A medical social worker post for St Brigid’s Hospice in Co Kildare was not recruited by the HSE for years, despite the serious concerns of a palliative medicine consultant and colleagues. Catherine Reilly reports
The protracted failure by HSE Dublin South, Kildare and West Wicklow (DSKWW) to initiate recruitment of a medical social worker for St Brigid’s Hospice in Co Kildare was having a “devastating” impact on patient care, a consultant in palliative medicine warned management last year.
In an email sent on 22 July 2022, Dr Miriam Colleran expressed her serious concern that the post was vacant for “over three years”, according to records released by DSKWW under Freedom of Information (FoI) law, following a lengthy delay.
“As I said in the voicemail, it is having a ‘devastating’ impact on our patient care and service not providing specialist psychosocial care,” outlined Dr Colleran to senior primary care manager in DSKWW, Ms Gillian Farrelly.
The matter of the vacant post became a crisis after the planned retirement in May 2022 of a bereavement specialist/former social worker who provided a family support service.
According to background on the medical social worker post provided by Dr Colleran in her email, a primary care social work service had been withdrawn from the hospice in 2019. “Then […] kindly restarted the family support service that she had previously provided, as an interim measure, to address patients and families need. This was not a MSW [medical social worker] post and was kindly funded by the Friends of St Brigid’s Hospice.”
Dr Colleran stated she had “repeatedly” raised the vacant post at DSKWW management meetings, “sent emails especially after […] gave notice on her planned retirement, submitted risk assessments and also recently an incident form.”
The HSE-operated hospice in The Curragh, which provides inpatient and community services, had no specialist palliative care (SPC) psychosocial service for patients, loved ones and families, warned Dr Colleran in her email in July 2022.
“There is no [SPC] bereavement support service and no psychosocial support to prepare children for the loss of a parent, sibling or beloved relative in SBH [St Brigid’s Hospice].
“This is a serious risk not just for patients but for the mental health of their families and loved ones coping with anticipatory grief and caring for a seriously ill loved one and for poorer bereavement and mental health outcomes in bereavement.”
The palliative medicine consultant also stated that two half-time chaplaincy posts approved for the hospice had not been progressed by DSKWW.
Funding for the chaplaincy and social work roles was approved in 2020, indicated the FoI records. The impact of the absence of these positions was the subject of numerous communications and risk assessments to DSKWW management, according to the records that covered the requested period of April 2019 to August 2022.
On 22 November 2021, in a discussion with DSKWW colleagues on the risk register, Dr Colleran stated that while some progress had been made with the approval of medical social worker and chaplaincy posts, the risks were “still open” as the posts were not filled.
The records showed that, on 5 January 2022, Dr Colleran raised with Ms Farrelly the planned retirement in May of the bereavement specialist who provided the family support service. Dr Colleran advised that the medical social worker post needed to be progressed “as soon as possible”.
Dr Colleran’s communications with DSKWW management, in which she reiterated her concerns, continued over the forthcoming weeks and months.
A risk assessment escalated to DSKWW primary care management, dated 7 April 2022, had warned of the “urgent need to progress” the medical social worker post. It warned there would be no formal psychosocial care service to hospice inpatients or patients in the community from 27 May 2022.
Last week, a spokesperson for DSKWW told the Medical Independent (MI): “The medical social worker post has been accepted, is at contract stage, and [with a] start date for March 2023.”
Prioritisation
The FoI records indicate that other healthcare posts across DSKWW were prioritised ahead of the social worker and chaplaincy roles in the recruitment process. In her email to Ms Farrelly on 22 July 2022, Dr Colleran had referenced a comment she claimed was made at a DSKWW management meeting that the medical social worker post was not advanced as there were “so many posts being progressed” for enhanced community care (ECC), a national reform programme to provide healthcare at a local level.
“I clarified with you by phone subsequently that neither of us had seen a formal document to defer the progression of SPC [specialist palliative care] posts to facilitate the progression of ECC posts,” added Dr Colleran in her email.
The consultant outlined she had had “intermittent in person meetings with you from 2019 about the progression” of the medical social worker post after DSKWW’s cessation of the primary care social work service at the hospice.
