding issue in global health care (Naylor et al., 2015; Rojas-Garcia et al., 2018). As the world's older population continues to grow at an unprecedented rate (National Institute on Aging, 2016), creating viable alternatives to hospitalisation becomes increasingly significant, as it is simply not possible to continue to match population growth with hospital beds. Rising demands on health-care systems has brought the issue of delayed discharges to the forefront of the United Kingdom (UK) policy agenda (Glasby, 2007; Bardsley et al., 2012; Edwards, 2017). The rationale for the growing concern is that a considerable body of evidence suggests that hospital discharge is a complex issue characterised by poor patient experience, fragmentation, duplication, inadequate communication, insufficient collaboration, delay and inefficiencies (House of Commons, 2016; National Audit Office, 2016; Edwards, 2017). Whilst delayed discharge impacts on all user groups, it is particularly associated with older people who are major users of the service (Abendstern et al., 2011; Cornwell et al., 2012; National Audit Office, 2016). Longer stays in hospital have a disproportionately negative effect on older people as they quickly lose their strength and mobility. It has been estimated by Resnick et al. (2016) that almost one-third of older patients experience functional decline during their hospitalisation. Many older people are leaving hospital with functional impairments and are less independent than when they were admitted (Oliver, 2015; Lafreniere et al., 2017).

As well as the human cost, delayed discharge represents poor value for money and places avoidable financial pressures on the National Health Service (NHS). It has been suggested that without ‘radical action’ the problem will deteriorate, and the system will become unsustainable (NHS Providers, 2015; Northern Ireland Audit Office, 2016; NHS England, 2017). Against the demographic challenge of growing numbers of older people there is a recognition of the need for a deeper, evidence-based understanding of the complex organisational and inter-professional issues that underpin delayed discharges (Swinkels and Mitchell, 2009; Challis et al., 2014). Achieving safe discharge as soon as possible after the initiating illness has resolved is important for both the patient and the acute hospital service. Identifying a means to reduce the time an older person spends in hospital and to avoid readmission is a key health policy consideration (Ham et al., 2012; Walker et al., 2018). In their review of integration in health and social care across the four countries of the UK, Heenan and Birrell (2018) note that it is widely accepted that an integrated system can address some of the perennial issues of fragmentation and poor co-ordination and lead to better outcomes for service users, particularly older people with complex needs. Uniquely within the UK, Northern Ireland has a structurally integrated system of health and social care (Heenan and Birrell, 2009, 2018), where hospital-based social workers operate at the interface between health and social care within a multidisciplinary team context. They assume primary responsibility for co-ordinating the discharge plan, ensuring a whole-systems approach that aims to deliver care, informed by a patient's preferences and goals. This research focuses on the implications of taking on this discharge planning role and the challenges associated with delivering social work interventions in a clinical setting. Although the focus of the research is on the Northern Ireland context, the study may have relevance for discharge planning and hospital social work both nationally and internationally.

Background

The origins of contemporary social work practice in the UK can be traced back to hospital almoners, first employed at The Royal Free Hospital in London in 1895 (Auslander, 2001). These professionals redefined how the health and wellbeing of people was understood with the development of a person-centred response to the needs of patients and their families. By addressing the social, emotional and economic impacts of ill-health, hospital social workers complement the medical model approaches within a clinical setting (Moriarty et al., 2019). Social work is a value-based profession underpinned by the principles of social justice, anti-oppressive practice and human rights. Hospital social workers draw on a breadth of knowledge, skills and values to advocate for patients and carers. These highly skilled professionals occupy a unique position within the hospital by being located both at the interface between health and social care as well as between the hospital and the community (Rachman, 1995; Mann, 2016; Heenan and Birrell, 2018). Internationally, there is a high level of consensus that the distinctiveness of hospital social work is due to its approach which provides a vital counterbalance to clinical models of illness (Chapin et al., 2014; Craig et al., 2015; Ambrose-Miller and Ashcroft, 2016; McLaughlin, 2016). Despite the fact that discharge planning has moved to the top of the policy agenda, the role and contribution of these professionals remains poorly understood. Moriarty et al. (2019) noted that not only was there a dearth of recent UK-based empirical research, but even regulatory reports on discharge planning or health and social care integration made scant references to social work. In their review of the effectiveness of adult social work, Moriarty and Manthorpe (2016) highlighted the invisibility of social work in health services research and stressed the need to acknowledge the impact of these practitioners.

