How Older People Move Between Health And Social Care In .
Beyond barriersHow older people movebetween health and socialcare in EnglandJULY 2018
About the Care Quality CommissionOur purposeThe Care Quality Commission is the independent regulator of health and adult socialcare in England. We make sure that health and social care services provide people withsafe, effective, compassionate, high-quality care and we encourage care services toimprove.Our roleWe register health and adult social care providers.We monitor and inspect services to see whether they are safe, effective, caring,responsive and well-led, and we publish what we find, including quality ratings.We use our legal powers to take action where we identify poor care.We speak independently, publishing regional and national views of the major qualityissues in health and social care, and encouraging improvement by highlighting goodpractice.Our valuesExcellence – being a high-performing organisationCaring – treating everyone with dignity and respectIntegrity – doing the right thingTeamwork – learning from each other to be the best we canbBEYOND BARRIERS
BREAKING BARRIERSContentsFOREWORD.2SUMMARY .4INTRODUCTION.81. OLDER PEOPLE’S EXPERIENCES OF MOVING BETWEEN HEALTH AND CARE SERVICES.122. HIGH-QUALITY CARE PATHWAYS: BARRIERS AND ENABLERS TO PROVIDING SAFE, TIMELYAND HIGH-QUALITY CARE.153. INCENTIVISING SYSTEM WORKING.404. BUILDING A SUSTAINABLE SYSTEM.48CONCLUSION AND RECOMMENDATIONS.57GLOSSARY.60APPENDIX: MEMBERSHIP OF OUR EXPERT ADVISORY GROUP.65REFERENCES.66HOW OLDER PEOPLE MOVE BETWEEN HEALTH AND SOCIAL CARE IN ENGLAND1
FOREWORDForewordIn the 70 years since the National Assistance Act and the newNational Health Service established the modern welfare state, ourhealth and care needs have changed and grown.We are living longer into older age. Women borntoday can expect to live 11 years longer thanthose born in 1948. As healthy life expectancyhas not kept pace with life expectancy, morepeople are living longer with complex healthproblems. Increasingly, our care must bedelivered by more than one person, and morethan one organisation.Alongside these demographic changes therehave also been changes in our understanding ofwhat high-quality care looks like. In 2018, weexpect people to experience personalised carethat is tailored to their individual circumstancesand joined-up to meet their needs. And weunderstand that people should be active partnersin decisions about their care.For people working in health and social care, thetask has rarely been more challenging, complexand uncertain. Trust and collaboration betweenhealth and social care organisations have neverbeen more important.This means that a system designed in 1948can no longer effectively meet the needs ofincreasing numbers of older people with complexhealth and care needs.In our review of care for older people in 20local systems in England, we found thatpeople experience the best care when peopleand organisations work together to overcomethe fragmentation of the health and socialcare system and coordinate personalised carearound individuals. This is already happeningin some places, but if we are to turn theseexamples of good practice into standard practiceeverywhere, then we must remove the barriers2BEYOND BARRIERSto collaboration at a local and national level andincentivise joined-up working.If we are to make integrated care a reality,we need to change the way we measureperformance, approach funding, plan theworkforce, and regulate services.The NHS and social care are two halves of awhole, very often providing support for the samepeople. We must create an environment thatdrives people and organisations across health andsocial care to work together, rather than drivingthem apart.We need to move away from efforts to measurethe performance of individual organisationsworking separately. Local and national leadersneed a single, shared approach to measuringhow well their whole system meets the needs ofpeople using health and social care services.We also need sustainable funding reform,supported by long-term investment and greaterflexibility that allows local systems to make thebest use of their resources to meet the needsof local populations. We need an approach thatsupports collaboration, rather than imposeslimits on how far local government and NHScommissioners can align or pool their budgets.Joined-up care also requires a workforceequipped to move between health and socialcare. Workforce planning needs to create theskills and career paths that allow people to workflexibly across the system as services evolve overtime to meet the population’s changing needs.
