Social care services can contribute to easing pressure on NHS

Severe pressures in hospitals this winter has seen thousands of operations cancelled, causing social care leaders to urge NHS bosses to ‘start listening’ and let care homes do more to help.

Elderly people are among those who are most at risk of illnesses such as flu during the winter months. NHS England has said hospitals, GPs, ambulances and other NHS services have been extremely challenged this winter, and have reported higher levels of respiratory illness and flu.

In the final week of 2017, the NHS 111 helpline received more than 480,000 calls.

Martin Green, chief executive of Care England, which represents independent care home providers, said: “The NHS Acute Trusts could significantly reduce winter pressures by establishing long-term relationships with independent care providers. The care sector has been saying this for years and yet again the NHS has not listened and is in yet another crisis”.

Health secretary Jeremy Hunt apologised to patients following a decision to postpone tens of thousands of operations in January because the NHS is struggling to cope with a surge in patients this winter.

Non-urgent treatments had already been cancelled until mid-January, but this has now been extended to the end of the month.

Handover delays outside A&E departments stop ambulances from getting to new emergencies. The handover of patient by ambulances at A&E departments is supposed to take no more than 15 minutes.

Almost 5,000 people were left waiting in ambulances outside A&E departments for one hour in the last week of December, as 12 hospital trusts revealed they had no beds free. These health trusts were operating at 100 per cent, well above the recommended 85 per cent.

A&E staff can’t move patients out of their department and onto hospital wards, because hospitals can’t discharge patients from their wards into the community. Shropshire County Council is working with care homes to ensure patients don’t stay in hospital any longer than necessary. The council is working to cut the number of patients delayed in hospital, known as a Delayed Transfer of Care (DToC).

At the end of December, Shropshire’s A&E departments got hospital staff from other wards to help with the volume of emergency patients it received and had already commissioned extra beds in care homes, which are block purchased to ensure they are there when needed.

The Shropshire-based care home The Uplands offers nursing and specialist dementia care. It is run by Marches Care and has been drafted in to help this winter. Mandy Thorn, the managing director of Marches Care and vice-chair of the National Care Association (NCA), which is made up of small-and medium-sized care providers says: “If care homes were more involved in local winter planning, which is actually a year-round issue, we would probably see less of a problem with DToC.”

She believes this would be possible if they are “engaged early enough and sensible and respectful contract discussions take place – around block contracts at a price that reflects the additional support that short-term admissions require.”

She says when it comes to care homes being used to address winter pressures it’s “a patchy picture across the country”.

“Smaller independent providers are not always considered when local authorities and CCGs get together to discuss their response to winter pressures. When health and care professionals get together to respond to hospital bed pressures, not every local area takes into account the residential and nursing beds that may be available.”

According to figures from the Institute of Public Care, from April 2012 and April 2017, the number of care home beds available fell by 3,769. Add to this a major staff retention and recruitment problem in the care sector and the country’s ability to respond to a winter NHS crisis gets more challenging.

Market intelligence

Responding to criticism from the care sector that some care homes’ beds are ignored in different parts of the country, Colin Noble, the leader of Suffolk council and health and social care spokesman for the County Councils Network, (made up of 27 county councils and 10 unitary councils), told “I think it comes down to market intelligence.

“Every single day we are working with every single care home. It’s a question of how much of a silo between CCGs [Clinical Commissioning Groups] and councils exists in an area. Local authorities know all of their care homes but that’s not always the case for CCGs.

“It’s a matter of CCGs using the council’s market intelligence about care homes.”

Job satisfaction

Mandy Thorne puts it simply. “Staff in my care home report increased job satisfaction because they see people admitted to us from hospital needing significant support who then leave to go home after a couple of weeks because they are well enough to return to their own homes.

“Long-term residents have also benefited because they can interact with a wider variety of people who come into the care home, and who by seeing people get better and go home they can be more motivated to do more themselves.”


