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
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.
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.
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.
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.
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.
Professor Paice agreed.
237. Joined-up services cannot work without joined-up
health and social care systems cannot easily share data about
an individual, the result is inefficiencies, delays, duplications
Professor Paice, Dennis Holmes, Dr Gordon and Dr Dixon all identified
the lack of data sharing as a key obstacle to integration.
A fuller care record for each individual would enable better analysis
of their case history to support better decision-making.
Better data sharing would also enable better planning of services.
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.
In Torbay, the same computer system is being used across health
and social care.
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.
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.
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.
We welcome this approach.
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
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,
241. New technologies are not a panaceathey
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.
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.
The use of technologies must also keep up with the high pace of
change in this sphere.
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.
The Department of Health has embraced the rolling out of telecare,
telehealth and assistive technology, and we welcome this.
Improving standards in social
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.
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.
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."
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,
Lord Warner agreed that "the pay of this work force is being
squeezed to really quite potentially dangerous levels".
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.
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.
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.
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.
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
carewhether delivered by the public sector or privatelyhas
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.
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.
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.
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.
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
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.
The Council also provides information to private buyers on what
to look for, and advice through financial planning advisers.
Leeds City Council's social workers will also help self-funders
construct care plans.
Dennis Holmes highlighted the power of withdrawing contracts,
telling us that such a decision would be advertised online for
the benefit of self-funders.
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".
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.
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.
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.
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."
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.
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.
Dennis Holmes and Norman Lamb MP also highlighted the role of
local Healthwatch organisations in supporting the CQC with monitoring
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.
Martin Green talked of a similar set-up being piloted by the private
care sector using a user experience questionnaire.
Tony Watts agreed that the idea had potential, as did William
Laing, who argued that the private sector was best placed to take
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
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
Q 312, Q 321; Q 565 (Professor Elisabeth Paice). Back
Q 582 (see Julie Foster and Dennis Holmes). Back
Q 624 (Dr Patel). Back
Q 346 Back
Q 574 Back
Q 622 Back
Q 333 Back
Q 555, Q 558, Q 562, Q 620 Back
Q 277 (Caroline Abrahams). Back
Q 623 Back
Q 555 Back
Q 560 Back
Q 251 Back
Q 279 Back
Q 694 Back
Q 308; Independent Living. Back
Q 280 Back
Q 509 Back
Age UK; Older People's Commissioner for Wales; Low Incomes Tax
Reform Group and Tax Help for Older People. Back
Q 69 Back
QQ 678-Q 679 Back
Department of Health, A Vision for Adult Social Care and
White Paper on reforming care and support. Back
Q 386 Back
The Health and Social Care Information Centre, Personal Social
Services Adult Social Care Survey, England 2011-12 (Final
Release), 2012. Back
Q 399, Q 401; Carers UK; Dr Chai Patel, HC-One; Q 638, Q 129. Back
Q 573 Back
Q 594 Back
Carers UK, Q 288 (Steve McIntosh, Policy and Public Affairs Manager,
Carers UK). Back
Q 375, Q 559, Q 377 Back
Q 377, Q 399 Back
Q 315 Back
Q 628 Back
Q 223, Q 375, Q 384, Q 629; Q 266 (Philip King, Director of Regulatory
Development, CQC). Back
Q 696 Back
Q 627, Q 377, Q 695 Back
Q 266 Back
Q 379, Q 381 Back
Q 383 Back
Q 564 Back
Q 564 Back
Q 398 Back
Q 394, Q 402, Q 403 Back
Q 627 Back
QQ 395-396 Back
Q 572, Q 385 Back
Q 567 Back
Q 419 Back
Q 572; Q 695 Back
Q 397 Back
Q 397, Q 403 Back
Q 572, Q 403, Q 404 Back
Q 696 Back