FOREWORDAnd efforts to join-up a fragmented healthand social care system must be recognised andreinforced by an improved regulatory frameworkthat looks at the whole system, as well as theindividual organisations within it. For CQC,this means we want the power to look at thequality of care across a system, as well as in theindividual organisations that provide health andsocial care services.These are difficult problems to solve. There havebeen attempts to integrate health and social caresince the 1970s. None has yet fully succeeded inovercoming fragmentation and achieving joinedup, personalised care for individuals. But it isclearer now than ever before what needs to bedone to address this great unresolved challenge.The question that remains is whether leadersworking locally and nationally have the braveryand conviction to lead the charge.Sir David Behan CBEChief ExecutiveHOW OLDER PEOPLE MOVE BETWEEN HEALTH AND SOCIAL CARE IN ENGLAND3
SUMMARYSummaryMost older people in England, particularly those with complexneeds, will receive care at some time. Their experience of care willoften depend on how well different services work together for them,their families and carers.CQC has reviewed 20 local health and caresystems, to understand how services are workingtogether to meet the needs of people who movebetween health and care services. Our focus waspeople aged over 65. In some areas, differentparts of the system are working well together. Inother areas, the system was less joined-up andnot working as well for people.zzIn the systems we reviewed, we found individualorganisations working to meet the needs oftheir local populations. But we did not find thatany had yet matured into joined-up, integratedsystems.zzHealth and care services can achieve betteroutcomes for people when they work together.Joint working is not always easy. The healthand social care system is fragmented andorganisations are not always encouraged orsupported to collaborate.An effective system which supports older peopleto move between health and care servicesdepends on having the right culture, capabilityand capacity. We have looked for effectivesystem-working and found examples of theingredients that are needed. These include:zz a common vision and purpose, sharedbetween leaders in a system, to work togetherto meet the needs of people who use services,their families and carerszz effective and robust leadership, underpinnedby clear governance arrangements andclear accountability for how organisationscontribute to the overall performance of thewhole system4BEYOND BARRIERSzzzzzzstrong relationships, at all levels, characterisedby aligned vision and values, opencommunication, trust and common purposejoint funding and commissioningthe right staff with the right skillsthe right communication and informationsharing channelsa learning culture.Health and social care organisations should worktogether to deliver positive outcomes for peopleand ensure that they receive the right care,in the right place and at the right time. In thelocal systems we saw, people were not alwaysreceiving high-quality person-centred care tomeet their needs, or getting their care in theright place.We have met hundreds of dedicated staff whoare committed to providing the highest qualityof care possible. Many regularly go beyond thecall of duty. Some exceptional professionals wemet are working across organisational boundariesto provide high-quality, personalised care andsupport to people, despite the barriers to jointworking.As a starting point, there should be greateremphasis on keeping people well at home.Investment in preventing health problems andkeeping people out of hospital where possiblewill be better for people and for the health andcare system. Bed occupancy in hospitals is higherthan ever. Local leaders need to be able to investin the prevention measures that will help keeppeople well.
SUMMARYIf older people have to go to hospital theyshould only be there for as long as necessary. Ifthey are ready to go home, they should not bedelayed. A recent focus on tackling these delayshas led to some improvements for people. Thisis important because older people, particularlyfrail people, can suffer harm and distress if theystay in hospital too long. Care providers need towork together to achieve the best outcomes, toensure that people who need care and supportare receiving it in the place that is best for them.People are not usually concerned with who isproviding their care. What they want to know isthat the care they are getting is right for them.We have seen examples where joined-up workingbetween health and social care services canachieve this.We have seen that health and care staff arecommitted to helping people. And where wehave found that there is one strategic vision,shared by leaders working across a local system,this provides clarity and a common purpose fororganisations and individuals working within it.To build on these strong foundations, overcomethe fragmentation of the system, and ensurethat more people experience high-quality,personalised care, we need to see changes to:zz the way the performance of health and socialcare is measuredzz the funding arrangements for health andsocial carezz the way the future shape and skills of theworkforce are planned, andzz regulation and oversight of health and socialcare.Better health and care outcomes for people relyon good relationships at all levels of services –the best ones are characterised by aligned visionsand values, open communication, trust andcommon purpose.Currently, people working within systems are notalways incentivised to work together. Most seniorleadership sits within individual organisations,requiring