Is it not time that we saw a closer working relationship between social care and the NHS to reduce the pressures of bed blocking. In Shropshire they have set a good example of forward planning, by block booking care home beds in advance. Colin Noble highlights the importance of market intelligence to alleviate the problem and Mandy Thorne suggests that more consideration needs to be given to smaller providers. Surely, making better use of what social care can offer will be of benefit to patients and hospitals and reduce the crises experienced by the NHS each winter. Come on NHS is it not time you started listening.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

The importance of exercise to service users in care and nursing homes

The importance of keeping people who use social care services active is highlighted in a recent study published in The Journal of Physiology. Older people who are inactive or sedentary for any period of time can rapidly lose muscle mass and mobility. Researchers have been able to document for the first time how the same period of inactivity has a greater and more severe impact on the muscle power of the lower limbs of the elderly than young people, which is essential for movements like climbing the stairs.

The disuse of muscles due to a sedentary lifestyle or short periods of inactivity caused by hospitalisation can dramatically enhance the decline in muscle mass, metabolic health and functional capacity. This loss of muscle power caused by disuse can be especially detrimental in the elderly.

The research, conducted by the University of Udine in conjunction with the University of Padova, involved studying the impact of complete inactivity in a group of elderly subjects that were bedridden in a hospital environment for 2 weeks, and their results were compared with young subjects.

In the elderly subjects, there was a difference in single muscle fibre response to disuse, a more pronounced loss of muscle mass and a change in how muscle contraction is controlled by the nervous system compared to young individuals. Furthermore, the recovery phase was more difficult in the elderly group.

Carlo Reggiani, the lead investigator on the project commented on the findings: “While clinical and epidemiological data on inactivity in the elderly are abundant, experiments on disuse and inactivity are seldom performed in elderly for several reasons. The results obtained are relevant not only to understand the inactivity-dependent enhancement of the decline (in muscle mass, metabolic health and functional capacity) but also to design new rehabilitation protocols where timing and intensity of the sessions are optimized.”

It is not uncommon for service users in care homes to sit for long periods of time, and in some cases because of ill health can be confined to their beds. As the aforementioned report shows inactivity and lack of exercise can have serious consequences for service user’s health and wellbeing and ultimately their quality of life.

The value of physical activity

Further evidence of the importance of an exercise program for service users comes from a taskforce report, under the auspices of The International Association of Gerontology and Geriatrics. Its recommendations on physical exercise concludes that beside activities of daily living dependency service users in social care services face other important medical challenges. Dementia care, behavioral and psychological symptoms of dementia falls, pain, the use of potentially harmful drugs (e.g., antipsychotics), and mood (particularly depression), and quality of life are often recognized by staff and experts as crucial issues for the care of service users.

Exercise training has the potential to improve many of the above-mentioned issues. Recent studies also suggest that exercise is of benefit for the mobility and physical function of people with dementia.

One of the key challenges for staff is to maintain service users’ functional ability, which is made up of subjects’ intrinsic capacity and environmental characteristics and the ability to cope with their functional limitations for as long as possible.

Overall physical activity has been shown to protect against activities of daily living disability. Experts in care home research and clinical care, with the support of the International Association of Gerontology and Geriatrics and the World Health Organization, have already recognized the importance of exercise for the quality of care of people who live in care homes.

Scientific evidence has shown that exercise training, i.e. a subset of physical activity that is planned, structured, repetitive, and purposeful, being generally used to improve/maintain physical and functional capacities, has been found to have positive effects on the ability to perform activities of daily living.


Motivation and pleasure are the key aspects to take into account when attempting to increase overall activity levels of service users. To increase service users’ motivation, it is important to build awareness of the importance of replacing sedentary time with physically demanding activities, even if those activities are of light-intensity (e.g. walking slowly). Staff should attempt to promote service users’ physical engagement during social and daily life activities. Building awareness should target both the service users themselves as well as staff, other healthcare professionals (including the primary care physician), service users’ family, and policy makers.

Proposed recommendations to increase overall activity levels

According to the International Association of Gerontology and Geriatrics, when considering the crucial importance of enhancing the overall levels of activity in the daily life of service users, the manager should consider:

1)   To adopt strategies for breaking the sedentary time of service users. Establishing short breaks (2-5 minutes) twice or three times a day is probably feasible in a care home setting.