Initial discussions had focused on the importance of a governance structure and support for the post. Dr Colleran noted she had suggested the possibility of aligning the post with Naas General Hospital, Co Kildare, after it was established that Our Lady’s Hospice and Care Services did not have the capacity to support the role from a clinical governance perspective.
On the same day as Dr Colleran’s email in July 2022, a senior nurse at the hospice submitted a national incident review form to colleagues and DSKWW primary care management. In the email thread, Dr Colleran stated it was “very sad and worrisome that a patient was unable to come here because of the absence of a SPC psychosocial care service…It is also reputationally damaging for SBH [St Brigid’s Hospice] and the HSE not to provide this core SPC service.”
Risk assessment
A background document accompanying a risk assessment on the vacant medical social worker post, dated 31 May 2022, provided further context on the implications of the staffing deficit.
The document described psychosocial care as “a key tenet of evidence-based holistic, person-centred, palliative care in keeping with the national advisory committee on palliative care (2001) and part of the HSE palliative care programme”.
“Providing psychosocial care is a core aspect of addressing patient’s mental health and wellbeing,” it outlined. “…Preventative health in palliative care is especially centred on preventing adverse bereavement outcomes including complicated grief and depression for the family or loved ones. It is important to address the grief and subsequent bereavement needs of children who have a loved one, a parent, sibling or close relative, who have life-threatening illnesses.
“Addressing the grief and bereavement needs of children and adolescents is specialist psychosocial care. Untreated these children and adolescents are at risk of serious mental health illnesses while growing up or in adulthood. SPC medical social workers (MSW) provide psychosocial care and bereavement support in accordance with the national advisory committee on palliative care (2001) and current evidence-based practice.”
The specialist who had provided the family support service at St Brigid’s Hospice had delivered a very comprehensive SPC psychosocial care service, including bereavement care and a specialist children’s bereavement service, according to the document.
Following their retirement on 26 May 2022 there was no formal specialist palliative psychosocial care service to either inpatients or patients in the community.
According to the risk assessment, there was an “urgent need” to progress the medical social worker post and to consider engaging a medical social worker via an agency with external supervision in the interim.
In communications with colleagues, Dr Colleran also stated that the hospice should have a minimum of two whole-time equivalent medical social worker posts in accordance with Department of Health policy.
Governance
Resolving the issue of clinical governance for the medical social worker post appeared to be a factor in the prolonged failure to recruit.
Following the approval of funding, records showed there were initial discussions between DSKWW primary care manager Ms Farrelly and Our Lady’s Hospice and Care Service in regard to the latter potentially recruiting and supervising the post.
On 13 August 2021, Ms Farrelly emailed Ms Audrey Houlihan, CEO at Our Lady’s Hospice and Care Services, and stated: “I need to progress the recruitment of this [social work] post as it has been highlighted again in the IPU [inpatient unit] and also with the community teams. Can I have an update as we have transferred the budget for the post across earlier this year and it is becoming an issue for the team.”
In response, Ms Houlihan outlined that “we are exploring options to ensure sufficient reporting/management structures are in place prior to recruiting this post”. From initial discussions “we have established that the post will be aligned to community services so we are trying to establish integration arrangements with inpatient services and how the reporting can be streamlined while different arrangements are in place for the inpatient social work service. The post will not be viable until we clarify these matters…We are anxious to progress this…”
However, this matter was not resolved by DSKWW, which had responsibility for progressing the post.
Over the course of spring 2022, Dr Colleran continued to regularly raise her concerns with DKSWW primary care management.
On 14 March, for example, Dr Colleran informed Ms Farrelly that further to her two voicemails she was contacting her as she was “concerned about the impact on patients and families” from the pending retirement at St Brigid’s and the unfilled medical social worker post. “Psychosocial care is a key aspect of specialist palliative care,” she outlined.
Ms Farrelly responded on 21 March to advise that this would be discussed at a meeting scheduled for 1 April.
On 7 April, Dr Colleran advised Ms Farrelly that a proposal to use cancer support centres in lieu of specialist palliative psychosocial care services at St Brigid’s was “inappropriate” even as an interim measure.
