Memorandum by Independent Healthcare Association
(DD 13)
CONTENTS
1 Executive Summary
2 Introduction
3 Delayed Dishcarges—
The Key Factors
4 Intermediate Care
5 Recent Developments
6 Conclusion—
Solutions for Care
1. EXECUTIVE
SUMMARY
1. Partnerships between the NHS, local authorities
and the independent sector already benefit hundreds of thousands
of people each year. In many cases these partnerships allow people
to be discharged from NHS hospitals into a more appropriate care
environment or to avoid hospital admission altogether.
2. Tackling the problem of delayed discharges
must require the optimal usage of independent sector resources
and services, as appropriate, for the benefit of NHS patients.
3. The independent health and social care
sector is today an integral part of the nation's health and social
care system providing 443,000 beds and employing over 750,000
people. Overall, the IHA estimates that the capital invested in
the UK's independent health and social care sector is in excess
of £15 billion.
4. The key reasons for delayed discharges
relate to:
— Delayed and/or inadequate care assessment.
— Funding constraints particularly
within Social Services Departments.
— Non availability of independent residential
care and nursing home places including specialist and intermediate
care facilities.
— Patients exercising their right to
choose an independent residential care or nursing home.
— Poor communication between agencies
and care professionals.
— Poor information systems.
— Poor organisation systems.
5. The IHA welcomes the government's intermediate
care initiative. Furthermore, the Concordat was a positive endorsement
of the role that the independent sector should play in the planning
and provision of intermediate care services.
6. Having identified the key factors necessary
for success of intermediate care and demonstrated that there are
beacons of success in various parts of the country, IHA is critical
that progress has not been more speedy or universal. However,
it appears that the funding issues, the necessity for a commitment
to joint working and the failure to include the independent sector
in the planning processes have all contributed to this lack of
progress.
7. The intermediate care policy has been
portrayed as a panacea to the problems of delayed discharges and
care of older people well in advance of the funding, commitment
and ability of the NHS and Social Services to successfully implement
the policy.
8. The NHS should recognise and value the
contribution that can be made to it by the independent health
and social care sector through: independent representation on
local planning forums; the mapping by the statutory sector of
available services in the independent sector; the establishment
of long term and properly funded contracts with the focus on achieving
high quality services and outcomes for patients.
9. The NHS should be required to commission
care services on a best value basis, thereby ensuring that alternative
provision outside the NHS is considered on a fair and equitable
basis.
10. An immediate increase in fees payable
to independent nursing and residential care homes is required
to ensure that adequate and high quality capacity is maintained
for the benefit of people who use the health and social care system.
11. The effective use of care funds is conditional
upon better strategic partnerships and joint commissioning between
health and social services. IHA believes that care trusts hold
the opportunity to better assess and purchase care services in
particular for older and disabled people.
12. Establishing more schemes which allow
GPs to directly admit their patients into independent nursing
homes would prevent unnecessary admissions to hospital. General
Practitioners wish to admit patients straight into independent
homes both to receive services and in some cases to ensure a place
of safety.
13. Strategic partnerships must also be
developed between the independent care sector and statutory health
and social care communities. These must be based on shared objectives,
clear outcome measures, long term contracts and adequate funding.
14. The NHS Executive should clarify the
priority and importance that intermediate care does or does not
have in comparison to other NHS and politically driven initiatives.
15. New policies such as intermediate care
should be properly evaluated over time. The independent sector
should be encouraged both to lead and contribute to such evaluations.
16. To aid better communication with the
NHS and social services a directory or list of all intermediate
care coordinators should be published with their contact details.
In this way, independent sector providers can be proactive in
demonstrating the high quality best value care services that it
can provide.
17. The funding of GP and other clinical
support services to intermediate care schemes should be clarified.
Clearly, if there are extra workload implications of an intermediate
care scheme for GPs and other clinical staff, these need to be
funded appropriately.
18. As the NHS moves to focus on patient
centred care and review its clinical governance arrangements it
must be remembered that the individual patient's journey may include
the receipt of care both within and outside of hospitals and both
within the NHS and the independent care sector. As such, independent
healthcare services must be seen as part of the overall health
and social care solution.
2. INTRODUCTION
19. The Independent Healthcare Association
(IHA) welcomes the Health Select Committee's inquiry into Delayed
Discharges.
20. The independent health and social care
sector is today an integral part of the nation's health and social
care system providing 443,000 beds and employing over 750,000
people. Overall, the IHA estimates that the capital invested in
the UK's independent health and social care sector is in excess
of £15 billion.
