When the NHS was founded in 1948, it confronted a very different set of priorities to those it currently faces. Average life expectancy was 66 for men and 71 for women, and the emphasis was on ‘care and repair’ and the treatment of infectious diseases.
Today, thanks to medical and technological advances, and rising standards of living, the landscape has utterly changed. Average life expectancy has rocketed; infectious diseases like Tuberculosis are a relative rarity; and outcomes for heart conditions and cancers have improved out of all recognition.
As Andrew Dilnot stated at the start of his 2012 review of the Funding of Care and Support, ‘It is a matter for celebration that people are living longer.’¹ However, these advances come at a price. People are living longer, but with long-term conditions, and this is putting pressure on health and social care systems. In the case of social care, these strains have been exacerbated by the serious cuts in local authority budgets in recent years – the Association of Directors of Adult Social Services estimates that over £3.5bn has been removed since 2010.² The NHS estimates that it faces a potential funding gap of £30bn by 2020 if nothing is done to alleviate the situation.
Five Year Forward View
The NHS Five Year Forward View, produced in collaboration with Public Health England and other national health and care organisations, and published last October, is an attempt to bring the NHS face-to-face with these realities and to set out how, by integrating its services much more and by placing more emphasis on prevention, it can continue to provide a universal health service.
At the same time, it wants to improve the service that patients and service users experience. As the Five Year Forward View notes; ‘Even people with long-term conditions, who tend to be heavy users of the health service, are likely to spend less than 1% of their time in contact with health professionals.’
By definition, then, this means placing the emphasis much more on what happens during the other 99% of the time. And this means both better integration – between GPs and hospitals; between physical and mental health; and between health and social care – and social care playing a more central role in people’s health and wellbeing.
Although social care is actually not mentioned very much in the Five Year Forward View – I counted roughly a dozen mentions – and few examples are given, I would advocate that social care providers – whether in the private or in the not-for-profit sectors; whether in home care or residential care; and whatever their client group – see this as an open invitation to get involved, and take it.
There are a few ways to get involved. Firstly, by getting involved in the new models of care that the NHS is proposing.
These care models are designed to follow a basic blueprint, and then to be adapted in different areas to put in place services that are fit for the needs of local populations. They are explicitly designed to break down the barriers between social care and health, and between primary and secondary care.
The first model is the ‘Multispecialty Community Provider’ (MCP). This allows groups of GPs to combine with other services, including mental health and social care, to create integrated out-of-hospital support. The second, related model, which takes things a stage further, is a vertically integrated hospital and primary care provider, or ‘Primary and Acute Care System’ (PACS), similar to the Accountable Care Organisations now being developed in the USA and in other European countries. These PACS will also be able to provide community services.
Some GPs are already developing proposals to become Multispecialty Providers. For example, the Whitstable Medical Practice in Kent has plans to join up with two other practices in order to become a federation covering 53,000 patients, and to run services including a nursing home (which it would build) and an extra care facility for frail elderly local people.
In Wessex, seven GP practices are teaming up with a small community hospital to set up an extended service for around 70,000 local residents, including mental health services for older people.
In the North West, GPs in Rochdale and Bury are looking at the interface between primary and secondary care, particularly in relation to early discharge schemes to get people out of hospital sooner.
Finally, in the West Midlands, NHS Dudley Clinical Commissioning Group is planning an MCP of integrated services across health and social care, serving 60,000 people, as part of a wider ‘network of care’.
New models of care
If you provide mental health services, there are plans in the Five Year Forward View to organise the system better, including through more effective integration of crisis services and more appropriate use of community settings. For providers of residential care for older people, NHS England has pledged better support for people with dementia, alongside more work with social care to develop new shared models of support, to reduce hospital bed use and increase quality of life. The criteria for these models are set out in the box.
Criteria for new shared models of care
Enhanced services in care homes should demonstrate:
- Strong and inventive partnerships, including with the community and voluntary sector.
- A focus on residents’ capabilities (ie an asset-based model).
- In-reach services provided in partnership.
- Use of new technologies and telemedicine.
- Innovative approaches to local assets, including intermediate and respite care beds.
- Multiagency and multi-disciplinary teams.
- Flexible workforce models.
- Redesigned hospital discharge processes.
- Training and support for staff and families around end-of-life care.
To support these new models of care, many places around the country, including the health and social care integration Pioneers, are introducing integrated workforce teams. In the London Borough of Islington, for example, there are joint community ageing and psychiatric liaison and assessment teams in place. Kent is aiming to deliver fully integrated health and social care teams and 24/7 community-based care during the course of this year. Birtley House in Surrey is piloting the Elizabeth Nurse accredited qualification for its care staff, to support staff to work in integrated settings. This trend will continue through the Five Year Forward View, with Health Education England charged with working with partners to commission and expand new health and care roles, in order to ensure a flexible workforce.
We already have great examples of social care providers working in partnership with CCGs and acute NHS Trusts, whether it’s Nightingale residential care home in London being funded through its CCG to provide on-site medical care, thereby reducing hospital admissions; Marches Care and Coverage Care in Shropshire working with healthcare providers on shared assessments in order to facilitate timely hospital discharge; Community Integrated Care’s arrangements with Pennine Trust North Manchester to offer short-term intensive care and support to older people recuperating or recovering from illness or injury; or the Royal Masonic Benevolent Institution using telemedicine, especially video links, to connect residents in care homes with consultants in hospitals.
You may already have similar experiences in your own organisation, or want to explore what partnerships might be possible. Now is the time to do so. In January, NHS England received more than 260 applications from groups around the country hoping to be chosen as ‘Vanguard’ sites to implement new models of care, and the shortlisted places were announced at the beginning of March.
NHS England will be looking for these new places to start implementation this year. So there is every reason for social care providers to get involved, either in this initiative or in similar programmes (for example, via the Pioneers or the Better Care Fund).
If your local CCG or acute trust hasn’t yet been in contact with you, be proactive: get in touch with them and show them how you can help. And persevere. I sometimes describe social care as the ‘invisible river’ running underneath, and supporting, healthcare, and there’s something of this in the glimpses of social care in the Five Year Forward View. But it doesn’t have to be this way: actually, it can’t if we’re to have a care service that works in accordance with what people want and need. The Five Year Forward View is an open door, and social care should be storming through it with all the force it can muster.
Debbie Sorkin is National Director of Systems Leadership at the Leadership Centre. Debbie.firstname.lastname@example.org Twitter: @DebbieSorkin2