Grainne Siggins, Director of Adult Social Care, London Borough of Newham, and Policy Lead, Association of Directors of Adult Social Services (ADASS), shares lessons on providing preventative approaches to social care commissioning and integrated programmes to improve transfers of care.
This presentation was recorded at our event, Better transfers of care for older people, on 21 February 2017.
Good morning everyone. I do feel that I'm possibly the only one in the room who actually likes the Better Care Fund. So the better care fund is a principal about the ability of systems and systems lead us to work effectively together. Ashley did mention it in terms of system planning and understanding the shape of out of hospital care and how people work together to do that. My view and from conversations I've had with people is a vehicle to leave a change. It has actually been effective. In terms of how we are using local resources and how we are contributing that resource to pay for those community based interventions now, as you can hear, that is variable and in part as most of us know Ashley possibly didn't get to the detail of, but did we actually ask the right question when we were trying to assess the effectiveness of the better care fund and integration and what it was we actually hoped for it to achieve. So do we still know what integration actually means? So I’ll just park that there because I did feel I needed to come in and I will touch on the money issue shortly.
So my starting point isn't about delayed transfers of care, it’s about planning effectively as a system to prevent people from going into hospital in the first place unless they have a medical need to do so. And again, planning at a local level to enable that to happen means that we as system leaders need to work effectively together to ensure that we are looking at good practice, looking at where the evidence is, not frightened to actually test things out and acceptance that some things might fail, to be evaluating the interventions that were put in place, but more importantly to establish robust relationships so they can all work effectively together to the benefit of our residents and patients.
So part of that is about understanding collectively what that local need looks like, especially relating to our older people population and thinking about how we are actually going to support people with self care, prevention, people being active members of their community. Most of us have developed prevention strategies which includes all of those things. So it is about being able to plan effectively together as commissioners, so we are collectively and together commissioning the right things so we are using our local money effectively. To be thinking about what the shape of health and care services look like, not health commissioners commissioning health services and not social care commissioning social care services, but thinking about how we are actually going to commission new models of care collectively together and specifying them in that way working together. It does mean fully integrated commissioning teams but it means working together to think about how we do that planning, where possible to cool budgets as most people have within their better care fund, and to actively make sure that we are not burdening our providers out there with multiple requirements for monitoring and information.
But where we are monitoring together, for example residential and nursing homes, where it is effective is where health and care organisations are actually working together with clinical input, CQC and others, working to actually effectively monitor the residential and nursing space including London Ambulance Service, looking at our conveyancing from the nursing homes, looking at driving up nursing quality, but collectively understanding what that system looks like.
So I'm starting with out of hospital care because I think that's where it sits. Do we all effectively use our data that we collect? We had a session in London about a couple of months ago where we were looking at the data, so commission support units, a huge amount of data available for the health system, public health, huge amount of data available for local authorities and CCGs, social care, huge amounts of data – do we all effectively use the range of data we've got to ensure that we are planning monitoring the effectiveness of those interventions to be able to monitor how efficient our system is, and I put that challenge out to all of us because I think it’s an area that often is neglected, but we do need to be thinking about how we get better and more effective at understanding the data and understanding where we are spending our money and the effectiveness of those interventions.
So what we do know is what works. Already we have in the better care fund lots of narrative coming out about how local systems are working effectively together, joint approach to self care and self care management within the community. I know the public health that come over to local authorities gave us significant opportunity to work more effectively together across a range of council services, housing and local communities, making sure that we are reaching people who are socially isolated and don’t effectively take up services in the community.
Effective approaches to joint assessment and care planning – so those areas obviously in Ashley’s report talking about have we got this in place, are we actually using it that happens in a range of different forms. Proactive care planning in the community, proactive management of people within our very high risk and high risk cohorts of individuals who have got multiple long-term conditions, who are risk of going into hospital, who need more proactive care. Do we all understand who those people are? Are we actually proactively managing them? In the systems that are effective in keeping people out of hospital, they've got a very proactive approach to the management and support of those individuals around primary care, around the hospital, looking at a range of multidisciplinary meetings that do take place. So in terms of rapid response, it’s taken us two years to actually get a community geriatrician into our rapid response service in Newham, recognising that we wanted to be supporting that cohort of patients who don’t really need to go into hospital but need a higher level of clinical input and advice than was available through community, and so it’s taken us two years. So just thinking about, just one example of are we actually effectively planning at our workforce level to understand what that change in shape of the system actually looks like in terms of a new shape of out of hospital care.