21. Tackling the problem of delayed discharges
must require the optimal usage of independent sector resources
and services, as appropriate, for the benefit of NHS patients.
While there are currently some good and growing examples of partnership
working between the independent sector and statutory authorities—such
as the Concordat and the agreement Building Capacity and Partnership
in Care—much more can be done to implement these respective
documents.
22. Partnerships between the NHS, local
authorities and the independent sector already benefit hundreds
of thousands of people each year.
— Independent nursing and residential
care homes together provide more than 430,000 beds in comparison
to 13,000 beds in mental health units and acute hospitals, and
offer a wide range of high quality services to local authority
and NHS purchasers.
— Independent nursing and residential
care homes provide more than 150 million bed nights of long term
care each and every year.
— The independent sector cares for
around 200,000 people in their own homes on behalf of local authorities
or around 56 per cent of the total contact hours of home help
or home care.
— The agreement issued on 9 October
2001 entitled Building Capacity and Partnership in Care demonstrates
the government's commitment to fully mobilising independent sector
social care provision and services. This enabling agreement will
hopefully stabilise the care home sector.
— A number of innovative and proven
intermediate schemes are currently working in independent nursing
and residential care homes.
— IHA estimates that in 2001 independent
acute hospitals treated around 100,000 NHS elective, critical
care and outpatient patients under the Concordat signed in autumn
2000.
— Independent providers offer around
a quarter of the country's combined acute mental health treatment
plus 55 per cent of NHS medium secure provision.
23. In the other European democracies, there
is a clear recognition that partnership working is good for public
sector services. In Belgium, two thirds of hospital beds are in
the independent sector. In Germany and Spain half the beds are
in the independent sector. In Austria, France, Greece and Italy,
one third of all hospital beds are in the independent sector.
And in Portugal and Switzerland independent hospitals provide
more than a quarter of all beds.
24. Overall, the IHA estimates that the
capital invested in the UK's independent health and social care
sector is in excess of £15 billion making it a vital part
of the nation's health and social care resource.
25. While the overall direction of such
partnership working is good news for NHS patients, there are nevertheless
areas of concern which are particularly pertinent to this inquiry.
These include:
— Inadequate funding for individuals
receiving independent care services
— Slow development of intermediate
care
— Lack of involvement of the independent
sector in long-term planning
26. In order to address these concerns,
IHA believes that the potential of the independent sector, and
in particular the care home sector, must be fully utilised. Only
in this way will delayed discharges be reduced and the objectives
of the NHS Plan fulfilled. To use independent mental health services
and acute hospitals for example but not appropriately fund care
homes is unsustainable. Using one without the other will achieve
very little. For NHS public private partnerships to work, all
the nation's health and social care resources have to work together
in a professional and financially viable, sustainable and unified
manner.
About the IHA
27. The Independent Healthcare Association
(IHA) is the leading association for the United Kingdom's independent
health and social care providers. Members include not-for-profit
services run by charities, mutuals and friendly societies, as
well as "for-profit" organisations—large and small.
These include:
— Independent nursing, residential,
domiciliary and intermediate care providers.
— Mental health hospitals.
— Substance misuse units.
— Pathology laboratories.
— And a host of other health and social
care companies.
28. The IHA was formed in 1949 with the
birth of the Association of Independent Hospitals and Kindred
Organisations and has existed in its current form since 1987.
It is a registered charity (296103), incorporated under the Companies
Act (2082270), being a company limited by guarantee.
29. The IHA promotes the highest standards
in the independent sector and strives to influence future policy
debate across health and social care. It maintains consultation
with government and other bodies on the provision of medical,
nursing and social care. It also analyses and disseminates information
to members, promotes knowledge of the independent sector to the
general public and encourages the right of individuals to choose
independent sector treatment and care.
IHA members
30. IHA members operate more than 86,000
beds and have a combined turnover of more than £4 billion
a year. There are three main groups of IHA membership: community
care, mental health and acute medical/surgical hospitals.
— IHA members provide more than 73,000
nursing and residential care home beds—out of a national
total of 430,000.
— IHA members offer over 3,000 beds
in mental health and substance misuse units.
— IHA members include over 200 acute
medical/surgical hospitals with more than 10,000 beds.
— The IHA's acute group includes all
the main independent hospital operators and about 90 per cent
of all independent acute hospital provision.