The multiplicity of roles undertaken by hospital social workers is a key theme in the existing literature. In their extensive review of hospital social work, Moriarty et al. (2019: 10) noted that ‘without exception’ research included in their study emphasised the multi-dimensional nature of this work. Contributions include assessment, discharge planning, counselling, advocacy and crisis intervention (Oliver, 2013; Craig et al., 2015; Mann, 2016; Fantus et al., 2017). Nilsson et al. (2013) reported that in Australia, hospital social work takes place across a number of domains but is predominately concerned with assisting service users and their families, usually in periods of change or crisis. These professionals balance complex family dynamics and provide essential support to those who are frail and vulnerable to achieve a safe discharge from the hospital (Craig et al., 2015; Mann, 2016). Social work operates beyond the immediate medical concerns of patients and into the wider social and economic context and its impact on health outcomes (Cleak and Turczynski, 2014). Multi-disciplinary working is increasingly viewed as an integral component in the delivery of health and social care. Social workers are a crucial part of a collaborative approach that brings challenges as well as rewards (Baginsky, 2014; Giles, 2016). Continuing debates about professional identity and philosophical differences between the medical and social model can cause practitioners to struggle to maintain a professional identity (Oliver, 2013). However, interprofessional working may also provide an opportunity to challenge power differentials and clarify roles (Ambrose-Miller and Ashcroft, 2016). Advocacy is generally considered to be a core aspect of the social work identity and it takes on particular resonance in a hospital context where patients may be frail and vulnerable, may not have relatives or friends to act in their interests, or may be faced with life-changing decisions (Sexton, 2012). The importance of advocacy in hospital social work with older people has been highlighted in a number of studies (Craig and Lorenzo, 2014; Findley, 2015; Kia et al., 2016).

In the last two decades, discharge planning has emerged as a major professional function in hospital settings and represents an integral part of social work practice (Holliman et al., 2001; Sulman et al., 2002; Watkins et al., 2012; Weerahandi et al., 2015). Whilst it is broadly accepted as a social work task, there is significant concern that increasing emphasis on discharge planning means that core social work roles in advocacy and counselling are being diminished (McLaughlin, 2016; Heenan and Birrell, 2018; Moriarty et al., 2019). Furthermore, the emphasis in acute hospitals of increasing patient throughput to make care more efficient and thus avoid delayed discharges has meant that aspects of the ‘traditional’ social work function such as counselling and providing emotional support have become secondary to assessing individual needs and planning for discharge. Phillips and Waterson (2002) argue that hospital-based social workers perform invaluable functions, not least in buffering patients and carers from pressures to move on too quickly. Incorporating a social dimension into the health-care system helps to prevent inappropriate discharges and provides emotional support in a complex and challenging process.

In the UK, the growth of what has been termed new managerialism or new public management (Newman, 2000; McLaughlin, 2016) has had a profound impact on the organisation of public-sector organisations. This ideology has witnessed the transfer of a range of business ideas associated with the private sector into the public sector with the aim of enhancing efficiency and effectiveness. It is associated with a focus on bureaucracy, guidelines and procedures alongside reduced professional autonomy and discretion. This managerial emphasis on targets and budgets rather than outcomes can put additional pressures on holistic assessments of the needs of patients (Webb and Levin, 2000; Sulman et al., 2002). Alongside this, a decade of austerity in the form of deep public spending cuts has been the dominant fiscal policy across the UK (Garrett, 2012; Hastings et al., 2015). In health and social care, this retrenchment has resulted in severe budget cuts, staff reductions and a focus on cutting costs (Eliasoph, 2011). As Grootegoed and Smith (2018) noted, the austerity agenda has had a significant impact on social work. They contend that theoretically the emphasis on individual responsibility and reduced public services presents both challenges and opportunities; whilst opponents of the austerity agenda (Smith, 2011) argue that it undermines social work's values and hampers the ability to provide responsive services. Additionally, the increased focus on reducing expenditure means social workers are viewed as more technocratic and remote. Others have, however, framed austerity as an opportunity to reduce bureaucracy and facilitate innovation (Garrett, 2012).