good working relationships andcollaboration to deliver joined-up services forpeople. Organisations answer to their ownorganisational objectives, commissioners andregulators. Leaders are judged on their successin terms of individual organisation performancemeasures, not outcomes for people cared for bya system.Senior leaders report a culture whereorganisations prioritise their own goals over thewhole system’s shared responsibility to peopleusing health and social care services. We heardabout tensions in organisations and acrosshealth and social care, influenced by systempressures and accountability against performancemeasures, such as delayed transfers of care.This behaviour hinders joint working. Wherewe have seen that leaders in systems have anunderstanding and appreciation of each other’sroles and responsibilities, this has helped to buildrelationships and improve outcomes for people.A new type of leadership approach is required,where leaders are supported and encouragedto drive system priorities collectively, throughsystem-based, shared and well-understoodperformance measures and accountabilities.None of the systems we visited had a fullyjoint, system-wide accountability framework.This means leaders are not accountable forthe outcomes of a wider system, beyondthe accountabilities of their individualorganisations. Individual governance andaccountability structures are well establishedat the level of organisations. However, acrossthe review programme we have found thataccountability for the performance of a system,in how organisations work together to meetthe needs of people in a place, has not beenuniversally established. Forums such as Healthand Wellbeing Boards, Sustainability andTransformation Partnerships and the Urgent CareDelivery Boards can all be drivers for systemworking. We found varying effectiveness of thesefrom system to system.To drive collaboration, there needs to be atransformation in the way the performance ofhealth and social care services is measured.Currently, performance is measured in individualorganisations, working separately. We need tosee a shared approach that measures how wellHOW OLDER PEOPLE MOVE BETWEEN HEALTH AND SOCIAL CARE IN ENGLAND5
SUMMARYa whole system is working to meet the needs ofpeople using health and social care services.Funding flows are also a challenge across systemsand financial pressures have affected jointworking.Separate funding streams and differentpayment processes can cause divides betweenorganisations in a system. This is seen in thedifferent approaches to eligibility for care, withNHS services provided for free at the pointof delivery and based only on clinical need,while social care delivery is means-tested. Thedominance of tariff-based funding has acted as abarrier to joined-up commissioning across healthand social care, and to investment in preventionand out-of-hospital provision.The Better Care Fund was a catalyst for jointfunding in most systems, bringing togethersystem partners to commission and deliverservices across health and social care. Despitelimitations in scope in some places, it has shownwhat is possible when health and social careorganisations are able to commission servicesfrom a unified budget.In June 2018 a long-term NHS funding plan wasannounced. This promises that by 2023/24 theNHS England budget will increase by 20.5 billion in real terms compared with today.For health and social care to plan collectively asa system for the long-term, funding security isrequired across both health and social care. Atthe time of writing there is no long-term fundingsolution for adult social care. A sustainablefinancial plan for adult social care is expectedas part of the forthcoming Spending Review,following the publication of the social care GreenPaper.We need to see sustainable funding reform thataddresses social care and the NHS together, andremoves the barriers that prevent social care andNHS commissioners from pooling their resourcesand using their budgets flexibly to best meet theneeds of their local populations.6BEYOND BARRIERSNational bodies have an important role to play inoverseeing the performance and quality of healthand care services and encouraging improvement.CQC has a role through its regulation of thequality of care. It is clear from our reviews thatassessing the quality of individual providers isimportant to ensure people experience safe,high-quality, compassionate care. But if we areto encourage and recognise efforts to collaborateacross the health and social care, then we alsoneed regulation to look at the quality of careacross whole systems. In reviewing systems, weare able to clearly understand what the journeythrough health and social care is like for peoplewho use services, their families and carers andthe safety and quality of this journey.The key to building sustainable improvementsin the quality of care for people is throughcollaboration across the health and socialcare system. Health and care systems facean unprecedented challenge in meeting theincreasing needs of their populations withinavailable resources. For systems to be sustainablethey need to have the right provision in placeand sufficient capacity to support people to staywell in the community or move smoothly throughthe system. This all depends on having staff withthe right skills, in the right place.There are significant challenges in recruiting andretaining frontline health and social care staffand we have seen the impact this has had on thequality of care people experience. This will geteven more challenging over time, as an ageingpopulation that has more complex long-termconditions increases the demand for health andsocial care services.