3. DELAYED DISCHARGES—THE
KEY FACTORS
31. This section touches on the causes and
effects of delayed discharges from NHS hospitals. Providing the
independent sector's perspective on the external factors it outlines
some of the contributory factors to this serious problem.
32. The key reasons for delayed discharges
relate to:
— Delayed and/or inadequate care assessment.
— Funding constraints particularly
within Social Services Departments.
— Non availability of independent residential
care and nursing home places including specialist and intermediate
care facilities.
— Patients exercising their right to
choose an independent residential care or nursing home.
— Poor communication between agencies
and care professionals.
— Poor information systems.
— Poor organisation systems.
33. An indication of the scale of the problem
can be seen in Table one which gives the total numbers of patients
aged 75 and over ready for discharge and still occupying a hospital
bed by region in 2000-01.
Department of Health statistics show that, in
the period October-December 2000, in England, the number of patients
aged 75 and over who were ready for discharge but still occupying
a hospital bed totalled 5,801, this broke down to:
1,250 patients were awaiting completion of an
assessment;
427 waiting for a domiciliary care package;
1,647 waiting for a residential or nursing home
placement;
626 waiting for a transfer to NHS non-acute care;
810 patients' assessments had been completed but
were waiting for funding; and a further 1,041 were waiting to
be discharged for other reasons"[1]1.
For 2000-01 this was (by region):
Table 1:
TOTAL NO. OF PATIENTS AGED 75 AND OVER READY
FOR DISCHARGE BUT STILL OCCUPYING A HOSPITAL BED BECAUSE THEY
ARE:
| Region: | awaiting social
services dept
(SSD) funding
| awaiting
completion of
assessment
| awaiting
domiciliary
package
| awaiting
nursing/
residential
placement
| Total no. of
patients aged 75
and over ready
for discharge but
still occupying a
hospital bed
| Total no. of
patients aged 75
and over
occupying an
acute hospital
bed
|
| North & Yorks | 77
| 143 | 42
| 185 | 548
| 6,605 |
| Trent | 40 |
63 | 55
| 106 | 356
| 5,121 |
| Eastern | 116
| 244 | 59
| 235 | 858
| 5,497 |
| London | 140
| 186 | 98
| 292 | 1,030
| 6,190 |
| South East | 150
| 151 | 54
| 352 | 1,206
| 8,215 |
| South West | 102
| 127 | 35
| 238 | 673
| 5,990 |
| West Midlands | 77
| 168 | 41
| 92 | 531
| 5,108 |
| North West | 108
| 168 | 43
| 147 | 599
| 6,800 |
| England | 810
| 1,250 | 427
| 1,647 | 5,801
| 49,526 |
Source: NHS Executive Common Information Core—Quarterly
Monitoring Activity Data 2000/01 (Year end information)
Assessment
34. A comprehensive, multidisciplinary assessment of
need is essential to allow further care services to be properly
defined and planned. Any delay in organising this assessment will
clearly delay discharge from hospital. In addition, the lack of
appropriate and skilled assessment will mean people either remain
or become inappropriately placed. In some cases, this is due to
a shortage of key personnel for example care managers. This will
have a particularly detrimental effect on individuals for whom
speedy access to rehabilitation services is necessary to stop
them becoming more dependent. Currently there is no agreed single
assessment process and this also greatly contributes to delayed
discharges.
Funding
35. The funding and expenditure of local authority social
services departments has a critical impact on NHS hospital service
and delayed discharges. Moreover, individuals remain in hospitals
unnecessarily because social services are either unable or unwilling
to fund their ongoing care services following hospital discharge
even if those services are available and ready to be used. In
effect, some social services departments operate unacceptable
waiting lists for social care services. This may involve setting
care home admission limits, operating allocation panels or a one-out,
one-in, policy.
Care Home Availability
36. IHA believes that one of the most significant factors
is the availability of care services provided by the independent
sector and in particular residential care and nursing homes.
37. The recent high number of home closures across the
country has caused additional pressures for NHS hospitals in many
areas. It is not appropriate for older people to be in an acute
setting unnecessarily rather than in alternative care services.