Methodology

The study involved semi-structured, face-to face interviews with 33 health and social care staff including 13 hospital-based and six community social workers, three members of social work management, five nurses, two occupational therapists, two physiotherapists, two general practitioners (GPs) and a consultant in geriatric medicine. This was a relatively small team of information-rich respondents who were articulate and willing to reflect on working in a clinical context. The hospital-based social workers assumed the lead responsibility for discharge planning and were attached to wards for older people (65 years and older). The research conforms to internationally accepted ethical guidelines approved by the relevant university committee and all participants gave their verbal consent. The interviews aimed to explore the role of the hospital social worker, with particular reference to their contribution to the hospital discharge process. A short interview guide with five open-ended questions was used to facilitate greater consistency in the data and enable participants to discuss their experiences and perceptions. The questions emerged from an extensive review of the national and international literature. They explored roles and responsibilities, professional identity, inter-disciplinary working, challenges and opportunities. The methodology included a mix of one-to-one interviews and small group interviews. The social workers and hospital-based professionals were interviewed in focus groups. The director of social work and the social work manager were interviewed on a one-to-one basis, as they were concerned that their presence could impact on participants’ willingness to speak freely. The GPs were also interviewed on a one-to-one basis for logistical reasons, as they were not based on the hospital site. All interviews were led by the author to ensure consistency. Each interviewee was assigned a reference number (1–33) which is included at the end of the direct quotes. These interviews were recorded and transcribed verbatim. The data created by the interviews were subjected to a rigorous, iterative process of thematic analysis to identify emergent themes and illustrative comments (Moran-Ellis et al., 2004). As recommended by Lincoln and Guba (1985), this process was followed by peer debriefing to provide an external check on the research process, to increase credibility and as a means to check interpretations from the raw data. A previous paper (Heenan and Birrell, 2018) focused on the findings in the context of multi-disciplinary working and social work education, whilst this work is focused on the tensions and challenges faced by social workers in this clinical setting. The findings are presented under three sub-sections, professional identity, new managerialism and advocacy. The interviewee response reference numbers are as follows: 1–13: hospital-based social workers; 14–19: community-based social workers; 20–22: social work management; 23–25: nurses; 26–29: physiotherapists and occupational therapists; 30–32: GPs; and 33: consultant.

Findings

Professional identity

There was a general consensus from the hospital social workers that discharge planning had become their core activity. Whilst there was an acceptance that they were best placed to undertake the discharge planning role, there was also frustration that it was poorly understood and undervalued. Managing the discharge process is a complex, multi-layered task requiring a broad repertoire of skills including negotiating and arranging support services, assessment of need, co-ordination and communication (Ambrose-Miller and Ashcroft, 2016; Moriarty and Manthorpe, 2019). The participants referred to the need to assess risk, prioritise shrinking budgets, manage expectations, and evaluate and monitor progress. The increasing emphasis on the hospital discharge process brought to the fore the long discussed but largely unresolved issue of the professional nature of social work (Oliver, 2013; McLaughlin, 2016). There was a perception from social workers that the public and other professionals did not have a clear idea of their distinctive contribution and this lack of clarity partly contributed to a trivialising of their role and status:

Personally, I have no issues with taking the lead on discharge planning, I think we are the obvious choice as we have a unique perspective and overview. It's bloody frustrating though when your role is viewed as a tick boxer or a bureaucrat who fills in the paperwork. We are skilled professionals. (Interviewee 1, hospital social worker)

It was suggested that the broad nature of the social work contribution meant that they were not associated with a narrowly defined set of skills and there was some confusion around professional identity:

Social workers can listen, understand and see the big picture. It's not just about one thing for us, it's everything. Sometimes people struggle to see the skill that is needed for that. (Interviewee 4, hospital social worker)

Some referred to this blurred identity as being ‘reductive’ and a threat to their professional status. One remarked that ‘we are viewed as glorified administrators’. Terms ‘discharge planners’ or ‘discharge co-ordinators’ were considered to be demeaning and not reflective of the complexity and multiplicity of their skills and roles. There was a broad agreement that the focus on discharge planning detracted from their other specialised functions such as counselling and advocacy. Acting as advocates for service users has been identified as one of their key skills (Heenan and Birrell, 2019) but one which had the potential to be controversial:

We are the lynchpin of the whole process, ensuring that information is collected and shared as effectively as possible, but to be honest there are days when it feels like we are just the general dogsbody. Often we have to challenge decisions and that doesn't make us very popular. (Interviewee 6, hospital social worker)

Some of the interviewees expressed annoyance and exasperation that their vital role was neither understood nor valued. The perception of a hierarchical system where social workers languished at the bottom undermined professional confidence and created feelings of isolation:

If you ask me, for social workers, hospital discharge is a double-edged sword. On the one hand, it gives us an opportunity to use our skills and get the best outcome for people who are often confused and vulnerable; on the other hand, the importance of our role is dismissed or even sneered at. We are seen as the difficult ones, always holding things up, always questioning. (Interviewee 7, hospital social worker)

