Last reviewed 20 January 2016
Jef Smith explores the problem of delayed transfers of care, as highlighted in a recent report authored by former Health Minister and Liberal Democart MP Paul Burstow.
When care is being provided to a service user across multiple providers, even should the standard of care be excellent from each individual provider, the experiences of service users can be needlessly uncomfortable, distress or even damaging if the different services involved do not join up smoothly.
It may seem like a perfectly natural thing to call for a “seamless” service, however, to extend the metaphor somewhat, it is worth considering that a garment without seams would probably be ill-fitting; what is required is careful attention to the stitching around the joins.
The same is true of care services. We cannot expect the transition from primary to secondary care, the communication between a GP and a pharmacist, or the discharge from a hospital to a residential care home, to take place without some disruption. Each of these processes is complex, and can involve the passing of records, changes of personnel, physical moves, or any number of other complicating factors. Yet, we have a right to demand and expect that the intermediary machinery works as smoothly as possible.
Paul Burstow, former minister of state for care services, currently leads the Right Place, Right Time Commission, the final report of which was published in November. The report’s brief was to study the long-standing but still critical issue of problems experienced by service users in the course of being transferred between care settings. Some of these shifts take place inside the complex structure of the NHS — between acute hospitals, between wards and units inside hospitals, between different areas of community support, and within mental health services — but the most notorious gaps are exposed when there is a need for a transfer from health to residential care or vice versa.
In launching the report, Mr Burstow remarked that delayed transfers of care (DToC) “can do real harm, especially to older people... Delays can be the difference between recovering independence or losing it”. He cited the diminution in muscle power which can result from as short a period as just 12 hours unnecessarily spent in hospital, and which can be critical to a person’s ability to stand unaided. Postural unsteadiness leads at least to needing to look for someone else’s help, but may also form the first step towards a fall which may lead to even more painful problems.
Such complications can quickly lead to a readmission to hospital, the costs alone of which provide a major incentive to improve performance. Preventable admissions are the other side of the coin to delayed discharges and both, to look only at the financial argument, are unwelcome to a cash-strapped NHS. The case is, of course, not only economic. Almost no one wants to be in hospital; despite best efforts, hospitals are generally unhealthy environments, especially for vulnerable older people, and the lack of good food, pleasant sitting spaces, and access to home comforts often makes them places most of us would like to get out of quickly, or preferably not go into in the first place.
The commission’s analysis of the reasons for such delays starts with rising demand, particularly from frail, elderly people with complex needs. There may, it acknowledges, be issues arising “within the hospital itself, such as managing the supply of medicines”, but the main reasons, it finds, lie in the social care system’s failure to respond adequately. Key elements include “delays in sourcing a care package”, “availability of staff to assess social care packages”, “workforce recruitment and retention challenges at all levels”, “care homes fishing in the same limited pool for staff” and “few pay incentives due to stretched social care budgets”.
The staffing of care homes certainly continues to be a cause for concern. The ambition for all front-line workers to be qualified, albeit only to a level the NHS would consider absolutely basic, has long been dropped. In many homes the best feasible outcome is that care assistants will be keen and friendly, will have had something more than basic induction by way of training, and will have an adequate command of English.
Department of Health policy on the care workforce, though never stated quite so explicitly, has been to not worry about the low pay and status of the work and its accompanying high turnover, as the resulting staffing gap has been largely filled with immigrant workers, generally nurses from East Asia and care workers from the EU. Recently, however, it has become apparent that actual and threatened curbs on the free movement of labour are undermining this dangerous strategy.
Of all the causative factors of DToC, however, it is the “stretched social care budgets” which have most clearly contributed to the statistics on delayed days, a rise, the commission notes with alarm, from 137,600 in August 2014 to 145,100 in the corresponding month in 2015. It will be difficult to reverse that trend without radically tackling the shortfall in resources suffered under the current austerity policy by the adult social services departments which are the major commissioners of residential care.
The modest measures announced in the Chancellor of the Exchequer’s Autumn Statement to permit local authorities to raise council tax do not adequately address this deficit. The Association of Directors of Adult Social Services (ADASS) immediately pointed out that the new power will discriminate heavily against councils with the greatest deprivation, and the lowest tax base will not take effect until 2017, thus failing to address the urgent current crisis and the introduction next year of the National Living Wage (NLW). This will make it even harder to implement the recently legislated national needs eligibility criteria — in short, the measure is too little, too late, and too local.
As if to underline the point, Four Seasons, the UK’s largest care provider, announced the pending closure of seven loss-making homes in Northern Ireland the day before the Spending Review was presented to Parliament.
Accessing other services
There are, of course, other gaps in the relationship of health and social care which affect the welfare of people moving from one system to the other. Residential care managers know to their cost the difficulties encountered by some homes in securing GP services for their residents without paying extra charges. Homes without in-house nurses cannot always access community nursing services to meet the needs of residents with chronic conditions. Ancillary health services such as physiotherapy are not always readily available, despite their proven value in preventing deterioration in the mobility and general welfare of older people with physical disabilities.
Further cuts to public health, which having been transferred to local government lies outside the budgetary protection afforded to the mainstream NHS, will further inhibit the development of community-based prevention.
Poor record keeping
The Burstow Commission draws attention to one other area of interagency disjunction, the imperfect sharing of care records. Homes’ residents have testified to the number of times that they have to repeat their personal data, to the lack of attention given by admitting hospitals to the information on care needs — information which residential care workers are particularly well-placed to supply. Critical details on post-hospital care and treatment are also often not passed on to care staff on a patient’s discharge.
A call to action
Among the “calls to action” with which the commission summarises its conclusions, there is a plea to councils, clinical commissioning groups and health and wellbeing boards to “involve the local independent, voluntary and community sectors in local planning and accountability arrangements”.
This is of course an admirably sensible injunction, since on the social care side of the divide these are the major providers, but how seriously did the commission take its own advice? Its nine members included no one prominent in the residential care field. Neither, in the list of those thanked for “contributing to our work by facilitating meetings, telephone interviews, or site visits, or by written submissions”, did I find Care England, the National Care Forum or any other body credibly able to speak for independent sector providers or their service users.
The Right Time Right Place Commission was established by NHS Providers, the association which formally represents the health trusts who manage the bulk of health services. The delivery of social care is quite a different matter, depending on thousands of organisations, large and small, commercial and not-for profit, some highly professional and others, frankly quite amateur. In short, they form a very different and much more diverse community than NHS providers, but when it comes to formulating policy and changing practice it is vital that their voices are also heard. As this report again demonstrates, there is a gap here which still yawns wide.