38. IHA believes that home closures are a direct result
of inadequate fees paid by local authorities for state-supported
residents in care homes. Well documented research has clearly
shown that fees payable to independent care homes by local authorities
fail to meet the cost of providing this care by around £60-£65
per person, per week. A recent survey by Paul Burstow MP estimated
that in 2001 charities who provide care home beds were having
to contribute an estimated £184 million per annum to meet
this shortfall. In recent years, fee increases to independent
care homes have averaged two to three per cent per annum. Whilst
supporting better staff wages and conditions it should be recognised
that these have increased costs to providers by around five to
10 per cent. As a result many independent care homes have become
unviable and have been forced to close with tens of thousands
of residents losing their homes. In all, it is estimated that
nearly 50,000 beds have closed in the independent sector since
1996.
39. Legitimate extra funding is available for individuals
through third party top-ups. However some authorities refuse to
allow homes to take such top-ups.
40. In some cases there is simply not the political will
locally to deal with these issues. This manifests itself as a
low political priority for the needs of older people or antipathy
to working with and utilising independent sector capacity and
residential care homes in particular. In some cases the decision
appears to have been taken to promote local authority Part III
homes over and above alternative best value homes in the independent
sector.
41. Independent care homes are forced because of inadequate
local authority fee rates to focus where possible on self funders.
In which case, overall available capacity for state supported
residents is reduced.
42. Waiting lists may also exist for domiciliary care
packages or equipment and adaptations of an individual's own home.
Again, the primary reason for these lists may be due to a lack
of money, or suitably qualified staff.
Choice
43. It is of course right that people are empowered to
make choices regarding the care home to which they wish to move.
In some cases therefore, discharge from hospital will be delayed
because the home of a person's choice has no vacancy available.
In this situation, if interim short term placements are being
considered people should have access to high quality care information
and if necessary advocacy services.
44. A number of specialist services for example rehabilitation
following traumatic brain injury are concentrated in a few areas
and as such it may be necessary for a patient to travel to receive
the treatment they require. Where patients are transferred some
distance across health and social care boundaries discharge delays
are more likely.
Information
45. In general, access to up-to-date information on care
service availability is crucial for both the individual and the
care professionals involved in the individual case. It could be
that inadequate information, for example on bed availability in
independent homes, or slow access to information for the individual
contributes to delayed discharge.
Communication
46. The issue of information also highlights the overall
importance of good clear communication between hospital staff,
other care professionals working outside the hospital—including
in the independent sector—and the individual involved, together
with his/her family. This can improve the speed of hospital discharge
but also prevent re-admission to hospital in the future. Clearly,
good communication also means ensuring that records regarding
assessment and care needs are shared appropriately with the care
professionals involved in the person's ongoing care.
47. The multidisciplinary nature of assessment and care
provision adds to the difficulty of communication as does the
lack of a single assessment process. However, care professionals
must ensure that lines of communication and responsibilities are
clear and understood by all involved.
Access to Intermediate Care
48. Access to intermediate care services will clearly
also impact on the ability of a hospital to discharge an individual.
IHA believes that the independent sector has a key role to play
in the planning and provision of these services. The independent
sector can contribute tangibly to the intermediate care initiative
and thereby help reduce delayed discharges. Further discussion
on this problem is noted in section four.
Poor organisational systems
49. Complex and rigid systems for allocating funding
frequently disadvantage patients. In Rotherham for example Social
Services panels meet only once a week. Once funding has been agreed
the placement must be made within two weeks; eg ten working days
or the funding is withdrawn in which case the whole process must
start again. This duplication and inefficient use of resources
contributes to delayed discharges, where the facility in the community
is not immediately available.
The effects of delayed discharges
50. The effects of delayed discharges are wide ranging
but of ultimate concern because of the impact they have on individual
patients. Remaining in an acute hospital setting inappropriately
is detrimental to a person's health and well being. Patients may
not be receiving the care input they require, particularly in
respect of rehabilitative services. It is also likely that people
will become unnecessarily institutionalised with all the concomitant
implications including hospital acquired infections, pressure
sores and depression. Deaths from hospital acquired infections
are around five thousand per annum. Many independent homes also
have to spend time dealing with patients continence problems brought
on by a prolonged stay in hospital.
51. Furthermore, unnecessary inconvenience and suffering
is caused to people whose operations are cancelled as hospital
beds are unavailable due to the problem of delayed discharge.
As a result waiting times remain unacceptably long.
52. The financial cost to the NHS and thus the taxpayer
of what is essentially a chaotic and fragmented system is profound.
