what matters to me? - local government association · what does a good home-first culture look like...

What matters to me?

Dr Shibley Rahman

MA PhD MRCP(UK) LLM MBA

‘Why not Home, why not today?’ Home First/Hospital Discharge

18 Smith Square, Westminster, London

Wednesday 3 October 2018

“Culture eats strategy for breakfast”

A change of mindset

• “Medical fit for discharge” vs “unsafe to admit”?

• An honest conversation that you can’t have 0% risk and 100% safety

• You need risk to live at all

• Not every “I has to be dotted” and “T crossed” prior to discharge?

• Discharge is not the end but a beginning

• Unnecessary assumptions: e.g. denying that carers are professionals in their own right, and know the patient extremely well, assuming everyone with dementia lacks mental capacity.

I’d like you to meet my mum.

The “hospital experience”

• Even before hospital, going through the NHS 111 algorithm was torture.

• The “This is me” info above mum’s head had not been updated.

• Bound to get off to bad start if you arrive in hospital at 10 pm and arrive at the ward the following morning at 7 am.

• Bound to end badly if you wait 6 hours for hospital transport.

Delirium-friendly ward?

Different HCAs every day.

Noisier @ night than Piccadilly Circus.

Loss in confidence.

“Bed rails”

No help in eating meals.

#EndPJParalysis (these adverse outcomes are not

minor – e.g. loss of muscle bulk, pressure ulcers,

DVTs, PEs.)

#HelloMyNameIs.

@dr_delirious

Communication

• “I’d like to see you walk to the toilet” (focus on assessments)

• No collateral history, even about function

prior to admission (?valuing carers, poor IT

systems)

• disempowering my mum for mental

capacity assessment (e.g. language)

• lack of communication over deprescribing

even if those decisions promoted delirium

(?end of life)

Disempowering people

• A culture of risk aversion

• “Best interests”

Them against us?

• Is “specialing” an abuse of human rights?

• For whom are “challenging behaviours” actually challenging?

Overestimating discharge needs

Difficult decisions

• All this puts people off aiming for home as a default – thinking that transfer to a care home (not a failure in itself) is the only option.

• Risk of institutionalisation, further delirium and acceleration in cognitive function after a single event of delirium can be high.

I strongly commend to you an attitude of ‘home first’.