SUMMARYWe found particular challenges in the care homeand domiciliary care workforce. Years of fundingreductions and the growth of competing jobmarkets in some local areas have left the carehome and domiciliary care market less able toattract a workforce. There are issues for thehealth and social care leaders to address. Peopleworking in health and social care are not alwaysseen as equal partners.As we move towards more integrated models ofcare, staff will increasingly need to work acrossboundaries and take on new responsibilitiesbeyond people’s specialisms, for example byundertaking care coordination and assessment.Knowledge and understanding of other healthand care services that can meet people’s needsin the community will be crucial in reducingpressures on hospitals. Systems need to beinnovative in how they recruit, train and usetheir workforce, so that staff have the abilityto provide joined-up care that is seamless forpeople who need it.Workforce planning as a system will be centralto this. Currently these issues are addressedwithin individual organisations, not as a wholesystem approach. Organisations need to workcollaboratively to develop a health and careworkforce that will meet the needs of peoplenow and in the future. An integrated nationaland local approach to health and social careworkforce planning is essential to providesustainability in local labour markets, and highquality, personalised care for people usingservices.Establishing the right health and care provisionfor the needs of a local population was one ofthe most significant challenges in all the localsystems we visited. We have found that thevoluntary, community, and social enterprise(VCSE) sector is under-used in the planningand delivery of services and often not seen aspartners. Health and care commissioners andproviders, including the independent sector, mustshare risk and work together as a unified system.Another significant challenge to health and socialcare integration is the ability to share informationto inform effective decision-making. This problemis not new. Poor information governance, or alack of understanding of rules and regulations forsharing information, can prevent joined-up careand support.Information is not always available in the rightplace, at the right time – this leads to delays,people having to tell their story multiple times,and a risk-averse approach to decision-making.Health and social care services are already undersignificant pressure, and demand for care is likelyto increase. We cannot solve this problem bycontinuing to work in the same way. We mustmake collaboration across health and socialcare the default option. This means removingthe barriers to collaboration and changing theway we measure performance, fund the system,build our workforce, and regulate services. Onlyby working across the health and social caresystem, recognising that health and care servicesare very often caring for the very same people,can we possibly hope to see the significant andsustainable change that is required.HOW OLDER PEOPLE MOVE BETWEEN HEALTH AND SOCIAL CARE IN ENGLAND7
INTRODUCTIONIntroductionCQC has completed a programme of targeted local system reviewsin local authority areas. This work followed the government’s 2017Spring Budget announcement of additional funding for adult socialcare and a joint request from the Secretary of State for Health andSocial Care and the Secretary of State for Housing, Communities andLocal Government.We were asked to find out how services areworking together to support and care for peopleaged 65 and over – people who experience theinterface between health and social care services.This report pulls together our findings.CQC is in a unique position to provide anoverview across the entire health and adultsocial care system and provide an independent,objective and trusted assessment of local systemsand what improvements are needed.Each local system review addressed the followingquestion:How well do people move through thehealth and social care system, with aparticular focus on the interface, and whatimprovements could be made?They are based on a dashboard of metricsindicating challenges with access and how peoplemove between health and social care services,including delayed transfers of care.In every system reviewed we found goodpractice. This has led to good outcomes