The average cost of treating a patient in an NHS hospital is estimated
to be £1,630 a week, whereas the average cost of care in
an independent nursing home is from £400 per week.[2]
53. While IHA recognises that the cost to the NHS would
be the same or greater for a new admission into a particular NHS
hospital bed it must be remembered that in the case of a delayed
discharge the £1,630 is being wasted on inappropriate care
and does not provide a Best Value option for the NHS.
4. INTERMEDIATE CARE
54. The IHA welcomes the government's intermediate care
initiative. The association believes that such care can enhance
the quality of an individual's life through the promotion of independence
and returning people to their own home. Indeed, the IHA's support
of intermediate care has been made clear through its signing of
the Concordat, For the Benefit of Patients in the Autumn of 2000.
Furthermore, the Concordat was a positive endorsement of the role
that the independent sector should play in the planning and provision
of intermediate care services.
55. Today, there are some excellent examples of the independent
sector providing much needed intermediate care services and contributing
directly to the reduction of delayed discharges in a number of
areas. However, much more must be done if the problems of delayed
discharges are to be truly resolved.
56. Schemes that IHA considers have been a success and
that demonstrate the validity of not only intermediate care but
the importance of working with the independent sector include
services provided by IHA members: Trinity Care in Leeds, Westminster
Health Care in Birmingham, Ashbourne Homes in Camberwell, Four
Seasons Health Care in Halifax and Craegmoor Healthcare in Powys.
57. In Leeds, Trinity Care has a contract to provide
seven intermediate care beds with Leeds City Council and North
Leeds Primary Care Group. Of 68 admissions to date, 41 have so
far been discharged back to their own homes.
58. In Birmingham, during the period 11 December 2000
to 31 March 2001 Westminster Health Care enabled 273 bed nights
for the NHS's Royal Orthopaedic Hospital Trust, 212 bed nights
for the NHS City Hospital Trust and 30 bed nights for the NHS
Good Hope Hospital Trust to be used for new patients and further
treatment.
59. In Camberwell, the Ashbourne Homes scheme ran for
three months with an estimated saving to the NHS of £108,000.
Occupancy during this period was 96 per cent. However, this scheme
has now closed due to a lack of statutory funding.
60. In Halifax, Four Seasons Health Care has a contract
for 15 intermediate care beds and five nursing/respite beds with
Calderdale Primary Care Group and Calderdale Metropolitan Borough
Council. To date, 42 people have been admitted of whom 31 have
returned to their own homes.
61. In Powys, Powys Health Authority fund a GP unit run
by Craegmoor Healthcare established in 1996. An important feature
of this scheme is the facility for GPs to admit directly into
the unit from the community thus preventing hospital admissions
which might unnecessarily block acute beds. All members of the
Community Team including GPs, community nurses, physiotherapists
and social workers visit patients at the unit. The average length
of stay is three weeks and in 1999 over 150 patients were admitted.
62. In each case, there were significant benefits for
the individuals involved and savings for the NHS. By including
the independent sector as a part of the NHS family and indeed
social services family a seamless and high quality service was
provided to individuals in appropriate settings ensuring that
the NHS used its own beds and resources efficiently and effectively.
63. In distilling the key factors in success from these
and other schemes IHA has identified:
— Positive attitude from statutory authorities to
the independent sector.
— Good two way communications between commissioners
and independe nt providers.
— Trust in the ability of the independent sector
to deliver high quality, best value services.
— Availability of identified long term ring fenced
revenue funding for the service.
— Commitment and involvement from general practitioners
and other clinicians.
— Good and clear information given to patients and
relatives throughout.
— On-going evaluation and review.
— Clear outcomes expected.
— Proven long term commitment to partnership.
— Fair and open contracting procedure.
— Independent sector involvement from the outset.
64. Having identified the key factors necessary for success
and demonstrated that there are beacons of success in various
parts of the country, IHA is critical that progress has not been
more speedy or universal. However, it appears that the funding
issues, the necessity for a commitment to joint working and the
failure to include the independent sector in the planning processes
have all contributed to this lack of progress.
65. Successful schemes are however, hard to come by and
the IHA receives more feedback on the difficulties faced by independent
providers in establishing real and ongoing partnership arrangements
with health and social services to provide intermediate care services.
The frustrations of the providers who have access to the resources
and expertise to contribute, is immense. Indeed, one of the schemes
mentioned above was discontinued due to a lack of ongoing funding
from the health authority.
66. Despite the assurances of considerable extra investment
for implementation of intermediate care, it is the independent
sector's experience that new schemes have either been cancelled
or cannot be established in the first place because the NHS and
social services maintain that they do not have the funding available.
