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Will the crisis in A&E increase pace in integrated health and social care?

This last week has seen some historic announcements that should have a lasting impact on the future of health and social care. Last Friday saw the publication of the draft Care and Support Bill after its public consultation and pre legislative scrutiny by the Joint Committee, led by Paul Burstow MP. The draft Bill has been amended and much improved. But there is still a way to go and many more amendments are expected as the Bill passes through report and committee stages in parliament.

Tuesday of this week saw the announcement by minister Norman Lamb MP, of plans to quicken the pace of joined up and integrated health and social care. This new initiative has been backed by health and social care leaders through a "shared commitment" to deliver integration, whose signatories include the Association of Directors of Adult Social Services, Local Government Association, Monitor and NHS England, as well as the Department of Health. Sign up by these bodies is critical to the success of these ambitious plans.

The goal is to deliver an improvement in service users' experience of care and getting much better value for money from health and social care. Barrier to integration will be removed. Far too many older people experience failures in integrated care and don’t receive the right support at the right time that could improve outcomes and save money. A number of local pioneers will be established. By the end of the year new indicators of progress on co-ordinating care and support, based on service user's experiences will be set up to gauge progress on integration. National Voices will set out what good integrated care looks like for service users.

But this will all be locally led with no central blue print. The concept of integrated health and social care is not new and there are good examples out there already. Will this plan with its new pioneers make a difference to the levels and pace of change? This week there is continuing hand wringing over the delays at over stretched A&E departments around the country. We know that emergency readmissions of those aged 75 and over, within 28 days of discharge have risen from over 187k to over 201k in the past year alone. At the last count, delays in discharging older people from hospital beds accounted for some 76% of all adult delays. Proper integration of health and social care isn’t a luxury or a nice to have but essential if the A&E services and hospitals can focus on the service for which they were set up to do. It is possible that the crisis around A&E will be as much a driver to integrate health and social care as the new Government announced plan.

The report Integrated Care and Support: Our Shared Commitment acknowledges that all sectors working together can provide older people with support to remain in their own home and that they don’t end up being discharged from a service into a void. At present to much of the systems financial resource is spent in the acute sector that would be better spent in the community. The authorities need to work in cooperation with all organisations including those in the charitable sector, like WRVS, who can provide the support and the resources to make the aim of integrated health and social care a reality.

New ONS data paints stark picture of ageing in UK - WRVS volunteers can help

The new ONS statistics on loneliness in older people, published today, paint a stark picture of growing old in Britain today, with almost half of those over the age of 80 feeling lonely. These feelings of loneliness are exacerbated by poor health and living alone, both of which we know increase as the nation ages. Those that feel lonely do fewer day to day activities creating a vicious circle of isolation with older people feeling trapped in their own homes. WRVS comes into contact with older people day in day out whose main company is the TV, and without our volunteers may not see another person from day to day. It doesn't have to be like this. Simple and cost effective solutions, such as befriending, can help tackle loneliness, help older people to stay connected to their communities and prevent unnecessary hospital stays.

The ONS have also today release a report on older people's wellbeing, leisure time and volunteering. With WRVS’ army of 40,000 volunteers, we know well the benefit of volunteering, as do the older people that our volunteers provide a lifeline for. The new ONS data shows that one in five of the over 50s volunteer and links volunteering with higher satisfaction in life. We know through our own research that older volunteers live happier and healthier lives and we see this every day, as over half of our volunteers are in this age group with some still volunteering into their 90s and over the age of 100. However, with an ageing population, this country needs more people to step up and volunteer to make life better for others. So we would encourage anyone thinking of volunteering to take the plunge and get involved!

Historic chances to health and social care begin this week

The delivery of health and social care has undergone major change to its core structures. Many of the changes have already taken place, but most took effect on 1 April 2013. These changes will have an impact on who makes decisions about NHS services, how these services are commissioned, and the way money is spent.

Primary care trusts and strategic health authorities have been abolished, and other new organisations such as clinical commissioning groups (CCGs) have taken their place. As of this week a total of 211 CCGs are responsible for £65 billion of the £95 billion NHS commissioning budget. All 8,000-plus GP practices in England are members of a CCG, putting the majority of the NHS budget in the control of frontline clinicians for the first time. The groups will include other health professionals, such as nurses.

