Health and social care leaders are grappling with the most difficult challenges in the most difficult times. But their task is not being helped by flawed assumptions about the key issues and over-simplification of the necessary responses. A smarter, better informed and more nuanced approach is required.
As more citizens want and need to use public services, the money must stretch further than ever before. And as the demand for higher quality is not matched by the supply of resources – either people or financial - so the task for senior leaders can sometimes feel impossible.
The media scrutiny, the force of regulation, the local vs national political environment, as well as 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 a major component of that new system. But will it be enough, and will it happen soon enough to make the difference needed to guarantee survival?
The Local Government Association (LGA), in partnership with Newton and the Chartered Institute for Public Finance and Accountancy (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 when faced with the shortfall of funding in both 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 2000 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 cost
- The largest opportunities lie in:
- avoiding admissions to acute hospitals,
- discharging to maximise independence
- utilising the skill mix of community teams.
Successful changes had 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. 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 served as the focus for 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: 40% of adult social care spending funds the 18-65 age group; 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: Whilst it is true that in the face of rising demand and reductions in funding, the number of delayed transfers attributable to social care have risen significantly, social care factors still only account for 35% of delays. The remaining 65% 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 shows that focussing on achieving the best and most independent outcome for the patient or service user is both important to them and saves money. It is consistency of 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: The LGA project found that a smaller than expected proportion of older people were admitted to hospital because of a lack of social care in the community. At times of high admission rates, many A&E departments report than admission was unavoidable due to the medical condition of the older person. This belies the common assumption that many older people attend A&E or are admitted to hospital because of a lack of social care.
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 two weeks after the care package began indicated that a third of 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. New solutions can then be tested, before they are rolled out locally. LAs and 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 would take the place of asking them to reduce the numbers of delayed transfers, when they have no control over the causes of delay 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. Whilst 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 sustained change that is needed.
Reflections on the current agenda
STPs are showing some signs of bringing leaders together. They are providing a forum within which discussions can take 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 and yet reluctant to examine why we do not put in place the change that we know is needed. That 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 demands continual reinforcement that the risks involved are worth taking, to see a more efficient and effective response.
Having a common aim and ambition will be critical to the success 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 targets we set must be based on best practice outcomes and we must identify the data that genuinely measures success. The wrong targets or the wrong measures associated with those targets drive the wrong behaviours and puts the money in the wrong place. By using delayed transfers of care as a key indicator, rather than outcomes achieved for people being discharged from hospital and the timeliness of appropriate solutions, we are in danger of taking the wrong actions.
For example, resorting to 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 (ACO’s) as a possible solution to an integrated approach 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 some 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.
ACO’s being an alignment of organisations bound by a common ambition and set of principles feels the right approach, coming together as equals, not one being absorbed by the other. Previous models of generic patch-based health and social care showed how MDTs in the community can work and provide a strong preventative approach.
In summary, the evidence tells us that there are plenty of opportunities to improve efficiencies and care for patients. Doing so at scale will be a challenge, that will require the right leadership to ensure key decision makers on the front line have access to the right knowledge to empower local teams to provide the right care, driven by the right metrics.
Ric Whalley is associate director at Newton.