What happens when they need care, have money but won't pay for it?

[VimtoPassion]

A friend is having terrible struggles with her father. He has always had some MH issues and has now started with some dementia. He has good days and bad days, but was recently sectioned and has been in hospital for several weeks.

They have changed and monitored his medication and they are now ready to discharge. He does seem much more coherent from the little I've seen, but they are saying they want to send him home with a care package, which he will have to fund.

He is saying absolutely not, he neither wants nor needs care and there's no way he's paying for it. So what happens?

They won’t discharge him home if he won’t be safe without.

What section was he in under? If under a section 3 he’ll be discharged under section 117 which means aftercare is free. If under a section 2 which is the most likely then I expect they’ll do a capacity assessment to see if he has capacity to make decisions about his care.

if the assessment shows he doesn’t have capacity then if there’s no POA, he’ll be referred to court of protection. However if he does have capacity to make decisions about his care including his ability to understand the risk of going home with no care then he could be discharged with no support. You can’t force care on people who don’t want it.

The friend must make clear to the hospital that she (or he) cannot help. The dad will have to sink or swim on his own. I know this sounds harsh. If he has capacity, he can choose to refuse help.

It’s pretty tedious and made up a lot of my casework in this field.

Ultimately someone has the right to make an unwise choice and refuse care if they have full mental capacity to do so and fully understand the consequences.

in reality you try your best to persuade them.

if capacity is lacking or borderline is really hard because unless someone already has power of attorney for finances it’s a long process to get deputyship so that someone else or the LA can access the persons money to pay for the care, but in that scenario the LA normally step in. Ultimately no one wants the person to come to harm. And if they lack capacity care will have to be provided and money sorted later.

however, imposing care at home on someone who doesn’t want it, capacity or not, is in reality hard because they may just not open the door or let the carers do anything but even an attempted or very quick visit in that situation can reduce the risk and pick up any problems early.

Also if they refuse paid care you out as much as possible in place to reduce the risk in other ways eg pendant alarm, neighbours or family checking in (no obligation though), district nurses, mental health team etc

As above, it depends a bit, but if he is deemed to not need any more treatment and to have capacity to make decisions for himself about his care then he is very likely to get discharged. Friend needs to step away, sadly.

And in his sort of situation what happens is the person bounces in and out of hospital unfortunately.
Hopefully if he understands it will reduce the risk of another hospital admission he might give it a go 🤞
If he doesn’t understand that… well you’d have to question capacity.

We had this with my parents, carers would be set up and my father would cancel them.
Eventually it became a safeguarding situation, both went into NH.
Very difficult, very frustrating and incredibly stressful.

Lots of people are shocked at how much the care is and baulk at the cost. I do understand that but find it sad when they refuse help that they need as what are there savings for really, especially when they don’t have kids to pass it on to

Do you think they'll just keep him in hospital indefinitely?

As has been said, you can’t force care on someone with capacity who refuses it.

It’s fairly common for people with dementia to fail to understand their own needs. And it may well not be ‘denial’ as such, but down to the fact that at any given moment they can’t remember that they can’t remember anything (if that makes sense) and can’t remember that they can no longer do all the things they used to.
My own Dm still honestly thought there was nothing wrong with her when she could no longer even make herself a cup of tea.

Sometimes, when a person stubbornly refuses the care they need, unfortunately you just have to wait for some crisis or other to occur, and hope it won’t be too horribly serious.

Have you heard about “bed blocking”? It’s a real thing where hospital beds are taken up by people who should be getting care at home/in residential care but for one reason or another it’s not able to be put in place.

What I will say @VimtoPassion is tell your friend to be hard nosed about agreeing to help her DF. As horrible as it sounds she needs to refuse to care for him without a care package in place. We had to do this with late-MIL as the hospital wanted to discharge her home to an unsuitable property. At the time I had a 3yo and a newborn and DH was working away Monday-Friday so we couldn’t manage it ourselves.

If he isnt section 117 eligible and there is a view he has capacity then its his decision.

In my local authority in situations like this we have an agreement with the NHS that they will fund up to 4 x 15 minute visits a day to administer medication and nothing else, with the agreement of the person of course.

It provides a check on the person through the day and ensures they at least they get their meds. It can often be used as a way to get the evidence that the person does/doesn't have insight into their care need longer term.

If medication administration is a need that needs to be met and he is refusing all other social care needs being met but he refuses to pay for it (meds isnt a social care need but is often provided by social care workers if they are there doing other things already) then friend / LA should definitely be thinking of approaching the ICB in their area for funding for the meds calls

Yes of course I've heard of "bed blocking", but we tend to call it a delayed discharge these days and our discharge teams are much firmer about supporting a discharge, hence why folk with no medical needs and with capacity aren't kept in hospital unnecessarily.

Delayed discharge is itself almost a thing of the past, what with Discharge to Assess (D2A) being all the rage.

Basically the NHS throws people who are medically fit for discharge out either into a care home that they have block booked beds in or back home with carers they pay over and above what the local authority can pay for or in house NHs care teams to get them off hospital property. The NHS pays for the care for up to 4 weeks and then disappears, leaving social care to pick up any complications such as the scenario in the OP.

It works well in theory if you only loom at hospital discharge in isolation. In reality although they are chucking people out quicker at the bottom end, we are piling them high at the top end because Social Care can't get carers/short term resi care directly from the community because the NHS has block booked it all so the only route in to care services ends up being via an often unnecessary hospital admission anyway.