Nurse managers have a vital role in the future success of social care

The government's promised social care measures will need strong nurse leadership and joined-up thinking to work

The government's promised social care measures will need strong nurse leadership and joined-up thinking to work

Reform of social care is long overdue. It is 70 years since the National Assistance Act created the system that still exists in the UK today.

The government has promised funding reform, with a green paper expected to be published this autumn.

Picture: Getty Images

But there is still much that can be done by leaders in the system. A Care Quality Commission (CQC) report, Beyond Barriers: How older people move between health and social care in England, has been drawn up from a review of 20 local authorities and suggests a host of ways that nurses can help improve the provision of care.

1. Take hospital care out to people’s homes

The CQC report said there was good evidence that taking services out to people’s homes, sometimes called hospital-at-home or virtual wards, can reduce hospital admissions and outpatient attendances. Many examples involve hospital staff and community teams, including district nurses, working together with social care teams.

2. Work in care homes

There were around 270,000 emergency admissions to hospital from care homes in England between September 2016 and September 2017, with more than one third of them staying over a week. In-reach services provided by advanced nurse practitioners, community matrons and district nurses along with GPs and consultants have been shown to reduce admissions.

3. Develop single-point-of-access schemes


The number of local authority areas in England reviewed by the Care Quality Commission

Many systems had developed specific ‘single point of access’ services to help people navigate the two systems. These were judged to be effective, particularly in times of crisis. There was variation in who could access them though; some were aimed at members of the public, some at professionals and some at both.

4. Explore the potential of personal budgets

Voluntary personal budgets and direct payments were judged to be good at allowing people to have choice and control over services. However, concern was expressed at the significant variations in take up, ranging from one in four people in some places to one in 20 in others.

5. Consider appointing ward-based social workers

Social care professionals frequently voice concern about not being involved early enough. This is important because they may have a better understanding of a person’s needs and can play a key role in organising care after discharge, the CQC said.

6. Improve information on discharge

The CQC said it had identified a problem with discharge summaries not always being provided or adequately filled in. Registered managers for domiciliary care were more likely not to receive one at all, the research showed.

7. Out-of-hospital discharge assessments

Traditionally, assessments to decide on post-discharge support are carried out on the ward. But the evidence suggests assessing people in their home can lead to less support being required as they are more able to demonstrate independence. However, this depends on having a team of specialists on hand to provide support straightaway, known as ‘discharge-to-assess’ teams.


The number of emergency admissions from care homes in England between September 2016 and September 2017

8. Invest in intermediate care and reablement

The National Audit of Intermediate Care has found that intermediate care allows 70% of people to return to their own home after a hospital stay, reducing the pressure on care services. Reablement achieves similar results, but only 3% of older people discharged from hospital receive the short-term help they need.

9. Joint leadership working

The sustainability and transformation partnership programme is bringing senior leaders from the NHS and social care closer together. There have even been some joint appointments to oversee integrated teams. Lower down, managers are developing closer relationships with their counterparts in different sectors in more informal ways, but more shared objectives and goal-setting could help, the CQC said.

10. Thinking differently about staff

Mobilising a workforce to work together in providing seamless joined-up care is a significant challenge when they work for different employers. Creating secondment opportunities and accreditation-style ‘passports’ to allow staff to move freely between the NHS and social care settings will help develop skills and enable better care and support to be provided to older people.

RCN professional lead for older people Dawne Garrett says what is noticeable is the important role nurses play in delivering many of the interventions.

She believes ‘good leadership’ will be important in making sure the measures are implemented across the country.

‘In times of financial hardship, we tend to be less sharing,’ she says. ‘We need to think much more about the outcomes for the individual rather than service-based targets.’

NHS Confederation chief executive Niall Dickson agrees: ‘This is a wake-up call; it shows the era of organisations just doing their own thing must end now.

‘The good news is that local leaders have begun to take this on board and more services are coming together to provide joined-up care. But everyone knows we need to go further and faster.’

The human cost of the problem

The Care Quality Commission looked at individual cases to see how patients were faring. In one example, an older women was living at home independently with the support of her son and help from a domiciliary care agency.

One Friday evening the woman 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 couldn’t go home. She stayed in hospital for more than a month, her condition deteriorated and eventually she was moved into a residential care home. She never saw her home again.


Transparency and trust

The social care sector has been vocal in calling for more money to be provided in the forthcoming green paper.

1 in 4

care providers in England said quality of discharge information was ‘rarely’ or ‘never’ sufficient

But leaders in the system believe there is still too much of a barrier between the NHS and social care.

Association of Directors of Adult Social Services president Glen Garrod says ‘greater transparency’ and ‘greater trust among colleagues’ are needed.

‘We need an approach that breaks down barriers to collaboration.’

UK Homecare Association chief executive Bridget Warr says this must include the independent and voluntary sector providers too as they deliver the majority of domiciliary care: ‘It will be more effective when we are recognised as equal partners.’

Meanwhile, Care England nursing adviser Deborah Sturdy says the lack of a joint approach to training staff and the variation in terms and conditions are major issues.

There are significant vacancy rates among social care nursing posts with strong evidence suggesting many move to NHS posts when they become available.

‘We have a 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.’

Read the Care Quality Commission report here

This article is for subscribers only