67. Whilst IHA accepts that the total extra funding will
not be available until 2003-04 it is regrettable that positive
ideas and initiatives cannot be simply progressed or developed
at this stage. IHA is further concerned that the 2002-03 NHS financial
allocations and priorities do not re-emphasise the distinct funding
for and priority of intermediate care services commissioned by
the NHS, the implication for health authorities being that intermediate
care no longer holds the political imperative it once did.
68. Bearing in mind the considerable organisational changes
taking place in the NHS, it could also be argued that intermediate
care has had to take a lower priority. Whilst the IHA appreciates
the aim behind the Department of Health document, Shifting the
Balance of Power Within the NHS[3]
of introducing more community focused commissioning it has meant
an interregnum between the work of health authorities and trusts
and the new strategic health authorities and primary care trusts.
Moreover, it will take time for PCTs and St HAs to build up the
organisational and managerial capacity to implement this policy
effectively.
69. It seems to have taken an inordinate amount of time
for key messages on intermediate care to reach NHS and Social
Services commissioners and to be put into effect. This is particularly
pertinent to the independent sector which has in some areas been
excluded from the development of intermediate care locally.
70. Failure to mobilise the full range of independent
sector resources, skills, experience, expertise and capital is
also a result of an insular NHS culture that remains suspicious
or unaware of the potential of the independent sector to help
ease pressures and contribute to high quality patient care.
71. One consequence of the NHS relying solely on an in-house
approach is that it restricts the opportunities for a real increase
in intermediate care capacity as opposed to a re-structuring of
already existing NHS capacity. The opportunity costs for the NHS
should also be considered. For example, beds developed for intermediate
care are not available for acute surgery thus compounding the
capacity problems in the NHS. It could also be argued that the
targets for extra capacity in overall terms of beds and services
for intermediate care are in themselves relatively modest. There
are 356,000 beds in the NHS and Social Services combined and 443,000
in the independent health and social care sector. Targets therefore
of 1,500 extra beds by March 2002 and 5,000 extra beds by March
2004 represent a small percentage of this total some of which
will be spare capacity.
72. Consultation on future intermediate care services
has recently started in North Staffordshire Health Authority.
The consultation document accepts that the independent sector
will only be used for an interim period until the health authority
has completed a new build unit for intermediate care. The planning
group who have prepared the document has no independent sector
member and no independent sector organisation has been invited
to comment as part of the consultation exercise.
73. Similarly, it is still far from clear that general
practitioners and NHS clinicians fully appreciate the contribution
the independent sector can make to intermediate care and thereby
the easing of pressures associate with delayed discharges. As
previously mentioned a hallmark of a successful intermediate care
scheme with the independent sector is the commitment of local
GPs to the aims and objectives of the scheme.
74. In summary, the intermediate care policy has been
portrayed as a panacea to the problems of delayed discharges and
care of older people well in advance of the funding, commitment
and ability of the NHS and Social Services to successfully implement
the policy.
5. RECENT DEVELOPMENTS
75. On 9 October 2001 along with the document "Building
Capacity and Partnership in Care" the government announced
an extra £300 million for local authorities to end unnecessary
delayed discharges from hospitals by April 2004. There is an interim
target of freeing up more than an extra 1,000 beds in NHS hospitals
by March 2002.
76. While all of this is to be welcomed, IHA remains
concerned that a sustained improvement will not be possible unless
the loss of independent nursing and residential care home places
is stopped. Fifty thousand beds have been lost over the last five
years or an 8.6 per cent reduction in capacity[4].
77. Despite many other forms of care services, it has
to be accepted that many individuals and their families value
the option of independent nursing and residential care homes.
For many thousands of people, this is their preferred high quality,
best value choice. In addition, independent homes provide flexible
intermediate, respite and day care solutions that support the
promotion of independence and the ability of family carers to
continue in this vital role. In summary people choose independent
homes because they offer individualised care, a comfortable environment,
companionship and accessible, flexible and high quality care.
78. As part of the funding announced by the government
on 9 October 2001 funding was set aside for the creation of a
national Health and Social Care Change Agent Team. This team will
support local health and social care communities in tackling delayed
discharges. The team will be able in addition to call upon a group
of around 30 professionals who can further assist in this task.
IHA welcomes the team and has put forward the names of members
who wish to be both appointed to the team or be a part of the
wider group. It is IHA's view that people with an independent
sector perspective will greatly add to the strength of the team.
