Social care 360: integration with other services

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17. Delayed transfers have improved

Delayed discharge from hospital due to social care have fallen

 

A delayed transfer of care occurs when a patient is ready to leave a hospital or similar care provider but is still occupying a bed. Administratively, delays are attributed either to the NHS or social care (or both) and can occur when patients are being discharged home or to a supported care facility, such as a residential or nursing home, or are awaiting transfer to a community hospital or hospice. The most common reason for delay is awaiting a care package at home, followed by awaiting further non-acute NHS care. Other reasons for delay include waits for assessments, waits for funding and patient or family choice. 

Delayed transfers from hospital due to social care have fallen sharply since a peak in the winter of 2016/17. This follows a concerted effort by local authorities and NHS organisations – under intense scrutiny from the government and NHS England – to reduce pressure on acute hospital beds.

A key factor has been extra money provided through the Better Care Fund, one of whose main goals was a reduction in delayed transfers.

So intense has that pressure been that it is easy to forget that it is the NHS, not social care, which accounts for most delayed transfers, albeit that they have risen less sharply (and have since declined less suddenly) than those in social care. And the reduction can also overshadow the reality that, for both social care and NHS delays, the figures are still higher than they were in 2012.

Clearly it is important that people do not spend more time in hospital than is necessary. However, too singular a focus on delayed transfers can take attention away from work to prevent admissions in the first place and from ensuring that transfers are not just made promptly but also appropriately. A recent review by the CQC also noted that focusing on delayed transfers in isolation can divert attention from other important opportunities to deliver better care. The Association of Directors of Adult Social Services believes that pressure to get older people out of hospital sometimes leads to them being moved directly into residential care when they do not need to be there.

And the focus on delayed transfers of care can also overshadow the reality for councils: four in five of their referrals come not from hospitals but community settings, and the greatest rate of increase in demand is coming not from older people but from working-age adults.

 

18. More people are receiving reablement

After a period of decline, access to reablement has increased

Reablement is one of a range of short-term services for people whose health has deteriorated and/or who need support to relearn skills to keep them safe and independent at home. It is categorised as a type of intermediate care, most commonly delivered by social care staff. The other types are crisis response, home-based intermediate care and bed-based intermediate care.

Reablement can be provided to anyone who would benefit but often in practice it is arranged as someone leaves hospital, with the aim of preventing them being readmitted. This measure shows that after a decline from 2013/14 onwards, the number of people offered reablement on leaving hospital increased in 2017/18.

The increase may stem from increased recognition of evidence that reablement works. The National Audit for Intermediate Care shows 75 per cent of people improving independence as a result of reablement, with typical gains in mobility and other abilities of over a third.

The rise in reablement packages is consistent with indicator 2, which shows local authorities providing more short-term care in 2017/18. Interestingly, this increase is greater for under-65s and may potentially signal increased recognition that younger disabled people, including those with learning disabilities, can benefit from 'pathways to independence’ planning.

Despite the overall increase in packages, national data shows that numbers receiving reablement vary greatly from one local authority to another: fewer than  1 per cent of over-65s leaving hospital in some areas but more than 10 per cent in others. 

And the National Audit of Intermediate Care estimates that – despite the effectiveness of services – in 2012 there was only around half of the capacity for intermediate care services needed to meet demand. This data does not suggest there has been much progress in closing the gap, particularly as some argue that at least 70 per cent of people who are assessed as having care needs should have an enablement-based service.

19. People are less likely to be receiving NHS Continuing Healthcare

The rate of take-up for NHS Continuing Healthcare is declining but there are wide differences of opinion about why

The NHS funds two elements of care that are very closely related to social care: NHS Continuing Healthcare (CHC) and NHS-funded nursing care. The rate of receipt for both has begun to decline since 2015/16.

NHS Continuing Healthcare (CHC) is a package of care provided outside of hospital that is arranged and funded solely by the NHS – via local clinical commissioning groups – for individuals who have been assessed as having a 'primary health need' as set out in the National Framework for NHS Continuing Healthcare and NHS-funded nursing care. 

NHS-funded nursing care is when the NHS pays for the nursing care component of nursing home fees. The NHS pays a flat rate directly to the care home towards the cost of this nursing care. 

CHC is a significant amount of expenditure – a National Audit Office report put it at £3.1 billion in 2015/16.

Crucially, CHC funds not only an individual's health care – which would be free under the NHS anyway – but also their social care, which otherwise would be means tested. Since social care costs can be very expensive, it can make a huge financial difference to an individual if they have to pay these costs themselves or, if that person has low enough assets to qualify for publicly funded social care, to the local authority, who will otherwise have to pick up the bill. 

CHC is divided into standard and fast-track. 

Individuals are eligible for fast track if they have a rapidly deteriorating condition that may be entering a terminal phase; for this reason, fast track is usually provided for a much shorter period of time than standard CHC. 

The number of people receiving standard – more long-term – CHC has declined since 2013/14 while the number receiving fast track – ie, short-term – CHC has increased. 

Continuing healthcare chart

The reasons for the overall decline are opaque and disputed. In 2015/16, NHS England was set a target to save £855 million in the projected growth of CHC and FNC costs by 2021. It told us that national eligibility criteria have not changed and that a key factor in the reduction has been ensuring assessments for CHC take place in the community or at home, rather than in hospital where an individual is most vulnerable and may be assessed for care that they don't in fact need.

Campaign groups argue this is not the main reason for the reduction and instead say there has been a determined effort by many clinical commissioning groups (CCGs) to reduce their costs in practice by setting the eligibility bar higher than previously. They point to wide variation in individual CCGs’ provision of CHC beyond demographic variation. NHS England told us variation will always exist, due to a wide variety of local demographic and other factors.