forpeople who use services, their families and carers.The systems we reviewed were facing significantchallenges – 19 of the 20 systems were selectedas comparatively challenged systems and thefindings should be considered in this context.This report makes recommendations for nationaland local leaders, to suggest the scale and paceof improvement needed for people to have betterexperiences when they use a combination ofhealth and social care services.We have identified what makes it easier andwhat makes it harder for local services to worktogether to make sure older people have atimely, high-quality and safe journey through thehealth and social care interface. In this report,we confirm and expand on what we publishedin our interim report to the Secretaries of State(December 2017). We also set out the actionthat needs to be taken to improve the quality ofthe journey for older people who move betweenhealth and social care services.There are two supporting documents for thisreport that provide more detail on the findingsfrom two evidence-gathering tools we used inthe reviews:zz the relational audit, examining the qualityof relationships between people working inhealth and social care systems;zz the discharge information flow tool, seekingperspectives from providers of social careabout the information they receive when olderpeople are discharged from hospitals and intotheir care.The 20 systems we reviewed (FIGURE 1) wereidentified by the Department of Health andSocial Care (DHSC) and the Ministry of Housing,Communities and Local Government (MHCLG).Within this report, we have included theexperiences of the some of the people we havemet and heard about in the systems we visited.We have not used their real names.8BEYOND BARRIERS
INTRODUCTIONFIGURE 1: THE 20 LOCAL SYSTEMS1. Birmingham2. Bracknell Forest3. Bradford4. Coventry5. Cumbria6. East Sussex7. Halton8. Hampshire9. Hartlepool10. Liverpool11. Manchester12. Northamptonshire13. Oxfordshire14. Plymouth15. Sheffield16. Stockport17. Stoke-on-Trent18. Trafford19. Wiltshire20. York9520311101815167171412132198614What we didStarting in August 2017, we have carried out20 local system reviews, using data analytics,observation, case-tracking, interviews, focusgroups and questionnaire feedback tools. Thedetailed findings from each system are in thelocal system reports published on our website.We collected qualitative and quantitative dataand supporting observations, which are explainedin this publication.We developed our approach to the local systemreviews in co-production with a range ofstakeholders, including national bodies, healthand social care commissioners and providers,voluntary and community sector organisations,and people who use services and their familiesand carers.HOW OLDER PEOPLE MOVE BETWEEN HEALTH AND SOCIAL CARE IN ENGLAND9
INTRODUCTIONFIGURE 2: HOW OLDER PEOPLE MOVE BETWEEN HEALTH AND SOCIAL CARE SERVICESAdmissionto hospital or alternativeMaintaining thewellbeing of a personin their homeStep downMaintaining thewellbeing of a personin their homeThe system reviews focused on the interfacebetween health and social care, looking at theplanning, commissioning and delivery of healthand social care services. We reviewed how eachlocal system works within and across three keyareas (FIGURE 2):zzevidence submitted by local stakeholders,including organisations that represent peoplewho use services, their families and carerszztwo questionnaire feedback tools completedby people working in the system (a relationalaudit and discharge information flow tool)1.maintaining people’s wellbeing at homezz2.care and support when peopleexperience a crisis‘pathway tracking’ for a small sample ofpeople who use services.3.step down, return to a usual residence,and/or admission to new residence.Each review involved:zzanalysis of available data and the productionof a local system data profilezza system overview information request(completed by the system)10BEYOND BARRIERSDuring the review we spent two periods on site ineach local system:zzIn the first period we spoke with people whouse services, their families and carers, andorganisations that represent people, includinglocal Healthwatch. We were supported byExperts by Experience, who have personalexperience of using health and/or social careservices, or caring for someone who useshealth and/or social care services.