IHA awaits announcements on the final makeup of the team and the
wider group. Indeed, in October 2000 the IHA put forward the names
of members to each of the eight NHS regions for consideration
as part of their teams of change agents. Four NHS regions appointed
independent sector people to their teams and IHA understands from
the Department of Health that in these areas the input of these
people was a positive experience for all concerned.
79. Care Direct is currently being piloted in a number
of authorities in the South West of England. For many people Care
Direct will be the first point of contact upon needing advice
when concerned with social care and benefit issues. Care Direct
is sited within local authority social services departments. IHA
believes it is vital that Care Direct has an understanding of
and access to information regarding independent sector care services.
IHA is not encouraged that to date this issue has been addressed
and the association awaits further details concerning how Care
Direct will operate. In many ways this illustrates the difficulty
faced by the independent sector in being involved in the development
of initiatives that will impact directly upon it.
Other Initiatives
80. The independent sector provides an extremely diverse
range of care services. Whilst this paper has concentrated on
the provision of services by independent nursing and residential
care homes, many innovative services are available which promote
speedy discharges from hospital and in many cases prevent hospital
admissions in the first place. Again, these services are focused
on promoting independence when and wherever possible.
81. Remote monitoring of people in their own homes can
for those who wish provide a safe and secure means through which
they may live independently.
82. The use of independent rapid response teams, supported
by the latest generation of monitoring technology, sometimes based
around an independent nursing or residential care home, can deal
with emergency situations in a persons own home which had they
not been available would have resulted in the person being admitted
to hospital.
83. As technology advances, many services once only possible
in a hospital setting can now be administered in peoples own homes.
Healthcare at home can deliver services that include, chemotherapy,
intravenous antibiotics, chronic obstructive pulmonary disease
patient services, and even early discharge schemes for orthopaedic
patients.
84. Again, the independent sector has considerable experience
in providing a wide range of services that fall under the rubric
of health education and promotion. Independent service providers
have years of experience in such areas as health screening, the
administration of helplines which make important, yet all too
often unseen, contributions to the health of the nation.
85. Additional services which the independent sector
might provide include assessment and treatment programmes for
maximising independence and a home assessment service for example
for those wishing to access disability grants. With reference
to these grants, assessments can be speedily carried out for people
who have often been waiting months for an assessment.
86. Unfortunately registered nurses working in the independent
sector have been prevented from undertaking the assessments for
"Free Nursing Care" as only a registered NHS nurse may
do these. This has diverted a considerable amount of resources
from the NHS and in particular district nurse services. This will
add to the pressure on the NHS which is trying to discharge people
into nursing homes (but who are awaiting a "Free Nursing
Care" assessment) or into their own home with district nurse
support.
87. Finally, the use of information technology and databases
not only help to inform patients and people of the services and
choice available to them, but it can greatly assist care professionals
to undertake their jobs in more efficient and effective ways.
For example, some companies are piloting the use of care home
bed vacancy information for care professionals so that they can
access provision more easily when they are planning a hospital
discharge.
88. NHS Direct which has been established to give confidential
health care advice and information 24 hours a day to the public
could provide a point of access to independent sector issues,
in particular, access to appropriate services available to the
public in the independent sector. The IHA is aware that this would
require the development of further protocols but has in the past
expressed its willingness to assist NHS Direct in providing that
appropriate advice that can be then disseminated to the public
should that be the nature of their enquiry.
6. CONCLUSION—SOLUTIONS
FOR CARE
89. In addressing the issues identified in this evidence,
IHA believes that the following points must be accepted by the
government.
— The NHS should recognise and value the contribution
that can be made to it by the independent health and social care
sector through independent representation on local planning forums;
the mapping by the statutory sector of available services in the
independent sector; the establishment of long term and properly
funded contracts with the focus on achieving high quality services
and outcomes for patients.
— The NHS should be required to commission care
services on a best value basis, thereby ensuring that alternative
provision outside the NHS is considered on a fair and equitable
basis.
— An immediate increase in fees payable to independent
nursing and residential care homes is required to ensure that
adequate and high quality capacity is maintained for the benefit
of people who use the health and social care system. The government
has recently allocated an additional £300 million cash for
change for social services over the next 18 months to reduce delayed
discharges and stabilise the independent care home sector. Whilst
IHA welcomes this move, the association in its contributions to
the Strategic Commissioning Group confirmed that the amount actually
needed is around £1.5 billion per annum to prevent further
erosion of capacity in the independent nursing and residential
care home economy. In addition to which the £300 million
is not ring fenced for spending in the independent sector and
as such its impact on stabilising the care home market is patchy.
