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Taking the initiative
driving integration

Debbie Sorkin reports on how residential and home care providers are playing a proactive role in working with health services, to improve the wellbeing and quality of life of the people they support.

Have you heard that clucking sound recently? It’s the sound of chickens coming home to roost. If you cut local authority social care budgets (to the tune of over £3.5 billion over the last four years according to the Association of Directors of Adult Social Services), at the same time as you let GPs skip weekend care and neglect other pre-emptive services like NHS 111, and you couple this with rising demand, then pressure builds up elsewhere in the system.

The pressure has been seen most acutely over the past few months in accident and emergency (A&E), with visits in England increasing by more than 400,000 so far this financial year, and waiting time performance slumping to its lowest level in a decade.

As Simon Stevens, Chief Executive of NHS England, and his partners have acknowledged in the Five Year Forward View, this way of working is simply unsustainable. Hence the plan over the next five years is to place much more emphasis on prevention, so that people are supported in the community, health and care services are much more integrated and there is less strain on acute services.

Social care providers are reporting that getting NHS Trusts to see what they can do to support the integration agenda, and to work in partnership, has been a frustrating experience, with
offers of help falling on deaf ears. It doesn’t need to be like this, and there is mounting evidence of the way in which providers across the private and not-for-profit sectors around the country are taking the lead in driving these new models of care.

Providers driving integration

At a basic level, providers are quite simply going in and sorting out issues that are leading to delayed hospital discharge. Langton Care, a small provider working with older people in Devon, is a good example. In one case, a service user had been in hospital recovering from a hip operation, and there appeared to be conflicting information as to why their transfer to residential care was taking so long. With the family’s permission, the Managing Director of Langton Care, Christina Sell, went to the hospital and resolved four separate – and as it turned out, easily resolved – issues that were preventing the service user from leaving.

The first issue stated was that the person could not be moved because of constipation: Christina explained that they could manage this in the home. The second issue given was that the person needed a particular kind of bed – again, one was already available in the home, but no-one in the Trust had thought to ask. Thirdly, there was a delay because medication had not been sent up from the Pharmacy, so Christina went to the Pharmacy to collect it. Lastly, there was no available transport, so Christina arranged for this and the patient was discharged to Langton Care the following day. The Discharge Sister was apparently amazed at how quickly they could react to each and every problem presented.

In Christina’s view, ‘On many occasions, as responsible providers and as people with a working knowledge of how the NHS and social care systems work, we have been able to cut through red tape, reduce lost bed days in hospital and provide the service user and their families with a service which they had chosen for themselves.’

Similarly, in Shropshire, Coverage Care, a not-for-profit organisation with residential and day services for older people, works closely with the NHS, either through clinical commissioning groups (CCGs) or more directly, in terms of clinical support for individuals, with acute, community and mental health trusts.

Coverage Care works with its local acute trust with referrals from ‘trusted assessors’. The aim here is to discharge to assess and move through the re-ablement process to enable a planned return home without an unnecessary long-term admission to a care home. Both Telford and Shropshire have witnessed a significant reduction in permanent admissions to care homes this year as a result of this and other initiatives. As David Coull, Chief Executive of Coverage Care, said, ‘The reality is that all social care is local, and the better health services are managed locally, in partnership with the same local social care services.’

Preventing admissions

This isn’t just about proper care of people leaving hospital. Providers have been working for many years to prevent hospital admissions in the first place. For example, Coverage Care has used this approach for more than five years, especially for people with dementia, working with a local consultant psychiatrist who spends an agreed amount of time, with his team, in Coverage Care’s 75-bed nursing home.

At the same time, they work with a modern matron who completes a weekly visit for any resident at the home who is unwell, spends time with the residents and prescribes antibiotics and other drugs as needed. Both projects have worked well and have been supported through the local CCG.

Likewise, Nightingale, which provides residential care for older Jewish people in South London, has been funded through its CCG for medical services to be provided on-site, rather than having to pay for GPs to come in, as had historically been the case.

A nearby practice provides a doctor who attends five days a week, a senior nurse practitioner, and a practice manager, who handles the administration. The CCG also funds on-site pharmacy services, which sit alongside audiology, dental services and occupational therapy. All residents are seen in the privacy of their own rooms. The outcomes have included lower rates of hospital admission and much faster hospital discharges. There is a huge advantage for the home through having the ability to ask a GP to attend multi-disciplinary team meetings for all their residents.

Leon Smith oversaw the introduction of these services as Chief Executive of Nightingale. In his current role as Executive Vice-President, he notes that as well as being much better for residents, ‘we are saving local hospital and community services a significant amount of money, and the overall service is a good example of how integrated health and social care can work.’

It’s true that Nightingale has a large number of beds, and is based in a relatively wealthy part of the country. But working in areas of deprivation and in challenged health economies, or being a smaller provider, needn’t preclude you from working in similar ways.

Community Integrated Care, for example, is working with Salford Royal Hospitals and University Hospitals of South Manchester on two Intermediate Care schemes, and with Mersey Care Mental Health Trust on a new service designed to ease bed blockages.

The Royal Masonic Benevolent Institution (RMBI), in its homes in Leicester, works closely with local GPs to get advanced agreed plans of care in place to help prevent hospital admissions. In Porthcawl, the RMBI is piloting a scheme with the NHS in Wales to help reduce unnecessary hospital admissions out of hours, as this is often when people are sent to A&E by covering GPs. They will connect directly with a central hospital, where a consultant will see the person via video link and have access to their observations. They will then be able to decide whether they do, in fact, need hospital treatment or whether they can remain in the home with appropriate care.

Finally, Marches Care, a residential care and specialist nursing provider in a predominantly rural area, works closely with local CCGs and trusted assessors, and has agreed protocols in place for shared assessments, to reduce any potential delays in admission.

Practical steps

All this is at odds with the commonly reported story of social care being a ‘major cause’ of A&E problems. It deserves to be more widely reported, and more widely promoted by the social care sector. If you’d like to do this, if you’d like to build better links with your local health economy, or if you’re having problems, there are things you can do:

  1. Engage with your local CCG(s), NHS Trusts and other system-wide groups – and just persevere until you find an ally.
  2. If you’re a smaller provider, think about building alliances and partnerships with others in a similar position, so that, for example, you might share on-site medical services.
  3. Concentrate on building relationships: getting things done often depends more on relationships, trust and commitment, and less on formal structures.
  4. Work with your local care association if they are involved in discussions around integrated services.
  5. Social care has long been a source of innovation and community links – don’t be nervous about bringing your ideas to the table and promoting them locally.
  6. Local promotion also means going to your local Health and Wellbeing Boards, council leads, MPs and local media.
  7. Think about developing your staff teams to work across systems and sectors. Collaborative skills are becoming more and more essential.
  8. See yourselves as part of the collective leadership of the system in your area, as well as leaders in your own services and organisations.

At the Leadership Centre, we want to help to change the narrative around the role that social care is playing in integration, and the positive effect that good providers can have. If you have your own examples that you’d like to contribute, or if you’d like to find out more about what other providers are doing, please get in touch. The more positive stories we can tell, the better.

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Debbie Sorkin is National Director of Systems Leadership at the Leadership Centre

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