House of Lords - Ready for Ageing? - Select Committee on Public Service and Demographic Change

Ready for Ageing? - Select Committee on Public Service and Demographic Change Contents

Annex 14: Health and social care: improving local care in practice (see paragraphs 33 and 34 of the report)

234. As well as shifting more focus onto the needs of older people in the community with long-term conditions, there are many other ways in which the delivery of health and social care to older people could be improved.

Reducing duplication and improving service

235. We have already discussed the need for health and social care to be better integrated. Older people do not want to have to repeat the same information to different professionals, or have their needs fall down the gaps between different systems.[391] We heard the case for care managers, who know the systems, can help people navigate through them, pull together funding streams, and advise people with personal budgets or help those who are paying for services privately.[392] Julie Foster, Associate Director for Adult Social Care, Torbay and Southern Devon Health and Care Trust, told us that Torbay's care co-ordinators are "the single biggest factor in making us more successful at integration", and Dennis Holmes did not think that integrated systems could work without a single point of contact.[393] Better co-ordination of care is crucial, and nominated lead care workers could help to bridge gaps between systems and make things happen, as well as ensure that older people feel informed and in control of their care.[394] We also encourage the health and social care services to consider how to ensure that professionals feel responsible for the whole care of the individual for whom they provide care.

236. Making sure that those delivering care can help to support that older person in a holistic way could save money and enhance wellbeing. Professor Mayhew told us that, in one study on intermediate care, he found there were, potentially, 22 different health services alone, excluding social care, which could be aimed at a person needing care at home. He questioned whether this was suitable, and suggested that a more multi-skilled care worker, who could undertake care tasks but also basic health tasks like taking blood pressure and blood samples, would improve the efficiency of home care.[395] Professor Paice agreed.[396]

SHARING DATA

237. Joined-up services cannot work without joined-up information.[397] If health and social care systems cannot easily share data about an individual, the result is inefficiencies, delays, duplications and suffering.[398] Professor Paice, Dennis Holmes, Dr Gordon and Dr Dixon all identified the lack of data sharing as a key obstacle to integration.[399] A fuller care record for each individual would enable better analysis of their case history to support better decision-making.[400] Better data sharing would also enable better planning of services.[401]

238. Some practitioners have made heroic efforts to join up the dots. Professor Paice told us that when the North West London Integrated Care Pilots brought together data across organisational boundaries, it had to ask 24,000 people for their consent, and only 300 objected.[402] In Torbay, the same computer system is being used across health and social care.[403] An electronic palliative care co-ordination system in London has resulted in the number of people in the system who die in hospital falling to half what it is across the rest of London.[404]

239. Enabling more data to be shared is crucial. Constraints must be removed, risk-averse attitudes must be reduced, and myths which result in people feeling unnecessarily restricted must be challenged.[405] If necessary, legislation must be introduced. The Secretary of State for Health told us that he was going to dictate from the centre on this issue, requiring hospitals to update GP records so that they contain full acute, tertiary and social care trails.[406] We welcome this approach.

USING TECHNOLOGY

240. Technologies, including telecare and telehealth, also have the potential to save money and improve the quality of care that older people experience, as well as prevent accidents and crises. We heard about fire alarms, movement sensors, alarm pendants, temperature alerts and programmes to manage complex medication regimes.[407] Professor Oliver warned us that a recent survey of European experts had found that of every country in Europe, "the UK was the least confident about its ability to use telecare, telehealth, new technologies."[408]

241. New technologies are not a panacea—they have to be used carefully to work well and be cost-effective. Telecare and assistive technologies have to be well-designed from the user perspective.[409] Caution is needed to ensure that older people do not feel increasingly marginalised by digitalisation and automation, and to ensure that an expanding reliance on telecare does not increase loneliness.[410] The use of technologies must also keep up with the high pace of change in this sphere.[411]

242. The Secretary of State for Health argued for better use of technology in terms of getting patient information to professionals' fingertips, and letting patients access the NHS as easily as they access banks or book airline tickets.[412] The Department of Health has embraced the rolling out of telecare, telehealth and assistive technology, and we welcome this.[413]

Improving standards in social care

243. Scandals in the recent past have highlighted that standards can fall below acceptable levels in care homes and hospitals, but standards of care delivered within the individual's home are equally important and are difficult to monitor. The state has a fundamental duty to ensure that the vulnerable are protected, including when care is privately provided.