On 3 May, Dr Colleran thanked Ms Farrelly for taking her call on the post. She noted that the option of linkage with Our Lady’s Hospice and Care Services seemed unlikely and that she had suggested a potential linkage with Naas General Hospital, about which she awaited an update.
Two days later, a nurse at the hospice attached incident forms in an email to a senior public health nursing colleague and stated: “I attach two NIMS [national incident management system] forms pertaining to lack of family support for patients/families in Kildare WW CPCT [community palliative care team] now that […] is retiring. We discussed this at our MDT [multi-disciplinary team] yesterday. It is a huge concern that this service is no longer available.”
On 21 June, Dr Colleran contacted Ms Farrelly to again enquire about the progression of the medical social worker post and also sought an update on the chaplaincy post.
Dr Colleran expressed her concern about the “risk of harm to patients and their families/loved ones (including an adverse bereavement outcome) due to the MSW vacancy and absence of a SPC psychosocial care for patients and families and absence of a bereavement service for bereaved families and loved ones”.
On 21 July, Director of Public Health Nursing in DSKWW, Dr Sheila Geoghegan, advised a nurse at the hospice: “It is not safe practice to deal with issues outside of [your] scope of practice.”
The nurse had stated: “I spent a significant part of my working day yesterday dealing with issues that were outside of my scope when we are already short staffed in our nursing cohort.”
‘Regressive decision’
The deficit in social work provision at the hospice followed a prior decision taken by DSKWW to withdraw a service. Between 2018 and 2019, HSE primary care social work had provided a service for the hospice. After being informed about the imminent termination of the service, the Principal Social Worker expressed alarm about the potential impact on patients and families.
In an email to HSE National Primary Care General Manager Mr TJ Dunford on 1 April 2019, Principal Social Worker Ms Brigid O’Donovan stated she had already attempted to address her concerns through her line management structure, ie, Ms Mary O’Kelly, Head of Primary Care, and Ms Anne O’Shea, Chief Officer, DSKWW.
“However to date I have not been afforded an opportunity to meet with them to discuss the matter further and I have been given a clear instruction that the service is to be terminated…”.
Ms O’Donovan warned it was a “very regressive decision”. She said it meant that in excess of 50 clients and their families at St Brigid’s Hospice would have their service terminated over the following two to three weeks “which will result in a high-risk situation for them and also for the HSE …Once again I am requesting that the national office take this situation on board as a decision of this magnitude is contrary to the national palliative care strategy and reflects poorly on the HSE.”
Response
In August 2022, DSKWW primary care management submitted a business case for an agency medical social worker due to “gaps in care in providing essential support to palliative care patients and their families”. This business case was dependent on the post not being filled from a panel.
A spokesperson for DSKWW told MI: “The medical social worker post has been accepted, is at contract stage, and [with a] start date for March 2023.” The spokesperson said the accepted post was permanent.
Clinical governance arrangements would be in place prior to the start date, they added. Meanwhile, the chaplaincy post was “at campaign development stage”.
Asked why ECC/chronic disease posts were prioritised for recruitment, as indicated in FoI records, the spokesperson commented: “This decision was taken as the bereavement support counsellor was in post (until May 2022) and provided the required services to the inpatient unit.”
They said “additional resources have been provided to the HR department to progress our recruitment requirements …”.
Funding for the posts had not been redirected elsewhere in the organisation, according to DSKWW.
The spokesperson said the risks associated with the vacant posts are “mitigated” by several measures. “Nursing, medical and health and social care staff provide support to patients and families within the scope of their practice. Where clinically indicated, referrals are made to appropriate support services. Patients may also attend other support services such as Cuisle, Portlaoise, and Newbridge cancer support groups.”
Six NIMS incident forms regarding the lack of a SPC psychosocial care service were submitted from the hospice’s community palliative care team, said the spokesperson.
No individuals had not been admitted to the hospice on the basis that the appropriate psychosocial service was not available, added the spokesperson.
Separately, the Department of Health informed MI that a new palliative care policy for adults is expected to be published in the second quarter of this year.
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