So Richard beat me to it in terms of articulating the numbers but there is significant variance across the country based on local demographic and the population of older people, but also the providers that exist in certain specific areas and the workforce that is available to actually work with the providers. We keep challenging ourselves and others, both regionally and nationally about are we actually working together to develop an effective workforce strategy that encourages people to actually come and work in the health and care sector at all levels and I don’t think we are. So I’ll just put that challenge to to us so when we talk about it on the London stage, we are doing bits and pieces but what we are doing to actually convince people to not work at Lidl and actually come and work in the care sector making these professions actually attractive with a real career pathway.
So there is areas that we are doing really well on and we've still got more to do, but areas where I don’t think we are actually touching the strategic reasoning behind it and we do have a frail team in any areas within our provider market, in the ADASS budget survey, Association of Directors and Adult Social Services that Richard mentioned earlier. We do an annual budget survey and significant numbers of directors have had care contracts given back to them, in part due to inability to actually recruit staff in specific areas, but also about sustaining ability of the funding model being applied through significant squeezing by local authorities of the care sector. Ad what we do know, we've had a significant reduction in adult social care budgets and local government budgets per se, but local councils have been going out to their populations and asking them to prioritise where do we spend our money and the proportion of spending and budgets of local authorities as a total proportion of their actual budget has significantly increased in relation to adult social care. So in the main, politicians are trying to protect adult social care and children’s services as an overall proportion of their budgets.
We had a query in ADASS the other week where it was commented that one local authority were preventing discharge because they hadn’t got the money to pay for the packages of care and support, so we went back to that local authority and it was a complete myth. What we do know from the part year, I think it was September, the quick survey of directors of adult social care services, we were £450 million overspent midyear. So local councils are going overspent rather than stopping providing care and support for people, and this is with the knowledge of local politicians who collectively were going to have to resolve that at the end of the year which with significantly shrinking reserves is going to become more difficult to do going forward. So I’ll stop on the budget because I know Richard probably doesn’t want me to talk about the financial sustainability of social care today. But just to reassure people that where we are getting the intelligence, we are checking things out, people aren’t languishing in hospital due to not being able to pay for X care home etcetera. In a lot of areas it’s the actual availability of the care home sector, care in the community and, arguably, the cost of care has got some impact on that.
In certain areas though we've heard where some areas are paying £17.50, £20 an hour for care and still unable to recruit carers which is becoming exceptionally difficult, especially with increasing complexity of the individuals who are coming out of hospital, yes they are medially optimised but people are still poorly, you know, they need to be given a chance to get a little bit better, so, to begin with when people come out, they do need a higher level of care and support and securing at very short notice a package of care and support double handed four times a day, sometimes 24 hours for some individuals, it is becoming increasingly difficult in terms of that.
So going back to my original point, what we need to do is work effectively as local commissioners across health and care to actually own the health and care system and shape something that actually is fit for purpose and that we are planning effectively together and use our local resources to best effect.
So, what do we know? So we've been looking at this now for years and years and years and intensely I would say two to three years, before the last election. We had a bit of a hiatus where delayed transfers of care were at an all time high at that point and the ministerial sub committee was set up and LGA were charged with setting up a little team with others, with Liz at the front there, it was ECIST at the time, or was it ECIP at that point? Yes? So to actually go in and support local systems to improve. So as part of that process, our learned colleagues who were part of that, actually looked at well what is working in local systems and how can we learn from what they are doing and actually publicise that to everybody and a lot of those what are now called high impact changes have actually continued to be embedded in terms of how local systems are working and becoming more effective. So those are the high impact changes and I’ll go through these one at a time, but I don’t think there is any surprises in this, so a number of these interventions rode into a number of years ago and what we didn't have at the time was well what does good practice look like, where are those examples, and actually provide some more enhanced information about what that might look like.
So I’ll talk through some of these today and will mention the ones that I know that Victoria has already created some quick guides on and I know Liz is here to talk about one of them.