2)   To systematically use simple strategies to stimulate service users to move: walking to the lunch/dining hall rather than using wheelchairs for people who are able to ambulate, and organizing events that require service users going out from their rooms.

3)   To avoid chemical and physical restraints as much as possible since they result in bed and chair-rest.

4)   To optimize the utilization of the architecture and equipment in order to promote mobility.

5)   Staff, should organise group activities that are motivating and pleasant, for example promoting chair exercises and dancing where appropriate.

6)   To use innovative solutions, such as using animal interventions and new technologies, in order to increase service users’ motivation and pleasure and, then, overall activity levels. Animal interventions have been shown to be effective in increasing physical activity in institutionalized older adults.

7)   The use of robots which have been shown to decrease feelings of loneliness and improve participation in activities.


The importance of exercise to service users in care and nursing is now supported by numerous health advisory studies worldwide. Managers of care and nursing homes should ensure that assessment of service user’s physical activity and a program of appropriate physical exercise forms part of the service user’s person centred care plan.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

Benefits of using arts in care homes

Registered managers of care homes are always on the lookout for person centred activities that will involve service users. The Social Care Institute for Excellence (SCIE), are promoting the benefits and the importance of art in care homes by bringing together a range of resources that allows managers to tap into and improve the quality of life for service users.

The following are links to general information produced by SCIE about the importance on arts in care homes and the resources available:

Creative Homes: how the arts can contribute to quality of life in residential care

This joint publication with NCF (the National Care Forum – the umbrella body for not-for-profit care providers) and NAPA (the National Association for Providers of Activities for Older People celebrates existing good practice in the use of the arts in residential care and demonstrates the value of art to improving the quality of life for people in care settings. (Baring Foundation).

Creative and credible: evaluation resources

This web-based resource provides information to help evaluate the impact of art and health projects. Sections providing information to help understand why you might need to evaluate, what approaches might be appropriate, and how to plan and implement evaluation for a project. (Willis Newson).

Local authorities + Older people + Arts = A creative combination

This publication describes the unique combination of roles and interests by local authorities which make them the ideal champions for arts and older people. These are: health and wellbeing; arts and cultural services; older people’s services and social care; social inclusion and leadership and coordination. These are illustrated by six case studies. (Baring Foundation).

Technically older: an update on digital arts and creative ageing

This report revisits and updates the work done for the 2012 publication Digital Arts and Older People. It explores developments since 2012 in the field of artists working with older people using creative technology. New and additional benefits of using digital tools with older people are considered and 10 new case studies of practice are presented. (Some of which are used in our topic areas.) (Baring Foundation).

Arts and dementia: bringing professional arts practice into care home settings

This report reviews evidence relating to the benefits of arts participation for people with dementia. It draws on research spanning the fields of health, dementia care and participatory arts. This is one of a series of publications around arts and dementia that have grown out of Live and Learn. (Collective Encounters).

Arts and dementia: Pocket guide for carers 2nd edition

All available evidence indicates that imaginative mental exercises have a direct, positive impact on the health of individuals living with dementia. Arts-based activities such as the ones featured in this guide have been shown to help people with dementia to manage their symptoms, significantly enhancing their quality of life in the process. This guide is the result of three years of research in Merseyside with the carers of people living with dementia (Creative Encounters).

Growing the Creative Ageing Movement: International lessons for the UK

This report highlights imaginative programmes that have been developed in communities across the UK by Churchill Fellows, following their global travels to witness inspiring practice in other countries. Projects, which have particularly concentrated on work around art and dementia have taken place under five topics: art form; day care; training for care staff; artists in care settings and evaluating impact. (Baring Foundation).

Creativity in care homes: evaluation report

The programme was delivered in 2012 by City Arts for Nottingham City Council. Events were held to stimulate interest in the project and provide practical support to staff from residential care settings. An artist in residence worked with a care home to trial different approaches to improve wellbeing of residents and to enable Activity Co-ordinators to continue the work beyond the project. (City Arts).

An evidence review of the impact of participatory arts on older people

This review is the first synthesis of the evidence base for the effects of participating in artist-led creative projects on older people. It concludes that ‘it is evident that engaging with participatory art can improve the wellbeing of older people and mediate against the negative effects of becoming older’. These impacts are explored in terms of mental and physical wellbeing at the individual, community and societal levels. (Mental Health Foundation).

