CQC report highlights shortfalls in care provision for over 65s
Beyond Barriers takes a holistic look at interaction of NHS and social care services in England
Beyond Barriers takes a holistic look at the interaction of NHS and social care services in England
In one of his final acts as CQC chief executive, before he stepped down in July, Sir David Behan unveiled a report which for the inspection body was quite unusual.
Instead of looking at and rating individual services, it took a holistic look at how the NHS and social care services in England interacted in providing care for the over 65s.
The report, Beyond Barriers: how older people move between health and care in England, drew on in-depth field work carried out in 20 local areas from major cities such as Birmingham and Liverpool to rural areas like Cumbria and Oxfordshire.
The number of local areas in England reviewed by the CQC
In publishing the report, Sir David highlighted one patient story in particular.
The woman, who was not named, was living at home independently with the support of her son and help from a domiciliary care agency.
One Friday evening she fell, bumped her head and was taken to hospital. She was not badly hurt and after one night in hospital she was ready to go home. But the right staff were unavailable over the weekend, so she could not be discharged.
On Monday the hospital was ready to discharge her, but because her home care support was no longer available, she could not go home. She stayed in hospital for over a month, her condition deteriorated and eventually she was moved into a residential care home. She never saw her home again.
‘Urgent necessity for change’
emergency admissions from care homes last year
Sir David says cases like this show the ‘urgent necessity for change’. But while the report details examples of how care can and has gone wrong, it also provides plenty of evidence of what works.
And this, of course, comes at a crucial time. Ministers in England have promised a green paper on social care funding reform this autumn, which the sector hopes will provide a significant boost, paving the way for more integration and joint working to support older people.
The Local Government Association is running a consultation on the green paper until 26 September.
So, what did the CQC find in the way of projects and initiatives to recommend? There was a wide variety, including:
- Hospital-at-home schemes and virtual wards to provide intensive care in people’s homes.
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care providers say quality of discharge information was ‘rarely’ or ‘never’ sufficient
- Hospitals providing in-reach into care homes to reduce emergency admissions.
- Social workers employed on wards to help with discharge planning.
- Discharge-to-assess schemes allowing people to be released from hospital as soon as they are medically fit.
- A higher priority being given to discharge summaries to make sure they are accurate and available on time.
- Intermediate care and reablement work to provide step-down services for people ready to leave hospital but not yet able to live independently.
- Single point of access schemes where patients and professionals can get advice and information about local support services.
- Befriending schemes and other social prescribing initiatives to keep people well and living independently.
Tax rises may be needed to boost older people's care
Tax rises and means-testing universal benefits such as the winter fuel allowance should be considered to help increase funding into the social care sector, according to council leaders.
The Local Government Association (LGA) said councils were facing a £3.5 billion funding gap by 2025.
To increase investment in the sector, it said a number of options should be considered including:
- Income tax rises for all
- National insurance increases
- A premium to be paid for by the over forties
- Means-testing universal benefits, such as the winter fuel allowance and free TV licences
- Allowing councils to increase council tax bills
LGA community well-being board chair councillor Izzi Seccombe says services are at ‘breaking point’ after decades of inaction.
‘We cannot duck this issue as a society any longer.’
But despite all the good work, the CQC said there was still some way to go and the systems in place were not yet ‘fully matured’ despite the dedication and commitment of many staff.
Care England nursing adviser Deborah Sturdy believes there is a fundamental problem holding the agenda back – and it is not just a question of money.
‘We know what works. The more interesting question is: what stops people adopting this wholesale?
'As far as I am concerned, there is a fundamental shift that’s needed for joint working. Currently there are two pay structures and terms and conditions in place.
‘We have come a long way, but without a change in the recognition, understanding and value of the part everyone plays in the delivery of services, I’m not sure we will shift the practice at the rate we need.’
The CQC report also echoes this. It says leaders in the system need to develop a ‘common vision and purpose’ by working together on joint plans for commissioning projects and developing the workforce.
On the latter it recommends more secondments and accreditation-style ‘passports’ to allow staff to move freely between the NHS and social care settings.
Royal College of Nursing professional lead for older people Dawne Garrett believes such initiatives will have a major impact.
‘I would like to see nurses being able to rotate through community, hospital and social care roles.
‘It would help develop the skills and experience we need to care for these patients and develop the right services.’
But she says you still cannot get away from the fact finances have played an important role in the slow uptake of integration. ‘In times of financial hardship, we tend to be less sharing.’
How local areas are making a difference
The virtual ward
District nurses, primary care staff and the voluntary sector are working with hospital staff in Sheffield to provide a virtual ward in people’s homes. Everyone registered with the service is risk-rated for possible hospital admission and regular reviews of their situation take place, just as they would on a ward. As well as getting daily support, patients are also taught how to self-care.
Helping isolated patients
In Bradford, a special district nurse health team had been established to focus on people with complex and long-term conditions and are isolated and unable to access their GP easily. Once patients are registered they are given a dedicated contact to call if they need help. It has reduced the need for them to access care in hospital.
Single point of access
An integrated contact centre has been set up in East Sussex to act as a single point of access for professionals and individuals. Staff at the centre can immediately assess and refer patients on for support for everything from crisis help to rehab and occupational therapy. Services such as meals on wheels and telehealth can be organised directly by the team.