Amongst the other health professionals there was broad agreement that social workers were highly valued members of multi-disciplinary teams. Their tenacity and ability to navigate complex systems were identified as key attributes. However, there was an acknowledgement that discharge planning was poorly understood and could be dismissed as a relatively unskilled administrative task. This was explained by a consultant:

In this acute hospital the key to efficiency and reducing unnecessary stays is effective, streamlined discharge planning. It is a critical function but usually completely misrepresented. I think it is completely devalued and widely thought of as just a clerical function. The specialised nature of their work is glossed over as it's just getting older people out the door. (Interviewee 33, hospital consultant)

An occupational therapist on the multi-disciplinary team reflected that many health professionals had little knowledge or understanding of the social work profession and the poor understanding had led to their knowledge and skills being undervalued:

It is hardly surprising that social workers feel marginalised as I used to think why does everything take them so long? But after a while you realise they are keeping the patient's voice heard, ensuring it is not drowned out by all those people who think that they know best. (Interviewee 26, occupational therapist)

In the integrated system of health and social care in Northern Ireland (Heenan and Birrell, 2018), social workers usually lead on discharge planning as they have access to and knowledge of social care resources in the community. Tensions occurred in the team when social workers were perceived to have spent too long on a discharge plan or were considered to be taking a risk-averse approach. Social workers reported that occasionally it felt like a challenge to ‘hold the line’ on their professional values and identity:

For us it is all about values and principles, they are at the heart of what we do, why we do it and how we do it. It's not an optional extra. (Interviewee 2, hospital social worker)

Sometimes it's a bit disappointing, there is a hierarchy in the hospital and we are the bottom feeders, but at the end of the day our input is vital. That's what matters. (Interviewee 12, hospital social worker)

This study found occasional friction and tension between the health and social care professionals, however, in general, collaborative working was described as successful and underpinned a whole-systems approach. The shift away from the traditional doctor-focused model of care has challenged some of the hierarchical assumptions ingrained in health-care systems (Oliver, 2013; Ambrose-Miller and Ashcroft, 2016). Collaboration often required trade-offs and working for the greater good, rather than prioritising some needs over others. Sharing power meant alliance building to make the system holistic and not simply working as a series of independent parts. A collaborative culture required time and commitment and leadership; it was an opportunity to challenge preconceptions and power differentials within the health-care teams.

New managerialism and austerity

There was a general agreement amongst the participants that the ethos of the hospital was strongly influenced by administrative practices associated with new managerialism which had pervaded into every aspect of policy and practice. This imposition of this new managerialism was associated with a proliferation of guidelines, procedures and checklists which had eroded professional autonomy and discretion (McLaughlin, 2016). The focus on value for money and the drive for efficiency had led to concerns that budget controls were being prioritised over need. Fiscal constraints dominated discussions and overshadowed principles of social justice and equality and, as Fantus et al. (2017) noted, this is a source of conflict and anxiety for social workers. It was contended that the emphasis on accountability and budgeting had no regard for individual needs which were often complex and multi-dimensional. Many referred to a ‘tick box culture’ where it appeared that paperwork rather than people had become the priority. The policy focus on quantitative output measures and the focus on targets intensified pressure on health and social care staff to expedite the discharge process. The target culture was commented on by a community-based social worker:

I really feel that the whole target culture just doesn't reflect how complex and challenging hospital discharge is for professionals. Increasingly we hit the target and miss the point. (Interviewee 15, community social worker)

Working in an acute hospital was described as a ‘pressure cooker atmosphere’, which could be challenging, disheartening, exhausting and, for some, directly impinged on job satisfaction. It was reported that against a backdrop of efficiencies, value for money and austerity, services were increasingly rationed and targeted at those perceived to be in the greatest need. In a context of diminishing resources, there was increasing emphasis on efficiency and effectiveness. Assessments and decisions about long-term care were often prompted by a crisis and required careful, measured consideration of an array of factors and this was often at odds with systems designed to contain costs and screen eligibility for services. A nurse reflected on how this culture impacted on her working environment:

The key question here should be what really matters and focus on that. If we meet targets but older people feel rushed and confused, are we doing our jobs? (Interviewee 23, nurse)

Another nurse expressed her frustration at what she viewed as a short-term counter-intuitive focus on hospital throughput rather than individual needs:

In a frantic atmosphere it is sometimes hard to explain that it takes time to understand needs, it involves negotiations and listening, building trust through conversations. Social workers have to resist any pressure to discharge people before they are ready to go home, as readmission is extremely stressful for all concerned. People are being discharged quicker and sicker and it makes no sense for any of us. (Interviewee 24, nurse)

A social worker reflected on the demands and expectations of this culture by simply saying:

We are measured within an inch of our lives and frankly most of it is utterly meaningless. (Interviewee 5, hospital social worker)

The increasing emphasis on clinical outcomes and process-driven targets in the hospital setting caused tensions within the multi-disciplinary team. It was suggested that a renewed emphasis on measuring outcomes and setting targets in social care did not and could not reflect the complex and individual nature of social care needs. The perceived different ways of working within health-care professions and conflicting pressures were identified as factors which could cause tension and reduce efficiencies. The time required to undertake complex, psycho-social assessments could prolong the discharge planning process, however, the social workers viewed the administration as simply unavoidable. It was suggested that the demands of management against a backdrop of austerity had skewed priorities with an over-emphasis on standardised outcomes. The social work manager explained that whilst she understood the need to measure performance, social care did not easily lend itself to metrics or indicators:

From the moment they arrive there is a clock ticking and we are all well aware of it, but that can never be the focus. The reality is though just huge pressure to clear the beds in the acute ward. For social workers cost is not just about the money, the budget, it's about the human cost, ensuring people are not just numbers. (Interviewee 20, social work manager)

The social workers stressed the importance of ‘client-centred’ care, which was described as ensuring that older people's views and preferences were at the heart of the decision-making process. Listening to and taking account of the wishes of service users was described as paramount. Social workers were adamant that their leadership in the process ensured that safety concerns did not subordinate the rights, values and interests of older adults in decisions that were fundamental to their quality of life. It was acknowledged that this approach was often time consuming but was non-negotiable in terms of protecting the autonomy of older people:

To others the discharge planning processes may seem cumbersome or not efficient enough but there will always be dilemmas about getting things moving quicker. Our focus is on the individual and their families and securing the very best outcomes. The vast majority of older people want to return to their own homes and we do our utmost to ensure that can happen. (Interviewee 18, community social worker)

Social workers reported concern that the increasing demand for services combined with ongoing financial pressures could lead to ageism where older people were viewed in a negative or dehumanising way. This ageism manifested itself in terms such as ‘bed blocker ‘or ‘frequent flyer’, which for many implied blame for patients, particularly older people. It was suggested that there was a need to reframe the target-based system and challenge derogatory terms and ideas that older people were ‘paralysing’ the health and social care system:

Language matters, important to remember that the people who are being called bed blockers are often frail and vulnerable. It's just unacceptable for them to feel that they are a nuisance or a burden, it should be challenged. The unrelenting focus on targets and budgets can put the emphasis and the blame on the individual. (Interviewee 11, hospital social worker)

The emphasis on discharging patients within limited time-frames was viewed as secondary to ensuring appropriate treatment for often frail and vulnerable patients. The ‘unrelenting squeeze’ on NHS resources and the increasing number of older people needing care meant a difficult balancing act for these professionals. They were, however, adamant that no-one would be inappropriately discharged as someone ‘needs a bed’ or in response to throughput requirements. Pressures on the health and social care system would not be allowed to compromise dignity and reduce an individual to an inefficient waste of space. Social work ethics underpinned decision-making and preserving the humanity of the sick and frail was described as ‘paramount’. Ideas of risk management and value for money have risen up the policy agenda, however, it was suggested that they could not be allowed to become the driving force of practice, superseding concepts of need and compassion.

Despite longstanding structural integration of health and social care in Northern Ireland, it is widely acknowledged that social care is viewed as secondary to health care (McLaughlin, 2016; Heenan and Birrell, 2018). Social workers referred to social care as ‘the poor relation’ or the ‘Cinderella service’. It was explained that in a hospital environment, clinical needs would always be afforded priority. The lack of resources in community care in Northern Ireland presented a significant challenge for those charged with designing care plans. Systemic underfunding of social care provision has serious implications for older people who required a package of care to support their move out of hospital. There was significant frustration that very often patients were medically fit to be discharged from hospital but were unable to leave as the necessary support was unavailable. Respondents voiced concern that a lack of resources in community care threatened to make providing accessible, responsive and flexible services that meet the needs of a diverse community very difficult to achieve:

The lack of resources within the community is a huge issue for older people. We can't get people the help they need because money just isn't there to provide it. People are stuck in the most expensive part of the hospital system, losing strength and worrying about getting home. (Interviewee 11, hospital social worker)

Not only were community care and social care described as underfunded and poorly valued, their relative lack of status meant that they were vulnerable to further cuts in funding due to short-term cost controls. There was almost unanimous agreement that austerity had disproportionately hit the most vulnerable in society and had a particularly negative impact on social work services. However, the respondents stressed their determination to ensure that cuts would not hinder their ability to deliver the best outcomes for their clients.