So you've already heard it today, early discharge planning. Now those of us that have been in health and care for some time, how often have we been saying estimated day of discharge, sort of, well, more or less as soon as a person gets into hospital. We still haven’t achieved that in all of the systems, so it’s understanding that it is still important to be able to, for elective care, planning even before the person comes into hospital, but for non-elective care, actually one eye on, we need to get this person out of hospital as soon as they are medically optimised and able to be discharged.
And some of that is just some of the basics. I know in our area we have people who hoard and often we don’t have any information about the home environment where the ambulance has just brought somebody from. So whilst that has actually improved, it’s been able to actually absorb all the information from those system partners into the person’s journey through the hospital because when it comes to supporting someone out of hospital really quickly, the state of the home and what person needs to go home, whether or not the central heating is working etcetera, is incredibly important.
So there is a little bit more detail in each of these but I’ll just talk one at a time. So what we also know is systems to monitor patient flow, where systems are actually effectively working together and we've got common pathways of care, we've got common protocols, we've got common procedures across the system, we can all look at everybody’s data, the flow through the system is more effective but we are not all there yet as some of the specific work that we have to do with local systems does show. The importance, as Ashley said, is making sure that everybody is attending multidisciplinary teams and that we in social care are also going case finding. So in reaching to the hospital to try to work with wards, to actually identify what are you doing with that individual, what is next. I know that they are using social care, how are we going to get the person out quickly, but making sure that we have got a proactive discharge plan in process and where all of the agencies are involved in those.
Now one of the areas that have come out as being effective, and I think you are going to hear from Tower Hamlets later and also from Liz, is around discharge to assess. So a person doesn’t have to have their full capability or independence maximised while they are in hospital. We used to have the step down beds and step up beds and all of that, I know it’s old currency now, but increasingly we need to focus on supporting people where the assessments actually started to be discharged in the community. Often some of these individuals with quite enhanced packages of care and support as they actually improve, enablement, rehab, and then the full assessment towards the end, and that's discharge to assess.
The system needs to be reshaped in order to enable that to happen and we now have the system resilience groups that were mentioned earlier are now A & E deliverables and operate generally at the same footprint. As part of the plan to improve the system we had to all have discharge assess models in place by the end of March this year. Now a lot of people are saying they've got elements of the system, so what does discharge to assess include but might not have a full discharge to assess model. So I will ask those of us who have got discharge to assess models, or have said that we have, to go back and have we actually hitting the target, missing the point, how effective is your discharge to assess model and are you actually operating at scale, have you evaluated it, what is the evidence around the discharge to assess model, because when you actually look at the social care numbers, the figures that we had in December 16 for social care, the largest proportion of delays related to people waiting for packages of care in their own home. If we are actually utilising an effective discharge to assess model that is operating at scale, we wouldn’t have that so I’ll leave you with that comment.
But seven day services, again how many of us have got full seven day services in place across the whole system, including community nursing. I know when we first started looking at this two years ago, people were counting emergency duty teams, support in hospitals, weekends as part of their seven day social work. I know that's changed over time. Two years ago, us in Newham, we changed our social work contracts so people now have to work seven days a week. I'm not sure how many areas have done that, but it’s important to be able to assure ourselves that we've got seven day service.
Trust in assess models – Victoria still working up a trusted to assessor with her colleagues in NHS improvement. Trust assess comes in a range of different forms. It can be equipment, it can be one assessment for social care or it can be a common assessment for care homes.
Focus on choice; we had the quick guide for the choice protocol, so again the work that we identified two years ago has been enhanced through the work with NHS England. It is important that we agree a protocol but actually make sure that that is then embedded and operational. So people in the main are actually getting the protocols in place, getting agreed by parties but how do you embed that and operationalise it? It’s important to evaluate a lot of these things.
And then enhanced health in care homes. Again most of us – I think we've got one person on the agenda talking about enhanced health in care homes. Obviously this was part of the Vanguard Enhancement, but recognising how a very different model of care and support to care homes can reduce hospital admissions and when people do have to go into hospital, can be discharged swiftly back into the care home.
So in terms of the high impact changes, I just wanted to promote this document. This is two years old and it includes all the detail in here. It’s on the local government website. You’ll understand that these initiatives that were gained from looking at good practice have been further enhanced through a range of quick guides which you’ll hear a little bit more about later.