244. William Laing, Chief Executive, Laing and Buisson (Consultancy) Ltd, told us that a large survey of recipients of social care funded by local authorities, run by the Information Centre for Health and Social Care in early 2012, had found that 71% of respondents using residential care had been very or extremely satisfied with their care; this figure fell to about 55% for users of home care.[414] This survey also found that while 30% of residential care or community-based care users felt they had as much control over their daily life as they wanted, 25% felt they had not enough or no control over their daily life. 6% felt less than adequately clean or presentable or not at all clean or presentable. 5% reported that they did not always get adequate or timely food and drink, including 1% who felt that this posed a risk to their health. 7% felt less than adequately safe or not at all safe with regard to abuse, falling or other physical harm. 25% said that care and support services did not help them feel safe. Regarding dignity, 8% reported that the way they were helped and treated sometimes undermined the way they thought and felt about themselves, and 1% reported that it completely undermined this.[415]

245. Low rates of pay for care workers who look after some of our most vulnerable citizens are part of the problem. Sue Redmond said that an important change would be to value what care workers do more highly: "They are doing the most intimate and the most amazing work for people and their status and their pay is very low."[416] Tony Watts, Independent Chair, South West Forum on Ageing, argued that because local authorities do not pay sufficient money to the care homes for each resident, staff are not paid properly, with the result that "You do not get proper training, you do not get the right staff and people go into it as a low-skilled, low-fulfilment job".[417] Lord Warner agreed that "the pay of this work force is being squeezed to really quite potentially dangerous levels".[418] Higher pay rates might encourage more workers into the sector, and could encourage a focus on care as an important growth sector for the UK economy, as in France.[419]

246. The way in which some care workers are expected to deliver care is also inefficient and an obstacle to good care. Care workers commissioned to deliver care during a 15-minute visit (travel time permitting), or to deliver a process such as getting a person up, are likely to become de-motivated and disengaged.[420] Wiltshire Council is now paying care workers according to "outcomes" for the people they care for, such as "'I want to get on with my life' or 'I want to be able to go and see my daughter'". Another aspect of Wiltshire's commissioned outcomes is reducing social isolation: introducing the older person to their local voluntary organisations or groups, or taking them to the library, so that the provider is incentivised to meet the outcomes that will directly improve the older person's quality of life.[421]

247. The Government should be careful that their actions do not work to suppress a healthy market in high-standard privately-provided social care. Phil Pegler told us that he wanted to stop providing care funded by local authorities, because the funding is too low to allow him a profit as the national minimum wage increases. He wanted to provide "a different type of offering that ... will suit the local community and provide a better provision and be more cost effective", but the market is too inhospitable.[422] The Government therefore need to be aware of the impact of local authorities' funding settlements on the private care market.

OPENING UP THE SOCIAL CARE SECTOR

248. Ensuring high standards of social care has to go wider than pay, commissioning or funding restrictions. Social care—whether delivered by the public sector or privately—has to be opened wide to public scrutiny and state inspection if the care market is to work well in the interests of its customers.

249. Older people and their carers need better information on privately-run care homes. When people buy care it is often a "distress purchase", and buyers are not well-informed because the data do not exist or because they do not know where to find the data.[423] Steve McIntosh, Policy and Public Affairs Manager, Carers UK and Martin Green, Chief Executive, English Community Care Association, both regretted that the Care Quality Commission (CQC) does not provide star ratings for care services. Martin Green told us that "what we have now is you are either a pass or a fail service and there is no way to identify whether or not a service is of a much higher quality", although David Behan, Chief Executive, CQC defended the quality of the CQC's reports.[424] The Secretary of State for Health confirmed that he would "like to introduce Ofsted-style ratings across the care home sector, across hospitals, across GP surgeries, the works", as long as it was done in a way that was academically and clinically rigorous.[425]

