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Three steps forward, one step back
Integration best practice and how to navigate the current health and social care landscape

Health and social care are changing, but they need to work together to keep the momentum. Debbie Sorkin delves into integration best practice and concludes that it’s social care leadership that makes the difference.

It is a truth not universally acknowledged that social care knows what the NHS is only starting to realise: that people are more than their conditions.

The NHS Five Year Forward View, originally published in 2014 as a roadmap for the health sector’s future, feels its way towards this, acknowledging that people are living longer, and with multiple conditions; that there needs to be a greater emphasis on keeping people well in their own homes, or in residential care; and that there needs to be a broader conception of health, with more attention paid to wider determinants of health and to overall wellbeing.

There is recognition that how we live now – and how long we live for – is not the same as in 1948, when the NHS was set up. As a result, the NHS is looking to recreate itself to take account not just of how people live, but of how they want to live. New structures are starting to take shape.

They’re called different things in different parts of the country – Sustainability and Transformation Partnerships; Accountable Care Systems; or Integrated Care Partnerships. They’re all at very different stages of development, but the underpinning idea behind all of them is to bring health, local government, social care, and the voluntary and community sectors together to provide better ways to support people and keep them healthy, and in a more person-centred way.

Accountable Care Systems

For example, Wakefield, which is moving towards an Accountable Care System, has set up connecting care hubs, based around primary care. They bring together different disciplines to provide a more holistic service.

One hub has a focus on working with a community geriatrician, with weekly GP visits to residents with complex neurological conditions in specific care homes. Two others involve advanced nurse practitioners acting as care co-ordinators for residents identified as high-risk, with regular pro-active care visits and better links with GP practices. A fourth is prioritising better collaboration between primary and secondary care, and Age UK, with better use of video links and access to shared care records.

Wakefield has worked with local providers to set up multi-disciplinary teams across health and social care, often with the registered manager being the pivotal figure, and working with a range of health and social care practitioners, including district nurses, social care staff, pharmacists and specialists in palliative care.

They have prioritised skills development for care home staff, so that staff can deal with more complex medical needs and prevent emergency call-outs. Teams use a screening process to identify care needs, and the aim is to support the care home to meet these needs in order to reduce reliance on hospital admission and improve people’s quality of life.

The system can point to positive, and quantified outcomes, including a 25% reduction in ambulance calls; 30% reduction in A&E attendances, and at least 50 weekly visits to care homes by GPs – a significant increase. As a result of care reviews, 53% of care home residents taking part in initial programmes have seen changes in their medication, often with less medication required.

Accompanying surveys have indicated improved quality of life for service users and increased job satisfaction for social care staff, which in turn has had a positive impact on recruitment and retention.

Enhanced Health in Care Homes

Similarly, The King’s Fund, in a report published in December, noted a range of benefits for care home residents arising from the Enhanced Health in Care Homes pilots, funded through the NHS New Models of Care programme and involving social care alongside GPs, community care and acute hospitals. Benefits included: 

  • Significantly reduced hospital admissions, A&E attendances and ambulance journeys.
  • Better continuity of care and involvement of residents and their families in care planning and review.
  • Better prescribing practice, including fewer inappropriate prescriptions.
  • Reductions in falls.
  • Better wound care.
  • Reductions in depression amongst residents.
  • Improvements in residents’ quality of life.
  • Increased confidence amongst care home staff, a greater sense of empowerment and feelings of connectedness to other services.

Providers doing it for themselves

You don’t have to be part of a pilot to get things moving. Social care providers are also working closely with the NHS and local authorities in other parts of the country, to get people out of hospital in a timely way. Hospitals can be dangerous places for older people. There is clinical evidence, underpinning a recent NHS programme called End PJ Paralysis, that people aged 75 and above can experience significant deconditioning and lose mobility if they stay too long in hospital beds without getting up and about.