Advocacy

A key theme to emerge from this research was the significance of advocacy and the importance attached to safeguarding and defending rights. Whilst advocacy is generally viewed as a core social work value (Ambrose-Miller and Ashcroft, 2016; Moriarty et al., 2019), it took on a particular salience in a clinical environment (McLaughlin, 2016; Heenan and Birrell, 2018). Participants expressed concern that this aspect of their role was under increasing pressure due to the focus on moving people through the hospital. To maintain professional integrity and values, advocating for one's client was described as fundamental. Advocacy was described as at the ‘heart’ and ‘core’ of social work practice. It ensured that older patients who might struggle to have a voice or navigate a complex system would have someone to listen to their concerns and act in their interests. Advocacy in this context involved both interventions for the older people within the hospital and signposting them to services within the community. These vulnerable patients were at risk of being disempowered by a complex, confusing and alien system. For many patients, hospital admission had dispossessed them of their dignity and self-confidence. They were overwhelmed by an unfamiliar, challenging environment. The significance of advocacy was explained by both hospital- and community-based social workers:

Often when people come in here, they are at a low ebb, bewildered and confused. They haven't planned to be in hospital and it's probably the very last place they want to be in. It's our job to reassure them and ensure they have some control over decisions that will impact on the rest of their lives. (Interviewee 15, community social worker)

The importance of being supportive was reiterated by a community-based social worker who stressed that supporting service users was an essential task of social work. Admission to hospital was often unexpected and frightening (Judd and Sheffield, 2010; Oliver, 2015) and should not be compounded by a lack of compassion and empathy:

It's hard to overstate how vulnerable older people can be when they find themselves in hospital. They need support, reassurance, time and understanding. That's our job, we navigate a way out which addresses their hopes and fears. Most importantly we listen and hear. (Interviewee 9, hospital social worker)

There were, however, serious concerns that the advocating aspect of their work was being marginalised and sidelined due to pressures of time and volume of work. There was increasing occupational pressure due to the escalation of workloads and the growing complexity of interventions, staff shortages and diminishing resources. Social workers had less time to build relationships or establish trust, which was described as ‘essential’ and ‘fundamental’. A procedurally driven assessment agenda with a reduced emphasis on building relationships impeded their ability to establish rapport and undertake problem solving. This created significant issues for social workers who were aware that their professional ethics could be compromised by institutional and systemic pressures:

There is increasing pressure and competing demands, but social workers bring a unique perspective and advocacy to the table. We see past the label of an illness or a condition. (Interviewee 2, hospital social worker)

A nurse suggested that the social work approach was often poorly understood and misrepresented:

Sometimes I think their focus on the whole picture is seen by others as a luxury, an indulgence that we simply cannot afford. You know not really our concern. They see the whole world, we just see our bit. (Interviewee 25, nurse)

A GP described social workers’ ability to navigate the complex and sometimes contradictory system of health and social care as ‘critical’ for those who were often coming to terms with an unplanned admission to hospital. He explained that older people in a hospital setting particularly valued the emotional support provided by the social worker:

Social workers address the social and emotional needs of the patient. They bring humanity to the whole process. Vulnerable older people trust them and can tell them what they want. Their advocating and supporting helps to ensure the best outcome. Without advocates older people can quickly become unheard and indeed invisible. (Interviewee 30, GP)

The social workers in this study expressed concern that the poor understanding of their role and their responsibility for co-ordinating the hospital discharge process meant that some of their core functions, most notably advocacy, could cause tensions within the multi-disciplinary team. Colleagues expressed frustration at time-consuming tasks that were referred to as ‘not really your job’. There was considerable anxiety that an increasing emphasis on the throughput of patients could force a more cursory approach to emotional support. For these professionals, it was crucial to protect the humanity and dignity of older people and address their fears about losing independence, power and control. Confused and anxious patients required emotional support and empathy, particularly in an unfamiliar clinical setting. For social workers, the priority was not on securing a speedy discharge but a safe transfer with an optimum package of support:

Pushing people out the door without understanding and addressing their needs is just counter-productive and makes no sense. It doesn't save money and serves no-one. It just stores up pain for later. (Interviewee 15, community social worker)

Advocacy was not confined to the individual or family level, but also involved actively promoting change at a systemic level and lobbying against unwanted outcomes of policies and practices. As Fantus et al. (2017) highlighted, health-care workers frequently encounter moral conflict when allocating scarce resources. The respondents reported that challenging the hierarchical power structures and advocating for patients’ rights by ‘speaking truth to power’ was ‘part and parcel’ of their job:

Social workers in a hospital will never win a popularity competition. We are often seen as a thorn in the side of those who come up with the new policies and strategies with little or no idea of how the theory will work in practice. (Interviewee 5, hospital social worker)

Debates on preventing delayed discharges have rarely acknowledged the wider role that social workers play in the support of patients (Moriarty and Manthorpe, 2016; Moriarty et al., 2019). Despite the fact that they are the professionals most involved in helping patients reach decisions and providing support for changed circumstances, their input is often overlooked. References were made in this study to the danger that social workers were increasingly viewed as ‘simply’ discharge managers, people who had boxes to tick and beds to clear. Participants suggested that resource constraints and the clinical environment contributed to a one-dimensional understanding of successful hospital discharge:

We are not here to get a quicker turnaround on beds or to move people where they are somebody else's problem. We are here to see the person and their unique needs. It's easy to get caught up in the system and lose sight of the person. Less time in meetings would be a good start. (Interviewee 8, hospital social worker)

Unsurprisingly, the bureaucracy and administrative demands associated with discharge planning were reported to consume increasing amounts of social workers’ time and energy. Administrative work impinged on their ability to undertake other activities. The emphasis on ‘bed-clearing’ meant that social workers had less time to spend with those dealing with the emotional upheaval of illness, trauma or loss.

Discussion

The pace and process of discharge planning has changed dramatically over the past decade and it is recognised that the way this transition is handled is critical to the health and wellbeing of older people (Durocher et al., 2017; Edwards, 2018). This paper explored the role of hospital social workers in the context of an increased emphasis on avoiding delayed discharges for older people and shrinking health and social care budgets. The findings reveal that working in this clinical setting presents considerable challenges for these professionals. As previous studies (Ambrose-Miller and Ashcroft, 2016; McLaughlin, 2016; Moriarty et al., 2019) have highlighted, the lack of a clear professional identity for social work is the cause of tension and conflict. Despite the multi-dimensional nature of their contribution, social workers are often narrowly conceived as co-ordinators of hospital discharge (Judd and Sheffield, 2010; Sexton, 2012). Social workers described this as reductive as it misrepresented the breadth and depth of their skills and knowledge.

Discharge planning was widely accepted as a key social work task and there was a recognition amongst other health-care professionals that social workers were best placed to lead this process. However, there was a strong belief that the increasing emphasis on discharge planning overshadowed and undermined the significance of their other roles (Webb and Lavin, 2000). As noted in the literature (Sexton, 2012; McLaughlin, 2016; Moriarty et al., 2019), the organisation of a hospital provides a number of challenges for these professionals. Significantly, responsibility for the discharge planning process is associated with a decline in status and an increase in administrative tasks. The findings reveal that the increasing emphasis on ensuring efficient and effective discharge had diminished the social worker's professional identity.

Previous studies have suggested that multi-disciplinary team working presents challenges and opportunities for social workers (Judd and Sheffield, 2010; Baginsky, 2014; Ambrose-Miller and Ashcroft, 2016; Moriarity and Manthrope, 2016). Social workers in this study welcomed interprofessional collaborative working and viewed it as an opportunity to challenge professional boundaries and the dominance of the medical model. They did, however, stress that the lack of clarity around social work roles was challenging and could impede effective team working. Inadequate support and a limited understanding of the values and ethics of social workers in a clinical setting have been identified as impediments to successful working (Baginsky, 2014).

One of the key findings of the study was that the current context of austerity and new public management was not always compatible with social work values. The focus on technical skills and the ability to complete assessments on time, alongside a dominant narrative of quantifiable performance criteria, failed to acknowledge the emotional aspects of practice. This emphasis on ‘speedy throughput’ has been referred to as ‘conveyor-belt care’ (Harlow, 2003: 35). The respondents acknowledged that the focus on meeting hospital discharge targets has seriously limited their capacity to provide a holistic service that adequately addresses the complex psychosocial needs of patients and carers. The emphasis on financial incentives and penalties combined with various other levers to drive performance was criticised as counterproductive and short-sighted. As existing research has highlighted, the provision of health and social care in an acute setting was complex and challenging and this was often not adequately reflected in a target-based culture (McLaughlin, 2016). The disconnect between what was measured and what was required to deliver a holistic package of care was criticised as ‘skewed’ and ‘inappropriate’.