CCGs will commission most services, including, planned hospital care, rehabilitative care, urgent and emergency care, most community health services and mental health and learning disability services. CCGs can commission any service provider that meets NHS standards and costs. These can be NHS hospitals, social enterprises, charities, or private sector providers.

To add to the mix are health and wellbeing boards; a new forum where leaders from the health and care system work together to improve the health and wellbeing of their local population and reduce health inequalities. Each top tier and unitary authority has its own health and wellbeing board. Board members will work together to understand their local community’s needs, agree priorities and encourage commissioners to work in an integrated way. The intention is that as a result, patients and the public should experience more joined-up services from the NHS and local councils in the future. Local boards are free to expand their membership to include a wide range of perspectives and expertise, such as representatives from the charity or voluntary sectors.

In addition each local authority will have a local Healthwatch organisation in their area. The aim of local Healthwatch will be to give citizens and communities a stronger voice to influence and challenge how health and social care services are provided within their locality. Local Healthwatch will also provide or signpost people to information to help them make choices about health and care services.

Add to this other bodies such as the NHS Commissioning Board, Public Health England and Healthwatch England to name but a few, and it becomes a complex maze to work oneself through. The intention is the make health and social care more integrated and responsive to the needs of the local community. Support for older people such as that provided by organisations like WRVS has never been more necessary given the constraints on central and local Government spending. It is in everyone’s interest to work towards making sure this new system delivers. Time will tell whether the changes bring about the transformation that is urgently required.

Going nowhere fast?

We all know how frustrating it is to be left marooned when the car is off the road for repairs, or the buses are unreliable in bad weather – but for over 18,000 older people in Wales, this isolation through lack of decent transport is a daily reality. New WRVS research released today has found that 17% of older people in Wales have been hit by a reduction in public transport services, with many being left trapped at home through poor access to public or community transport.

Whilst the narrative of cuts in transport services is not new, it is about to get a whole lot more severe. The recent Welsh Government announcement of the merging of different funding streams for transport services has signalled a massive 26% reduction in subsidies for local transport services – and across Wales, the impact is already being felt as vital local services are withdrawn or cut to the bone.

Frustratingly, this is happening at exactly the time when those services are needed the most. Figures indicate that 66% of Welsh single pensioners do not have a car, and it has also been shown that 40% of households without a car feel that local bus services fail to meet their travelling needs to the local town or shops, and 65% believe services are inadequate for travel to their local hospital. Further cutbacks will make a bad situation worse, especially for older people – reliable local transport networks become increasingly significant as people get older, with journeys for essential items and social activities sometimes becoming more of a challenge.

At the heart of this is the extent to which transport planning takes account of the voices of older people. Today’s WRVS research indicates that older people feel dis-empowered and disenfranchised; 23% of respondents did not feel able to make comments or complaints about local transport services, and this clearly has an impact when services fail to meet their needs. It should shame us as a nation that nearly 20% of older people are unable manage the walk to/from their nearest public transport, and that many of that same group feel unable to do anything to challenge the system.

This is not, however, simply another request for more money. What today’s research underlines is that we can spend existing resources more shrewdly on services which protect the most vulnerable. Community transport (such as Bwcabus or WRVS services) is a great example, with schemes being viewed much more positively than regular public transport, and rural areas in particular benefiting from such services. Community transport is also rated extremely highly by users in terms of its social impact and for its social return on investment.

We need to help promote community transport, and ensure that funding is there for schemes to become sustainable in the longer-term. We should start by increasing the proportion of transport funding which has to be spent on community transport – realigning spending priorities to ensure that we keep vulnerable older people connected and independent. We also need to ensure that older people have an outlet to express formally their concerns about transport, so that their voice is not marginalised or ignored. Without these sorts of fundamental changes, we may find ourselves waiting for a bus that simply never comes.

Ready for Ageing?

A year ago the House of Lords decided that the social changes that were being experienced with many more people living longer needed investigating as they couldn’t find evidence that it had been looked at comprehensively by Government before. Today the Lords Select Committee on Public Service and Demographic Change published its highly anticipated report. The key message is that are as a nation we are “woefully underprepared for ageing”.