zzINTRODUCTIONDuring the second period, we took a team onsite for a week to hold focus groups with staff,carry out interviews and visit services. Thereview team included CQC staff and supportfrom specialist advisers, including currentand former directors of adult social services,chief executives of local authorities and seniorhealth professionals.A local system report was produced after eachreview, showing findings, highlighting what wasworking well and where there were opportunitiesfor improving how the system works for olderpeople using services, their families and carers.Each local system report has an assessment ofjoined-up working, the integration of systems, andhow these were working for people in the area.We commented on the maturity, capacity andcapability of the local system, and we sharedthe data profiles used to inform each reviewwith the system. Reviews were followed bylocal summits, facilitated by the Social CareInstitute for Excellence (SCIE). These broughttogether system leaders from the local areas andrepresentatives from national bodies, includingthe Local Government Association, NHS Englandand local Healthwatch.The summits were to discuss the findings fromthe reviews and for system leaders to developaction plans. Sometimes this might lead to workwith national bodies to help enable leaders toimplement changes at a system level.SCIE was asked by the DHSC to provideindependent support to local systems to assistwith the development of plans that addressedthe findings and recommendations from CQC’slocal system report.Local system reviews reportThis report is mostly based on analysis generatedby CQC:zz qualitative analysis of local system reportszz quantitative analysis of CQC and national datazz quantitative and qualitative analysis ofquestionnaire feedback tools completed bypeople working in the systems (a relationalaudit and a discharge information flow tool).Where other data is used it is referenced inthe report. The analytical findings have beencorroborated and in some cases supplementedwith expert input from our local system reviewteam, specialist advisers and analysts to ensurethat the report represents what we saw duringthe reviews. The report was developed with thesupport and challenge of an external expertadvisory group.HOW OLDER PEOPLE MOVE BETWEEN HEALTH AND SOCIAL CARE IN ENGLAND11
1 . O lder people ’ s e x periences of moving between health and care services1. Older people’sexperiences of movingbetween healthand care servicesWe saw many examples of good practice atindividual organisations within systems. We alsosaw the way that systems are not working in thebest interests of people who use services, theirfamilies and carers, because organisations in asystem are not joined up.Older people often need to move betweendifferent kinds of care. When they do, all servicesinvolved in their care have a role in keeping themsafe and helping them move smoothly betweendifferent aspects of their care – so they mustwork together. This is especially important whenpeople are being discharged from hospital toreturn home, or if as a result of their health andcare needs changing, they move somewhere else,such as a care home.Across the reviews we heard many peoplecompliment and praise the work of healthand social care staff and the organisationsthey represent. We also heard many storiesfrom people who were admitted to hospitalbut were unable to go home when they wereready because health and social care serviceswere not joined up. For some older people,the consequences of this are severe and lifechanging.12BEYOND BARRIERSAvoidable admissions anddelayed transfers of care – whydo they matter?People told us that when they are admitted intohospital, they only want to be there for as longas they need to be – when they are ready to gohome, that is what they want to do.There is strong evidence that when an olderperson unnecessarily spends time in hospital, itcan be detrimental to their health and wellbeing.Being inactive means older people are morelikely to lose their ability to perform everydaytasks. A length of stay in hosp
z the right staff with the right skills z the right communication and information-sharing channels z a learning culture. Health and social care organisations should work together to deliver positive outcomes for people and ensure that they receive the right care, in the right place and at the right time. In the
When segmented by gender, more older women tend to live with their children compared to older men. In older female households, 62% of older women live together with one child, while 22% live alone. In contrast, in older men households, 45% of older men live together wi
older people and on the health and social care system is significant and of great concern. Pain in older people is an increasingly important health issue, and one that requires urgent attention. This publication aims to highlight the issue of pain in older people by exploring older
to good care. Food is fundamental to quality of life and, for many older people in particular, can be critical to their health and well-being. Unplanned or unexplained weight loss can make older people vulnerable to disease and may be fatal. People’s appetites also reduce with age, so keeping older people interested in food is a challenge.
Eating well: supporting older people and older people with dementia Practical guide Helen Crawley and Erica Hocking THE C AROL INE WALK ER TRUST. Published by The Caroline Walker Trust, 2011. ISBN 978-1-89-782039-1: Book and CD-ROM The Caroline Walker Trust 22 Kindersley Way Abbots Langley
VOICES report Eating Well for Older People with Dementia,6 produced in 1998. A computer program called the CORA Menu Planner,7 produced in response to the publication of the first edition of Eating Well for Older People, has provided a practical tool for those planning menus for older people and is now extensively used across the UK.
lead to difficulties in eating, and absorbing medications . oral health care right is a key part of supporting older people’s health, wellbeing and dignity. British Geriatrics Society With growing numbers of older people needing resi . have implications for an older people’s health more generally as well, and is linked to several other .
Older Adults 7.5% Reasonable A1C goal for healthy older adults 7% May be appropriate if it can be safely achieved in healthy older adults with few comorbidities and good functional status 8.5% Appropriate for older adults with multiple comorbidities, poor health, and limited life expectancyFile Size: 1MB
aged 65 and older in 2015; by 2050, the older popu-lation will make up more than a quarter of Europe’s total population. The older population in Asia and Latin America and the Caribbean will grow the fastest of all regions, with Asia’s older population almost tri-pling in size from 341.4 million in 2015