There was strong support for the view that the austerity agenda had disproportionately impacted social care budgets (Eliasoph, 2011; Grootegoed and Smith, 2018). This has had serious implications and has negatively impinged on the ability of social workers to provide appropriate care. The findings were consistent with the view that the neoliberal agenda undermined the social work profession (Rogowski, 2010; Wallace and Pease, 2011). There was no support for the contention that budget cutbacks could allow for more creative approaches (Garrett, 2012). This was dismissed as fanciful nonsense. Budget cuts, diminishing resources and a focus on targets had placed additional stress on these professionals, jarred with their value base and impacted negatively on job satisfaction. As Hughes et al. (2014) noted in their review of the impact of the austerity agenda, reduced budgets have disproportionately affected the most vulnerable individuals. Health and social care are fully integrated in Northern Ireland and theoretically this should address longstanding concerns about the hegemony of health care. However, as previous research has noted (McLaughlin, 2016; Heenan and Birrell, 2018), whilst structural integration facilitates joint working and collaboration, it does not address longstanding power imbalances. Social care is viewed as inferior to health care and was underfunded and undervalued (Heenan and Birrell, 2018). Delayed discharge from hospital was described as an inevitable consequence of cuts to social care budgets. The findings in this study reinforced the need to adopt a whole-systems approach to health and social care.

Existing research has identified advocacy as a core function of social workers (Sexton, 2012; Moriarty and Manthorpe, 2016; Moriarty et al., 2019). Advocating on behalf of patients and their families was described by these social workers as a fundamental aspect of their role and contribution. Effective patient advocacy can preserve autonomy and ensure that older people maintained the highest possible quality of life (Oliver, 2013;Ambrose-Miller and Ashcroft, 2016). Social workers are skilled professionals who can validate the experiences of patients, support effective communication and enable patients to be more in control of their health-care pathway (Giles, 2016). Advocating for vulnerable patients is a complex, often time-consuming process that is poorly understood and contentious (Judd and Sheffield, 2010; Findley, 2015; Heenan and Birrell, 2019). Similar to the findings of Ambrose-Miller (2015) in a study of inter-professional working, advocacy was identified as having the potential to cause conflict among team members. There was a significant concern that the increasing emphasis on patient throughput and containing costs presented a threat to this signature aspect of social work practice.

Conclusion

Securing timely and effective hospital discharge is a key concern in current health and social care policy. In the context of increasing demands, enhancing service capacity and diminishing resources, reducing delayed discharges is arguably one of the biggest priorities for the NHS. It is not just about the money though, extended stays in hospital are particularly detrimental to the mental and physical health of older people. Time spent in hospital when medically fit is an unnecessary risk to health and wellbeing. The austerity agenda has ushered in a renewed emphasis on efficiency and effectiveness, and added pressure to increase the throughput in hospitals. Retrenchment has also meant severe cuts to health and social care budgets and resources. In Northern Ireland, despite structural integration in health and social care, these cuts have disproportionately affected social care. Underfunding in social care is, however, a false economy as it impedes the ability to provide an adequate response to the needs of older people. Delayed discharge is complex and multi-faceted and requires a whole-systems approach with a focus on the needs of the individual, rather than a focus on bed usage.

Hospital social workers play a pivotal role in ensuring the smooth transition out of hospital to appropriate care, yet their contribution remains poorly understood. Assessments of preventing delayed discharges rarely involve discussions about the role that social workers play in the treatment and support of older people in hospital. One of the main challenges for hospital social workers in a context of constrained budgets, austerity, efficiencies and performance management is to ensure that their unique contributions are fully understood and acknowledged. Their work is often narrowly conceived around co-ordinating hospital discharge and administrative tasks, and their other roles, particularly advocating for their clients are, overlooked. Social workers advocate on behalf of their patients, using their professional values and principles to identify needs and concerns. Older people may be frail and vulnerable when they are admitted to hospital, and may have to face life-changing decisions which can be both challenging and frightening. Social workers engage in complex, emotional and psychosocial situations with the aim of empowering and enhancing the lives of their clients. This study highlights the significant role played by these professionals and highlights the need to identify organisational and system factors that impinge on their delivery of effective interventions.