Many of us will be living 10 years longer than we were expected to when we were born. Whilst there is a very real issue now, we don't have to look that far forward to the change accelerates. For example, by 2030 the number of people aged over 85 will have doubled.

The key message from
the report is that are
as a nation we are
“woefully underprepared
for ageing”

The Committee is concerned about how older people will support themselves and has highlighted three key areas that need addressing. The first is around pensions and encouraging saving, the second around working past traditional retirement age and lastly around unlocking assets within their own homes.

On health and social care the Committee believes that the system is not designed to deal with long term chronic conditions, but more acute conditions and therefore it will need radical change. It argues that there needs to be a shift in focus and vision in England to improve integration and prevention, with an aim of keeping older people safe in their own homes rather than in hospitals. It suggests looking at merging health and social care budgets and providing care 24hours a day, 7 days a week for 365 days of the year. The Committee recognises the valuable contribution that voluntary organisations such as WRVS already make, but recommends that central and local government work with the third sector to increase volunteering especially by older people to support older people.

Ageing is a huge social change that will impact on everyone. Government therefore needs to have a firm understanding of what this means in terms of the UK’s population, society and public policies and develop a coherent strategy going forward. The Committee is critical of the current and previous Governments over many years that have failed the grasp the enormity and urgency of the situation. The Committee calls for the issuing of a White Paper before the next general election setting out the issues and how we should prepare for longer life. All parties should consider an ageing society in their manifestos for the next election.

The Committee also recommends that whoever is successful after the election should establish two cross party commissions to respond to the ageing society; one would look at finance and the other health and social care.

This report offers a unique opportunity to tackle some difficult issues and to bring about real change. Let us hope that this opportunity is grasped by all parties as we head towards the next election. Read the full Ready for Ageing report.

Social care funding: key decisions still to be made

Yesterday’s confirmation by the Health Secretary revealed that the cap on social care will be set at £75,000 in England. This headline has received a cautious welcome from most quarters. However, the cap cannot be looked at in isolation and at the moment it is still difficult to see how many older people and those entering old age in the coming years will be affected as there are still a number of unknown factors. In addition, boarding and food costs are not included in the cap. The objective is to try and ensure that people living in their own home are not penalised unfairly as they are still responsible for paying their housing costs. These so called “hotel” costs will be capped at £12,000 a year.

The cap won’t take effect until April 2017 and the Government has stated that £75,000 in 2017 is in effect worth the equivalent of £61,000 in today’s prices. The current threshold over which support is not provided is rising from £23,250 to £123,000, a rise of nearly £100,000. This means that more people will be entitled to receive some support for their care albeit on a sliding scale.

The big element missing in all of this is at what level the national “eligibility criteria” will be established. At the moment councils are free to set the criteria at low, moderate, substantial or critical. This perpetuates something of a postcode lottery. As funding has become tighter, an increasing number of local authorities have set their criteria at substantial. At the last count well cover 82% of England’s local authorities were at a substantial level or higher. The level at which this is set will be important calculating how many people will be supported. The higher the eligibility criteria bar is set means that those with lower needs which may prevent or delay more intensive and expensive interventions may miss out.

But the response to Dilnot is not the full answer. Implementation of these changes and those proposed in the Care and Support Bill won’t take effect for over 5 year’s and there is already a shortfall in the funding of adult social care that will increase during this time as local authorities make further savings.

All of this goes to demonstrate that volunteers working within organisations such as WRVS are key in delivering the practical support that older people want, but without the huge bills attached, not just for now, but for the long term.

WRVS response to the announcement on social care costs

Paying for care in old age is a significant worry for many people. However, for a large number of people going into a care home is the last resort and most older people would rather live independently in their own homes for as long as possible. Supporting them to do this doesn’t have to have a large bill attached. Practical support provided by volunteers at crucial times, such as settling people back into their homes after a major operation, will be central to us managing demand for health services in lean times. WRVS volunteers bridge that gap through a whole range of practical services, such as supporting older people to continue do food shopping; making sure their houses are warm and cupboards well stocked when they are discharged from hospital or just a friendly face popping in to see them regularly. This support is relatively inexpensive but the rewards are considerable.

