Adult Social Care Glossary, v 0.6

There are some words that automatically make me go hmmm, and several that really make me squirm. But, as I wrote in my original ‘why language matters’ blog post, the language of the social care world is so deeply entrenched that we don’t often think about the true meaning or impact of the words we use, or question why we continue to use them. And I’ll admit I hadn’t thought too much about the term ‘discharge’, until I heard Glyn Butcher talk about what the word means to him [1].

So, this blog is a reflection from us both, about what the word ‘discharge’ represents, and why it’s a word that makes us both go hmmm…

[⚠️ Trigger warning. Includes references to suicide and suicidal thoughts.]

Discharge.

It’s one of those words we hear, and we read, and we use a lot in relation to social care.

At a national level, the term dominates the discourse.

There’s the narrative of blame in the media. Social care blamed for ‘delaying discharges’ and the ‘increased pressures on our NHS’. ‘The population’ blamed for ‘ageing’ and for having ‘increasingly complex needs’. And ‘vulnerable patients’ blamed for ‘blocking beds’.

A narrative fuelled by campaigning organisations, with repeated calls for the government to ‘fix social care’ to ‘relieve pressure on the NHS’.

And a government response focused on ‘rolling out’ and ‘scaling up’. On ‘integration’ and innovation’. ‘Data’ and ‘technology’. ‘Virtual wards’ and ‘hospital at home beds’. An expansion of “services to keep vulnerable out of hospital.” A £500 million Adult Social Care Discharge Fund “to help free up hospital pressures and reduce strain on NHS”. “£1.6 billion to improve hospital discharge arrangements.” Funding to “prioritise those approaches that are most effective in freeing up the maximum number of hospital beds and reducing bed days lost.” Funding to “boost general adult social care workforce capacity… where that will contribute to reducing delayed discharges.” “A concerted focus on supporting discharge of those with particularly complex care needs… to free up hospital capacity.”[2][3][4][5][6]

While the national lens focuses on “freeing up beds”, not building better lives, and on ‘patients’ (specifically “the most vulnerable, frail and elderly patients” [7]) not people, the ‘operational’ vocabulary is one of transactions.

Discharge pathways. Discharge services. Discharge models. Discharge to assess. Discharge planning. Discharge procedures. Discharge decisions. Early supported discharge. Safe discharge. Timely discharge. Delayed discharge.[8]

The language of process and flow. Production lines. The health and social care sorting office.

One out, one in.

But underneath this dehumanised and dehumanising language, there are human beings. And I’d like to share what the term discharge means to one amazing human being – my pal Glyn.

“The word discharge sends shudders through my body, through my mind. I associate it with loss.

I spent 25 years in a [mental health] service trying not to get discharged because to me discharge meant abandonment, to me it meant being alone. My family was in mental health, my benefits were in mental health, my housing was in mental health, all my friends were in mental health, so why would I want to leave? Even hospital care – my friends were in there. So I fought against being discharged every single day so it wouldn’t happen to me, because I didn’t want to feel alone. On a Friday night when all the services were closed, I’d be stood on a bridge saying ‘I’m going to kill myself’ so the police would come and lock me back up and put me back through the front door again.

People are entrenched in services for decades. So, what does discharge feel like? It feels like people are taking away something from you that is normal, like eating and breathing. If someone decides they’re going to take something away from you, what are you going to replace it with? People don’t know what to fill it with, so they create more problems in their life to get back in. The point is they have to fill it with something.

The word discharge makes me shudder. I can feel the blood draining from my body. I feel sick in my stomach if I hear the word, and I experience flashbacks from past experiences of being discharged and the total emptiness I felt inside. I feel naked, alone, lost and abandoned. I lose all hope. The voices I hear and my suicidal thoughts intensify. That’s the power of language. That’s the power the word discharge has on me.

I associate being discharged with being inadequate. You are discharged from the army for doing wrong. Discharged from a job because you cannot do the work.

Being discharged means I’m on my own.”

The dictionary definition of discharge is “tell (someone) officially that they can or must leave a place or situation”. “To throw off or deliver a load, charge, or burden”. “Something that is emitted” (like sewage). [9][10]

The term “implies execution and completion of appointed duties or tasks”. Indeed, it originates from the late Latin term ‘discarricare’ (unload) and Old French ‘descharger’, becoming a Middle English term meaning ‘relieve of an obligation’.[11]

As Glyn says, “the focus is all on what you’re leaving, not what you’re going to”.

On the benefit to the service, not the person.

On what’s ending, not what’s next.

And there’s often an undertone of options being exhausted, and responsibility relinquished.

‘We have nothing more to offer you.’

‘There is nothing more we can do.’

Job done. Get out. The end.

With no acknowledgement of how frightening those words can sound and how lonely that reality can feel to the person – and to any people close to them – with no idea what the future holds.

Instead of the relentless and oppressive narrative of ‘discharge’, our focus needs to change to ‘going home’.

And yes of course there is already the mantra of ‘home first’. But that’s still ultimately a process full of pathways, where ‘home’ = your “usual place of residence”, where you are “discharged to be assessed”. Where the attention is on ‘transfer of care’, on “helping people get out of hospitals and into social care support”. On people “being cared for in the best place for them”.[12][13]

On getting care, not getting a life back – regardless of age or stage.

‘Going home’ doesn’t mean being ‘placed’ in a ‘bed’ or a ‘care setting’.

It means going (back) to a place that feels like home.

It means finding, or returning to, the place where you feel you belong.

[For references/footnotes please see original article]