The Care Quality Commission (CQC), has published a report bringing together key findings and recommendations for change, following the completion of 20 local authority area reviews exploring how older people move between health and adult social care services in England.
Many older people have complex needs, and meeting these needs usually requires more than one professional and more than one agency to work together. CQC’s local system reviews provide a detailed insight into the journey through health and social care for people who use services, their families and carers – and identify where there are gaps which mean that people experience fragmented or poor care.
‘Beyond Barriers’ highlights some examples of health and care organisations working well together – and of individuals working across organisations to provide high quality care. But the reviews also found too much ineffective co-ordination of health and care services, leading to fragmented care. This was reinforced by funding, commissioning, performance management and regulation that encouraged organisations to focus on individual performance rather than on positive outcomes for people.
The lack of a shared plan or vision resulted in people not receiving the right care in the right place at the right time – with consequences ranging from care being provided at greater expense than necessary, to increased pressure on services, to people’s quality of life being significantly diminished.
In one example, an older lady was living at home independently with the support of her son and services from a domiciliary care agency. One Friday evening she fell, bumped her head and was taken to hospital. After a night in hospital she was ready to go home – but because the right staff were unavailable over the weekend she could not be discharged. On the Monday morning she was ready be discharged, but because her home care support was no longer available, she couldn’t 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.
As the NHS approaches its 70th birthday, genuinely person-centred coordinated health and care cannot just be a long-term ambition – it is an urgent and immediate requirement for meeting the changing health and care needs of people living longer with increased complex conditions. The NHS and social care are two halves of a whole, providing support for the same people and there must be a shared vision and performance measures at a local and national level that recognise this.
The report sets out a number of recommendations designed to encourage improvement in the way agencies and professionals work to support older people to stay well, including:
The development of:
an agreed joint plan created by local leaders for how the needs of older people are to be supported in their own homes, helped in an emergency and then enabled to return home; supported by:
long term funding reform – involving national care leaders as equal partners – in order to remove the barriers that prevent social care and NHS commissioners from pooling their resources and using their budgets flexibly to best meet the needs of their local populations; underpinned by:
a move from short-term to long-term investment in services, and from an activity-based funding model towards population-based budgets which encourage collaboration between local systems.
A single joint framework for measuring the performance of how agencies collectively deliver improved outcomes for older people. This would operate alongside oversight of individual provider organisations and reflect the contributions of all health and care organisations – including primary, community, social care and independent care providers – rather than relying primarily on information collected by acute hospitals.
The development of joint workforce plans, with more flexible and collaborative approaches to staff skills and career paths. National health and social care leaders should make it easier for individuals to move between health and care settings – providing career paths that enable people to work and gain skills in a variety of different settings so that services can remain responsive to local population needs
New legislation to allow CQC to regulate systems and hold them to account for how people and organisations work together to support people to stay well and to improve the quality of care people experience across all the services they use.
Sir David Behan, Chief Executive of CQC, said:
“Our findings show the urgent necessity for real change. A system designed in 1948 can no longer effectively meet the complex needs of increasing numbers of older people in 2018. People’s conditions have evolved – and that means the way the system works together has got to change too.
“We have seen the positive outcomes that can be achieved when those working in local health and care organisations have a clear, agreed and shared vision together with strong leadership and collaborative relationships, and we met some outstanding professionals, working across organisational boundaries to provide high quality care. However, their efforts were often despite the conditions in place to facilitate joint working, rather than because of them. We need incentives that drive local leaders to work together, rather than push them apart.
“These twenty local system reviews highlight both the barriers that prevent collaboration – and the real impact that this lack of collaboration has on older people. Today we are calling for those barriers to be broken down. We are making specific recommendations to local and national leaders and government on new approaches to funding, commissioning, performance measurement and regulation, designed to encourage local systems to work together more effectively to deliver personalised care to the people who rely on their services, and to safeguard quality of care into the future.”
Care Minister Caroline Dinenage said:
“This report confirms what we already know – the provision of NHS services and social care are two sides of the same coin and it is not possible to have a plan for the NHS without having a plan for social care.
“There are good examples of progress in integrating health and care, including through the Better Care Fund and ongoing joint health and social care assessments pilots, but we know we need to do more. That’s why we will publish a green paper in the autumn on social care around the same time as the Government’s long term plan for the NHS.”