250. Regulation alone is not enough to create transparency and fully monitor or drive up quality, as David Behan, Sue Redmond and Norman Lamb MP acknowledged.[426] We heard that there is also a role for local authorities, in commissioning the care that they fund, to assist the majority who are paying for themselves.[427] In Wiltshire, 70% of social care is bought privately, but Wiltshire Council has used its commissioning power for the other 30% to monitor and influence the standard of the private providers it contracts with, giving an effective quality stamp that people buying privately can trust.[428] The Council also provides information to private buyers on what to look for, and advice through financial planning advisers.[429] Leeds City Council's social workers will also help self-funders construct care plans.[430] Dennis Holmes highlighted the power of withdrawing contracts, telling us that such a decision would be advertised online for the benefit of self-funders.[431] These are examples of excellent practice, but they are not consistently followed, meaning that being able to make an informed choice is "just pot luck".[432]

251. While local authorities can influence the social care market, they are limited as to how much information they can provide self-funders. Sue Redmond told us that social services could not advise people paying for their own care on whom they should use, due to competition law.[433] But users of these services are free to share information with each other. David Behan considered that "the voice of people that use services" is one of the most important influences on the quality of care.[434] When we discussed the idea of an informal system of care home monitoring by older people, Sue Redmond confirmed it was established practice in a number of local authorities, and that Wiltshire already had older people assessing all of its care agencies, with training and support.[435] Dennis Holmes described "dignity champions" who help to monitor care homes in Leeds, and Martin Green told us that something similar was also happening through the Experts by Experience programme which the CQC has developed, but that it "needs to get more traction and needs to be part of, perhaps, every inspection."[436] Tony Watts confirmed that it was already working in parts of the country, often led by older people's groups, but that many of these groups were closing down because of a withdrawal of funding.[437]

252. As well as welcoming visitors in, care homes should engage more with their local communities. This would have a triple benefit: these homes would be more open to scrutiny, would be able to spread knowledge about effective practice to local informal carers, and would improve their own profile.[438] Dennis Holmes and Norman Lamb MP also highlighted the role of local Healthwatch organisations in supporting the CQC with monitoring care.[439]

253. The users of care services are increasingly able to share more information with each other, which should also improve openness and help self-funders to find good quality care. Sue Redmond told us that "Older people, people who use the services, rating them themselves is the best advice you can get", so local authorities are starting to set up versions of a TripAdvisor-type website forum to allow these people to share their experiences.[440] Martin Green talked of a similar set-up being piloted by the private care sector using a user experience questionnaire.[441] Tony Watts agreed that the idea had potential, as did William Laing, who argued that the private sector was best placed to take this forward.[442] Norman Lamb MP told us that the Government were already creating quality profiles of individual care homes, which include the CQC rating and are intended to include the new quality rating, and which could include user reviews: these "could be an incredibly powerful driver towards improving standards because information is power." He also raised the possibility of requiring all care homes to maintain a direct link on their websites to their CQC rating.[443]

254. We are encouraged that the Government are looking at how to improve the private social care sector, and urge them to provide support for a transparent, good quality private social care market.

SPREADING GOOD PRACTICE

255. We have explored a number of ways in which pioneers on the ground are moving health and social care for older people forward. We congratulate heroic professionals such as those in Torbay and the North West London Integrated Care Pilots who are striving to make the poor system function. Innovative experiences need to be learned from, shared and copied.

391 Q 239, Q 560, Q 658 Back

392 Q 312, Q 321; Q 565 (Professor Elisabeth Paice). Back

393 Q 582 (see Julie Foster and Dennis Holmes). Back

394 Q 624 (Dr Patel). Back

395 Q 346 Back

396 Q 574 Back

397 Q 622 Back

398 Q 333 Back

399 Q 555, Q 558, Q 562, Q 620 Back

400 Q 277 (Caroline Abrahams). Back

401 Q 623 Back

402 Q 555 Back