In 2001 the Kings Fund published the report Future Imperfect?[5]
It estimated £700 million was needed in the care home sector
to improve the recruitment, retention and training of care staff.
— The effective use of care funds is conditional
upon better strategic partnerships and joint commissioning between
health and social services. IHA believes that care trusts hold
the opportunity to better assess and purchase care services in
particular for older and disabled people. The current division
in the funding and management structures of health and social
services directly contribute to delayed discharges. Perverse incentives
exist for example if a person remains in hospital then social
services budgets are unaffected. Similarly, it encourages a blame
culture and the passing of responsibility from one to the other.
IHA believes the barriers between health and social care should
be brought down for the benefits of people who seek seamless services.
— Strategic partnerships must also be developed
between the independent care sector and statutory health and social
care communities. These must be based on shared objectives, clear
outcome measures, long term contracts and adequate funding. The
involvement of the independent sector in the planning processes
is essential if the targets of the NHS Plan are to be met. Equally,
the independent sector must strive to make a positive and inclusive
contribution to the planning framework. IHA welcomes the recent
"Building Capacity and Partnership in Care" agreement
and will work constructively to ensure its principles are implemented
both locally and nationally. Draft good practice guidance on partnership
working, including the independent sector, as part of the Learning
Disability Strategy is also to be welcomed. There should be independent
care home and acute hospital representatives on every local capacity
planning group in the country.
— As the NHS moves to focus on patient centred care
and review its clinical governance arrangements it must be remembered
that the individual patient's journey may include the receipt
of care both within and outside of hospitals and both within the
NHS and the independent care sector. As such, independent healthcare
services must be seen as part of the overall health and social
care solution.
Intermediate Care
— Despite the intermediate care circular "HSC2001/1:LAC(2001)1
Intermediate Care" there remains confusion locally as to
how much money is actually available to develop new intermediate
care services. It is clear that some independent care initiatives
have simply been stopped due to a lack of money. IHA believes
that a circular should be issued stipulating the precise amount
of funding each health and social care service has been allocated
for the purpose of developing intermediate care. In addition,
the NHS Executive should clarify the priority and importance that
intermediate care does or does not have in comparison to other
NHS and politically driven initiatives.
— New policies such as intermediate care should
be properly evaluated over time. The independent sector should
be encouraged both to lead and contribute to such evaluations.
Clearly, joint objectives based on reaching positive outcomes
agreed at the outset between independent providers and statutory
sector partners would greatly aid the subsequent evaluation of
such schemes. It is clear that intermediate care has the potential
to impact positively to reduce NHS hospital waiting lists and
trolley waits as well as reduce hospital admission rates in the
first place. However, the lack of solid data sets to form a base
line are a major problem.
— Where examples of successful and high quality
intermediate care schemes exist there should be a systematic means
by which they are circulated and disseminated. In this way, it
is hoped that a shift in culture will occur overtime and that
the transition towards a genuine approach to partnership working
will result. IHA believes that national associations will have
a key role in circulating and disseminating good practice. The
Department of Health should support the ability of associations
to undertake this role.
— Establishing more schemes which allow GPs to directly
admit their patients into independent nursing homes would prevent
unnecessary admissions to hospital. Prior to 1993, this arrangement
flourished and as such delayed discharges were not the problem
that they are today. In some cases an immediate place of safety
will be required or in others a range of care services which the
independent homes are well qualified to provide.
— To aid better communication with the NHS and social
services a directory or list of all intermediate care coordinators
should be published with their contact details. In this way, independent
sector providers can be proactive in demonstrating the high quality
best value care services that it can provide.
— The funding of GP and other clinical support services
to other intermediate care schemes should be clarified. Clearly,
if there are extra workload implications in an intermediate care
scheme for GPs and other clinical staff, these need to be funded
appropriately.
Independent Healthcare Association
21 January 2002
1
Independent Healthcare Association, 2001, Costs of Care 2001-The
Facts, IHA. Back
2
Minister for Health, Jacqui Smith MP, Written Answer 19th November
2001. Back
3
Shifting the Balance of Power within the NHS, Department of Health,
July 2001. Back
4
Laing and Buisson 2001. Back
5
Future Imperfect?, Kings Fund, 2001. Back
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