By Paul Carey-Kent, Policy Manager, CIPFA
Health and social care leaders are grappling with the most difficult challenges in the most difficult times.
As more citizens want and need to use public services, the money has to stretch further than ever before and as the demand for higher quality is not matched by the supply of resources – both people and financial – so the task for senior leaders can sometimes feel impossible.
The media scrutiny, the force of regulation, the local vs national political environment, and rising public expectations demand a different solution, one that is sustainable and fit for the future.
We believe the better integration of health and social care services has to be the single biggest component of that new system. But will it be enough, and will it be soon enough to make the difference needed to guarantee survival?
The LGA, in partnership with Newton Europe and CIPFA, is facilitating a series of conversations with local leaders across the country to debate and go some way to answer the questions facing us as leaders. Is integration of health and social care the answer to the challenges? Will it be enough, and when will it really happen? Or are both parts of the system reluctant – believing, perhaps, that the real problem is a lack of investment in health and care services?
Feeding into this, and future discussions, are the findings of the LGA report: Efficiency opportunities through health and social care integration. This details work with five English health and social care systems to explore the scope for improving efficiency through the better integration of services.
By focusing on the decisions made through multi-disciplinary reviews of over 2,000 case notes, the following conclusions were drawn by the local teams:
- 45% of pathway decisions could be improved – and in over 90% of those cases the alternative option was already available and almost always at a lower level of care.
- The largest opportunities were in avoiding admissions to acute hospitals, discharging to maximise independence and in utilising the skill mix of community teams.
- Successful changes have been made in pockets across each of the systems studied, with the common factor of these successes being the approach taken to change – the key to embedding lasting behavioural change was how the change was done, rather than the specifics of what was done.
Government concerns around social care currently focus on reducing hospital admissions and delayed discharges. The new money recently announced focused on the burden on the NHS caused by poor patient flow and delayed transfers of care. However, the headline narrative draws on several assumptions which have in fact become well-rehearsed myths and barriers to effective collaboration. Dispelling these myths, and offering potential solutions were the topic of the first working group session, held with health and local government leaders from the South East of England.
Dispelling the myths
“All the pressure on social care budgets is caused by older people.” Forty percent of adult social care spending is on the 18-65 age group, and the financial pressures are also particularly severe in learning disabilities, where demand is increasing. Older people leaving hospital represent a small percentage of the demographic demand in the community, where safeguarding concerns consume the social care resources.
“Delayed transfers are caused by a lack of social care.” Social care reasons remain a minority cause of delay, and while it is true that 20 councils accounted for 50% of the delayed discharges, these are also 20 of the largest councils. Raw numbers that do not take account of population size cannot be used to assess relative performance. Sixty-five percent of delays occur within the health system, particularly in delays for assessments and intermediate care.
“Reducing delayed transfers is the key to improving efficiency.” Person-centred care drives improved efficiency – Newton’s work proves that focusing on achieving the best and most independent outcome for the patient or service user both matters to them and saves money. It is consistent clinical and professional decision making across care pathways which creates an efficient multi-disciplinary system – regardless of whether the organisations are formally integrated. Moreover, inappropriately fast discharge can cost more if people are given too much care or the wrong care rather than return home with the right personalised health and social care package.
“Increased social care support will prevent unnecessary hospital admissions.” A sample analysis (referenced in the LGA report) demonstrated that only 10% of admissions had a social care component which could have prevented admission. This belies the common assumption that many older people attend A&E or are admitted to hospital because of a lack of social care: A&E departments report that admission was unavoidable due to the medical condition of the older person. The use of multi-disciplinary teams in the community is the kind of preventative approach which, just as in acute settings, needs consistent clinical decision making following clear care pathways.
“Integrating structures will transform patient care and create a financially sustainable future.” Maybe, but only if transformational cultural and behavioural change underpins the structural elements of integration: clarity of roles, improved communication, shared strategic ambition, risk sharing and financial transparency. A system co-designed by and for patients based on the best clinical practice drives efficiency and quality more than structural change. Integrating the current inadequately funded and inefficient community health and social care services will not produce an effective and efficient new system.
Offering potential solutions to achieving health and social care collaboration
The right menu of service is often available but the conversations are not taking place to help leaders and practitioners make the right decisions. In one area, sample tracking showed that only 10% of people who went from short-term medical care to long-term residential care should have done so. In another area, it was found that one team judged 70% of discharges suitable for reablement, another team just 10% – and that didn’t change when the populations were reversed. In a third area, undertaking a review after two weeks indicated that a third of care recipients no longer needed the amount of care they were receiving. Tackling such discrepancies in professional practice could be a much quicker win than changing structures or reforming care models.
The best way to achieve buy-in is to agree the vision, empower local leadership and co-design new ways of working with frontline teams and partners. Then you can test new solutions, before rolling them out locally. Local authorities and clinical commissioning groups (CCGs) could, for example, ask care providers, trusts, GPs and the voluntary sector: "How can we commission so that you have the greatest chance of helping us secure the best long term solutions for the population?". This is instead of asking them to reduce the numbers of delayed transfers when they have no control over the causes of delay which happen beyond their own boundaries, either in the hospital or in the community.
To be credible, solutions need to be scalable as part of a wider roll out and implementation. Local solutions and effective local leadership demonstrate that delayed transfers can be managed if key changes are implemented in the way trusts operate, the way care markets are commissioned, the way the workforce is developed and the priority that is given to managing change over a realistic timescale. While we know there is no quick fix we are still seeking to achieve short term improvement to long-term system-wide solutions and in doing so create the resistance to sustained change that is needed.
Reflections on the current agenda
Sustainability and transformation partnerships (STPs), putting aside how they were introduced, are showing some signs of bringing leaders together. They are acting as a framework within which discussions are taking place about how to create a sustainable future for health and social care in a different way, with a greater understanding of the respective challenges, generating a more collaborative approach.
But in the past we have been good at having strategic conversations, good at discussing new solutions to perennial problems but we have been reluctant to truly examine why we do not effect the change that we know is needed. It requires a new balance of power by putting the patient at the centre, it requires an understanding that sustainable change takes time and it will take investment in a workforce that understands the need for change. It also needs continual reinforcement that the risks involved are worth taking to see a more efficient and effective response.
Having a common aim and ambition is a key plank of STPs – professionals, politicians and the public can all align behind a strategy which delivers the best possible care for patients. But how do we know what that is and how do we measure it? Best practice tells us what we need to do, but without continual reinforcement of the need for consistent decision making based on the data available, and a culture of collective accountability to achieve the best outcome, we will continue to run inefficient and poor services. Any data we collect must be based on best practice outcomes - the wrong measures drive the wrong behaviours and puts the money in the wrong place.
There is an over-provision of social care. Too many residential care placements, and too many high cost care packages designed to get people out of hospital quickly but often substituting for a lack of community health resource and primary care support. We are investing in solving a problem we have created by measuring the wrong indicator – an indicator measuring process not outcomes.
The emergence of accountable care organisations (ACOs) as a possible solution to an integrated approach that brings opportunities in creating one workforce, engaging primary care, having a single budget and presenting a united front door to patients and the public. Certainly, it might be easier to create the united ambition amongst the staff in one organisation, but we have the experience of integrated mental health trusts now decoupling to teach us that unless attention is paid to the different professional cultures and the changing needs of patients, then the structure will not survive.