Social Services & Wellbeing (Wales) Bill

After months of waiting and delays, the Welsh Government last month unveiled its revised Social Services & Wellbeing (Wales) Bill – which will probably be the most wide-ranging piece of legislation which the Assembly will pass in the current administration.

As one of the biggest organisations delivering volunteer-led services for older people in Wales, WRVS wholeheartedly welcomes the principles and ambition of the Bill. The renewed focus on wellbeing is particularly welcome; the new Bill incorporates “domestic, family and personal relationships” into its definition of wellbeing, and this chimes with our own research that social interactions are seen by older people as the most decisive factor in defining their sense of wellbeing.

But improving wellbeing cannot just be a cosmetic change. It has to be underpinned by a social services system which helps give people a quality of life – there is no sense in having a generation of older people with working hip replacements, walk-in baths but nothing to live for. Our own research has found a tendency for public bodies in Wales to concentrate on services that focus on improving physical wellbeing, to the detriment of those which address emotional and social wellbeing.

So we also strongly welcome the duty on local authorities to provide preventative services and to promote the availability of voluntary sector preventative services. Preventative services boost older people’s independence and also save public money in the long-term. We strongly believe that a greater focus on prevention, if properly executed, can be a win-win scenario for Wales.

Yet the Welsh Government’s ambition comes at a time when local authorities are making it harder and harder for people to access low-level services. As the Welsh Local Government Association has noted: “Due to the intense financial pressures that councils are now facing, most local authorities have raised the eligibility threshold to ‘substantial’ and ‘critical’... The risk is that moderate need may escalate to substantial without appropriate or adequate community support.”

Because of this, plans within the Bill to standardise eligibility criteria could be a double-edged sword. They will only improve social services for people on the receiving end of they go hand-in-hand with a commitment that local authorities cannot use the change in order to raise eligibility ceilings and remove the very services which help older people to stay independent.

The Bill also needs to ensure that older people with low-level needs can get “that little bit of help” easily, without needing to go through a formal assessment or getting embroiled in the official social services system. Information, signposting and assistance should be independent and accessible to all – but even more importantly, it needs to be provided for free, even if the services to which it directs people come at a cost. Otherwise, older people are discouraged from even looking for help, which ultimately costs them their independence and costs the state more money.

The Social Services & Wellbeing (Wales) Bill has been a long time in the drafting – and that looks to have been time well-spent, given the scope and ambition of the Welsh Government’s plans. We welcome the progress so far, but with the note of caution that the Bill can only make Wales a great place to grow old if it is made more explicit about how it will help people to remain independent, active and socially connected during their older age.

Are we prepared to reduce emergency readmissions rates for older people?

The focus of the older people debate centred this week was on the Government’s plans to radically reform pension provision and provide a flat rate pension of £144 a week by 2017. This announcement by the Pensions Minister Steve Webb MP completely overshadowed figures published on the same day by the Department of Health showing that over a ten year period emergency readmissions for the total population had increased from 370,940 in 2000/1 to 648,147 in 2010/11. When taking a closer look at the 75 and over age group, the figures are even more worrying. The raw data shows that in 2000/01 the numbers of emergency readmissions for the older age group were just under 100,000, but by 2010/11 had doubled to just over 200,000 a year. This equates to a rise in emergency readmissions for the older people from 11.04% to 15.69%. One can ponder why this is the case, an increase in the numbers of older people, changes in counting methodology, definitions and various other possible changes in circumstances, but nevertheless the rise is still significant.

There is a crucial role for the emerging Clinical Commissioning Groups to play in ensuring that the support and the services that keep people safe at home are made available. Over recent years money has been transferred from the mainstream NHS to local authorities for the purposes of reablement and post discharge support in addition to more general social care.

There is a growing consensus that low level social care that provides vital practical support is preferable to them returning to hospital shortly after discharge when it is not necessary. During Health oral questions on Tuesday, Stephen Dorrell MP, Chair of the Health Select Committee, quizzed the Minister saying that one of the most effective things to do to improve the patient experience of health and care is to improve the co-ordination, not just between the hospital service and community-based health services, but between the NHS and social care.