The complexity of the assessment process for CHC makes it extremely difficult to identify the extent to which these differing explanations are valid, though the width of the difference between the two positions suggests an urgent need to do so. 

NHS-funded nursing care is only available to those who require the input of a registered nurse, live in a nursing home and have been assessed for CHC but found ineligible.

Reasons for its decline are again difficult to unpick, though there may be a connection to the fall in the number of nursing home beds in relation to the over-75 population (see indicator 16), which in turn may be related to the trend towards supporting people in their own homes for longer.

20. The number of grants to improve disabled people’s homes has increased

Increased central government funding may lead to bigger increases in Disabled Facilities Grants – but from a low level

Disabled Facilities Grants are potentially an important part of strategies to enable older and disabled people to live independently in their homes for as long as possible.

Disabled Facilities Grants especially help the growing numbers of home owners on low incomes to fund essential adaptations like level access showers ('bathroom modifications' make up over half of all grants), stairlifts and ramps. They are not the only source of adaptations – local authorities and CCGs provide smaller adaptations such as grab rails, as well as loaned equipment such as bath seats, through the Integrated Community Equipment Service. However it's not possible to identify nationally the numbers provided or the amount spent on them. 

Central government funding for Disabled Facilities Grants (paid through the Better Care Fund) has increased significantly – and will remain at higher levels until at least 2019/20 – but the average number of grants completed per local authority is now only marginally higher than it was in 2010/11. This may be because we only have data on the numbers of new grants until 2016/17. However, some funding for Disabled Facilities Grants also comes from local authorities and they have decreased the amount they invest, particularly in 2016/17, so the overall increase in expenditure may not be as great as thought.

Certainly, there will have to be a step change if they are to meet expectations that grants would double from the 41,000 estimated to have been completed in 2014/15.

And even if it were achieved, it would fall far short of meeting all demand: a 2014/15 survey found that 1.9 million households in England had one or more people with a long-term limiting illness or disability that required adaptations to their home. 

Comments

PatriciaHamilton

Position
recipient of direct payments for PAs,
Organisation
none
Comment date
05 August 2019

I am 75 and live alone; receive Attendance Allowance, and direct payments from my local Council.

I have several disabilities, and cannot find the type of PAs I need.

DFG 5 years ago provided a stairlift, and 4 years ago, a wetroom.

After a year of OTs visiting me, on and off, looking at my front door and garden, they decided that I cannot have a ramp to go in and out of my (owned) house in a wheelchair, because the front garden is too steep. They said that when/if I had to be in a wheelchair full-time, I would have to move house. I have MS, meningioma and several other medical problems. I cannot walk outside the house unaided, or into my garden unaided.
I have only a few hours of care per week allowed, which means that I have nobody to cook me a meal. I can only have a shower once a week if I know that a key-holder is on her way to me, or is here. Nobody will work for less than £12 or £13 per hour in this area, so I am paying them more than the direct payments budget I receive, which already includes my payment of £68 per 4 weeks.

I have given up going anywhere except for medical appointments, ie no social life.
I have to pay for taxis, and rely on taxi drivers to push me in my wheelchair inside the building to which I need to go, as I can no longer walk, pushing my wheelchair for support. My main PA cooks food to put in the freezer for me - but does not work on Mondays that are Bank or school holidays, and has no car. There is a limit to what she can do in 4 hours a week, when she does come!

So, I agree with your findings that Councils do not get enough funding from Central Government; that the eligibily for home help has not increased for too many years, leaving many needy people without any direct payments - and that PAs will not work for the minimum wage. And poor pensioners cannot afford to pay the £16-£18 minimum demanded by agencies.

I have already taken some equity out of my house for some essentials - and now am trapped by it, when told I have to move to get level access.

I get depressed, and have no friends to visit me. My son cannot visit me, nor I, him.

I have IBS and am losing weight. I saw an NHS dietician last year and was put on the Low Fodmaps Diet. I will see somebody again in a few months time. I was told not to go below 8 stone, to which I had gone by then, but in the past months I struggle to stay above 7.5 stone.
As I cannot prepare proper meals, and am intolerant to most foods, I reply on lots of tea and chocolate brownies to survive. Only the Sainsburys free-From brownies are OK since they do not contain potato starch.

If I did not have a disabled son, too far away to meet, to support by telephone, life would not be worth living, most days. He does not get the support he needs to live alone.

We are both have the Autism Disabilty (he is mentally higher functioning than I am, especially since the MS has damaged my cognitive abilities, but he has more extreme social anxieties.) He cannot cook a meal, or do the washing up. Cannot go out of the damp basement flat through fear that the third attempt to kill him might suceed, and has just been served an eviction notice.

And both of us are fighting the DWP to keep our benefits.

Truth is stranger than fiction, As you write, many of the statistics really needed are ones that are not collected.

Today I was able to write all this, but the past two days I was in an MS fog and could not use my brain to think or write at all.

Lee Avery

Position
children's adult Mh and sub Misuse SW,
Organisation
LB Croydon
Comment date
07 August 2019

There continues to be a lack of integrated commissioning and pooling of Health and Social care budgets. Means that there is replication in silo's of NHS and Social care to achieve inter related outcomes, that essentailly are not joined up, work against each other, create gaps and waste. Ultimately the safety of patients and residents is common goal but is compromised. Reserach and review about working togther consistently shows this eg Triennial and Biennial Serious Care Reviews, Munro Report, Think Family etc

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