Sebastian Walsh: Medically fit, awaiting social

“Patient remains medically fit for discharge. Plan: Awaiting social.” On countless times during my foundation year 1 I wrote words to that effect in patients’ notes during ward rounds. It is an all too familiar tale. An elderly person is admitted to hospital with an acute illness, which is treated, but the patient is judged unsafe to return to their home environment. They then enter into the painfully slow-paced jungle of care packages, funding applications, and placement allocations which can take weeks and months to arrange.

My first job as a foundation year 2 doctor was on a geriatric ward designed for patients with dementia and a concurrent physical illness. It is a consultant geriatrician-led ward in the centre of a busy district general hospital. In my first month, we cared for patients with acute bowel obstruction, a fractured neck of femur, and a suspected meningo-encephalitis. However it wasn’t this variety that really grabbed my attention.

So what did? There are three ways in which this ward was completely different to any ward I have experienced as a student and clinical trainee:

  • The process:

For a typical patient, I would start by obtaining a thorough collateral social history, then compare that to my clinical observations, discuss inconsistencies with the multi-disciplinary team, and then together come up with a long-term plan for maximising that person’s quality of life. This would then be discussed with relatives, and if possible the patient.

I had stopped writing “awaiting social,” and become part of the process myself. In doing so I wasn’t just treating patients, I was understanding people.

  • The pace:

Discharge is never rushed. Nor though is it delayed unnecessarily. The key is learning who will benefit from being allowed to settle on the ward, enabling full assessment of what they can and cannot do, and thus what support they will need on discharge. An extra day or two of admission translates to good clinical care (and common sense) if it leads to a more accurate assessment of the patient, a better discharge plan and a longer hospital-free period overall.

  • The environment:

The two female bays share an activity room where patients and relatives can socialise. This is mirrored on the male half of the ward and the two activity rooms are joined by a small garden area. Socialising can replace the reality of being in hospital with a more calming feeling of normality.

Each bay of five patients has a nurse and health care assistant. Beyond attending to basic needs such as drug administration, observations, turning patients, feeding, washing and toileting, staff also have time to talk to patients. This companionship alone can help settle patients and make them more co-operative. This leads to a better understanding of what they will be like at home and a more accurate assessment of their needs.

Low discharge rates, high staff-to-patient ratios, and even a garden in the middle of an acute hospital—this isn’t a story you expect to read amidst those of an NHS in crisis. But the ward’s approach to dementia care makes complete clinical sense, and is evidence based. Additionally, this model of acute dementia care offers the real possibility of reducing re-admissions and giving the NHS the return on investment it sorely needs.

Sebastian Walsh is an FY2 doctor working in the West Midlands with a long-term career interest in academic public health.

Competing Interests: None.


Shamil Haroon, Public Health, Epidemiology and Biostatistics Clinical Research Fellow, University Of Birmingham, UK, who reviewed the manuscript, and provided advice regarding academic writing style.


[1] Brooker D, Leung D, Bowley K et al. The Dementia Care Bundle: Improving quality and safety of hospital care for patients with acute physical illness who have co-existing dementia.  Published online, access date: September 2016.