However, WRVS research into the relationships that are being formed at a local level are not as advanced as one would like to see at this stage. Of the 98 PCTs that responded to a WRVS FOI enquiry into relationships with the local authority, 20 had pooled budgets, and 3 had informal regular meetings. Just a single PCT had established a joint working group with representatives from local authorities specifically for commissioning services related to admissions/discharges.

On Monday the Guardian published data from its survey in which professionals working in local government said they did not have the knowledge and expertise to commission services. The vast majority (77%) said they needed more training to do the job of commissioning well, while 14% said they were already being expected to perform jobs without the necessary skills. Just 8% said they felt fully equipped to take on the job of commissioning. Almost half of those surveyed admitted they had not heard of the Social Value Act, which requires public bodies including councils to consider the social value of a contract when procuring services and goods.

Penalties on readmission rates were introduced to improve clinical practice and it is estimated that the cost to the NHS of patients being readmitted to hospital within a month following discharge is £2.2bn. It is clear that the increase in unnecessary emergency readmissions of older people is unsustainable and takes up valuable resource which could be more effectively used elsewhere in the healthcare system. It is still early days, and it may take some further steps and time but there are cost effective solutions that exist for example, Home from Hospital services, that can deliver better outcomes on the ground. It is time that more use is made of these types of service.

So where's the strategy for the long term?

Understanding and getting to grips with the opportunities and challenges of an increasing ageing population is one of the key conundrums that the Government and wider society has to currently face.

The pre Christmas House of Lords debate on the place of older people in society highlighted the net financial contribution that older people make to the UK economy, citing the WRVS figure of £40billion benefit in 2010. But it’s not just about finances. Earlier this week in a response to a tabled question, Baroness Warsi said that the Government recognised the importance of the issues facing people in later life and the contribution they make to society, but did not have all the answers. She added that the Age Action Alliance was created in recognition of the need for a radical shift in approach and its vision was informed and driven by older people themselves.

The Lords Committee on Public Service and Demographic Change took oral evidence from Ministers Hunt, Lamb and Webb on Wednesday. In response to questions around what the Cabinet had done collectively to address issues arising from an ageing population, Hunt said that it had taken some good first steps but agreed that there was much more that it could do. He agreed that the ageing population was a nettle that had to be grasped. He saw the 2 biggest issues being the sustainability of the NHS and pension provision. The Committee Chair appeared sceptical; saying that the Committee had not seen much in the way of a coherent long term strategy to look at the scale of the challenges around ageing and that most work undertaken was fiscal and short term in nature.

Early in the week, the Coalition’s mid-term review re-confirmed the Government’s support for the principles set out in the Andrew Dilnot report. But any detail as to how the future costs of adult social care would be met was disappointingly absent. Just a couple of days later to emphasise the urgency, analysis by London Councils estimated that the funding gap for providing adult social care in London will amount to £907m within five years. Councils in London currently spend a third (£2.8 billion) of their total budgets on adult social care and this is set to rise dramatically as the number of Londoners aged over 65 increases by some 50,000 during the next five years.

So in a week when detail was thin on the ground about long term thinking on the future funding of care and for older people more generally, it is clear that there is a major role for the third sector to step up to the plate and take on an enhanced role. But this week there was criticism of the Government from the Chief Executive of AVECO that the potential for charities to transform public services remains largely untapped, with reforms in too many areas either glacially slow, as demonstrated by social care funding reform.

In his response, the Civic Society Minister said that harnessing the spirit of common purpose witnessed in 2012 so that together big social problems could be tackled was a cultural change that won’t happen overnight, especially in challenging economic times. He acknowledged that Britain is blessed to have some of the most generous people and the most innovative charities in the world.

He is right - the spirit is there, in spades. It is estimated that in the UK about 20 million people volunteer in some form. In WRVS alone over 50% of its 40,000 volunteers are over the age of 65. Not only are the volunteers helping older people in a more cost-effective way than through expensive state mechanisms like the NHS, but they are helping themselves to enjoy better mental and physical health outcomes. This is essential as the Government plans its strategies for the future. And WRVS, in celebrating in 2013 its 75th year of civic service, is keen for this message of volunteering to amplify and grow.