In Portsmouth, Agincare, working closely with Portsmouth City Council and Queen Alexandra Hospital, has successfully proven the benefit of Discharge to Assess (D2A) using its live-in care workforce to get people out of hospital in a timely manner.

Using Better Care Fund monies, the initial scheme – since extended – guaranteed rolling discharge capacity of between five and eight live-in care workers per week, to offer practical support, enable assessment at home within 48 hours, and offer up to 24-hour support and continued assessment over a period. The live-in care workers and NHS workers also trained together.

Again, there have been real financial savings for both adult social care and the NHS. However, the real benefits have been to patients and their families. The scheme has significantly reduced hospital stays. Only 6.5% of the patients involved in the pilot were readmitted to hospital, against a national average of 12.2%, and in the words of one family, ‘We usually have to fight to get support, but this was so easy.’

Long slog

From a social care perspective, and in other places, it can feel like a long slog to this brave new world.

In last month’s CMM, Simon Whalley, Chair of Birtley House, an Outstanding-rated residential care and nursing home based in Surrey, described the problems and frustrations he has been encountering in setting up a pilot for a new scheme, a Virtual Care Home.

Simon has been trying to bring together Royal Surrey County Hospital, Surrey Heartlands Sustainability and Transformation Partnership, Guildford and Waverley Clinical Commissioning Group and local domiciliary care services and care homes to develop the pilot.

The idea is to deliver the services of the care home in a number of settings and be monitored by technology. The scheme also aims to give all those supported a sense of belonging.

On an operational level, it should help people get out of hospital sooner; manage care to reduce unnecessary admissions to hospital; help older patients go home and remain living there in a fully supported way; and prevent readmissions to hospital.

These are all laudable aims, and in theory, all the partners have bought into the idea. However, getting it off the ground is something else entirely.

As Simon noted when I spoke to him about setting up the pilot, ‘Key personnel keep disappearing, which makes it very challenging. Those involved recognise the issues that arise from…the NHS…and the silo-thinking common within the public sector, but it’s often a case of one step forward and two steps back.’

Making it work

If this is your experience, what do you do? I think the first thing is to know what you’re dealing with, and to keep going. You’re working in a complex system: where things are new; where ideally you wouldn’t start from here; where issues or people keep shifting; where no-one has all the answers or is entirely in charge; and where all your plans come up against those twin barriers of real life and other people: other people with different priorities and perspectives to you, and who – unreasonably and infuriatingly – don’t immediately unite around your position.

In a complex system, uncertainty is the norm, and there won’t be a linear relationship between what you do and what happens. There’s no management lever to pull.

However, there are things you can do to make progress. We know these work thanks to research, stories from other places and independent evaluation:

  • Start small and from where you are – look for progress rather than overnight success.
  • Build-up relationships, trust and influence across a system, so you’re less vulnerable when someone leaves partway through the process. Systems move at the speed of trust.
  • Find a coalition of the willing – a few people who think the same way you do – and work with them. Don’t try to get the whole system to the starting line in one go.
  • Work from a common purpose – something you all really want to do; and where you all understand what that entails for other people.
  • Once you’ve got common purpose, work from ‘clarity for now’ – just enough space so you know what you’re doing next. You don’t need a five-year plan.
  • Tell emotionally resonant stories – have a consistent narrative, based on evidence, about what you’re doing and why/how it will bring benefits.
  • Frame your stories in ways that appeal to different audiences.
  • Understand that this will feel messy and take time.
  • Know that doing this really can work – there will be setbacks, but you can get real change.

If you’re in social care, you’re probably used to working in this way anyway. This means you’re in a great position to step up to the plate and lead the way in showing how you work in complexity – in other words, in the real world. It’s social care leadership that enhances the quality of care, and quality of life, that people experience. It’s social care leadership that makes the difference.

Debbie Sorkin is National Director of Systems Leadership at the Leadership Centre. Email: Twitter: @DebbieSorkin2

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