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Older people’s health and social care poorly coordinated and fragmented

Too much emphasis on individual performance rather than outcomes, says regulator

Caroline White

Friday, 06 July 2018

Older people’s health and social care is often poorly coordinated and fragmented, concludes a new report* from the Care Quality Commission (CQC), based on 20 local authority reviews looking at how older people move between health and adult social care services in England.

This fragmentation is reinforced by funding, commissioning, performance management and regulatory arrangements which encourage organisations to focus on individual performance rather than on positive outcomes for people, it says.

While the report highlights some examples of health and care organisations working well together, and of individuals working across organisations to provide high quality care, it also found too much ineffective co-ordination of health and care services.

The lack of a shared plan or vision resulted in people not receiving the right care in the right place at the right time, with consequences ranging from care provision needlessly costing more, to added pressure on services, and people’s quality of life being significantly diminished, says the report.

It cites a case of an older woman living at home independently with the support of her son and a domiciliary care agency. After a fall, she was taken to hospital, and was ready to go home after one night, but because the right staff were unavailable over the weekend she couldn’t be discharged. Then her home support services weren’t available, so she still couldn’t go home. She ended up staying in hospital for over a month, during which time her condition deteriorated and she was moved into residential care. She never returned to her own home again.

Genuinely person-centred coordinated health and care cannot just be a long-term ambition, says the report. It is an urgent and immediate requirement for meeting the changing health and care needs of people living longer with increased complex conditions.

The NHS and social care are two halves of a whole, providing support for the same people and there must be a shared vision and performance measures at a local and national level that recognise this, it emphasises.

The report sets out a raft of recommendations designed to improve the way in which agencies and professionals work to support older people to stay well.

These include the development of an agreed joint plan created by local leaders for how the needs of older people are to be supported in their own homes, helped in an emergency, and then enabled to return home; supported by long-term funding reform to remove the barriers that prevent social care and NHS commissioners from pooling their resources and using their budgets flexibly to best meet the needs of their local populations.

In turn, this needs to be underpinned by a move away from short-term to long-term investment in services, and from an activity-based funding model towards population-based budgets which encourage collaboration between local systems, says the report.

A single joint framework is needed to measure the performance of how agencies collectively deliver improved outcomes for older people. This would operate alongside oversight of individual provider organisations and reflect the contributions of all health and care organisations, including primary, community, social care and independent care providers, rather than relying primarily on information collected by acute hospitals, it recommends.

Workforce plans should be developed jointly, with more flexible and collaborative approaches to staff skills and career paths, says the report. It should be far easier for individuals to move between health and care, providing career paths that enable people to work and gain skills in a variety of different settings so that services can remain responsive to local population needs.

And finally, new legislation is needed to allow CQC to regulate systems and hold them to account for how people and organisations work together to support people to stay well and to improve the quality of care people experience across all the services they use.

Sir David Behan, CQC chief executive, said: “Our findings show the urgent necessity for real change. A system designed in 1948 can no longer effectively meet the complex needs of increasing numbers of older people in 2018. People’s conditions have evolved - and that means the way the system works together has got to change too.

“We have seen the positive outcomes that can be achieved when those working in local health and care organisations have a clear, agreed and shared vision together with strong leadership and collaborative relationships, and we met some outstanding professionals, working across organisational boundaries to provide high quality care. However, their efforts were often despite the conditions in place to facilitate joint working, rather than because of them. We need incentives that drive local leaders to work together, rather than push them apart.”

Care minister Caroline Dinenage said: “This report confirms what we already know – the provision of NHS services and social care are two sides of the same coin and it is not possible to have a plan for the NHS without having a plan for social care.

“There are good examples of progress in integrating health and care, including through the Better Care Fund and ongoing joint health and social care assessments pilots, but we know we need to do more.”

The government is set to publish a green paper on social care in the autumn, when the long-term plan for the NHS is also due to be announced.


*Beyond barriers: How older people move between health and social care in England. A report prepared by the Care Quality Commission, July 2018.

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