The participative arts for people living with dementia: a critical review

This review of academic and grey literature contextualises the participatory arts for people living with dementia and provides an overview of some of the art forms that are most widely used. Looks at the benefits of using participatory arts and highlights some of the current gaps in the knowledge base. (International Journal of Ageing).

Arts in care homes resource pack

This online resource pack brings together a collection resources to help promote the importance of arts and creative activities for older residents in care homes. It aims to support care staff to plan and run creative arts sessions and help then work with professional artists. (Care Inspectorate).

Learning for older people in care settings: a guide for activity coordinators and care staff

This guide is for activity coordinators and other members of care staff involved with, or interested in, supporting older people to take part in learning activities. (National Institute of Adult Continuing Education).


The Social Care Institute for Excellence and their partners should be commended for bringing together this resource pack that promotes the importance of the arts in care homes. This can be seen as a valuable tool for managers and an essential means of improving the quality of life for service users.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

The postcode lottery in the provision of quality care in nursing homes

People reading the recent article by Claire Ellicott political correspondent of the Daily Mail on 27th December 2017, based upon the Care Quality Commission findings into inadequate quality of care in nursing homes will be alarmed.

CQC figures in their report reveal that in some parts of the country three quarters of nursing homes are failing.

  • Nearly one in three (30.1 per cent) of all nursing homes ‘require improvement’ or are ‘inadequate’, according to Care Quality Commission reports.
  • And most regions have experienced care problems, with 93 per cent of areas having homes that need improvement.
  • In Kensington and Chelsea 75% of homes were rated as requiring improvement.
  • Of the 5,300 homes inspected this year, 2,000 were found to be inadequate or in need of improvement

The figures highlight the postcode lottery in the provision of quality local care across the country.

More than a third of nursing homes in the North and a quarter in the South either needed improvement or were deemed inadequate.

The issue is particularly acute in central London, where Westminster has a 50 per cent rate of failing homes, despite being under the nose of MPs at the Houses of Parliament.

In the Royal Borough of Kensington and Chelsea in London, where Grenfell Tower is situated, 75 per cent of nursing homes were rated as requiring improvement.

In Salford, 64.3 per cent or more of nursing homes were rated as ‘requiring improvement’ or ‘inadequate’, while Coventry had 60 per cent and North Tyneside 62.6 per cent.

In Wakefield, 52.6 per cent, are rated as ‘requiring improvement’ or ‘inadequate’ while the figure in Wolverhampton is 58.3 per cent.

Elsewhere, half of nursing homes in Hull, Newham, Telford and Wrekin, the Wirral and Derby were found to be failing.

According to the Daily Mail the stark survey underlines the extent of the crisis facing England’s broken care system, which is providing substandard care despite sky-high prices.

Earlier this year, the Daily Mail revealed social care was struggling so much that four in ten care homes were failing inspections.

Of the 5,300 homes inspected this year, 2,000 were found to be inadequate or in need of improvement.

Currently, rules mean care home residents have to use their assets to pay the full costs of their care until they are reduced to their last £23,500.

The cost of their care is taken off the value of their home after they die, denying thousands of children their inheritance.

David Cameron pledged to introduce a cap of £75,000 on care costs two years ago, but this has now been shelved until after 2020.

Theresa May announced a plan for families to keep £100,000 of their assets but with no upper cap on costs during the election.

However, the pledge was abandoned after critics dubbed it the ‘dementia tax’.

The new figures were provided directly to the Labour Party by the CQC and are based on the watchdog’s most recent investigations.

Barbara Keeley, Labour’s social care spokesman, said a lack of nurse training places and bursaries had affected staffing levels.

‘Nursing care providers are struggling to recruit and retain staff because of a lack of registered nurses but similar trends are present across the care sector because of the impact of cuts on pay and conditions for other care staff,’ she said.

Last month, analysis by Which? found that more than half of all elderly care places in England are in failing care homes.

In six local authority areas, more than 50 per cent of the beds available were rated as inadequate or needing improvement.

The council in Kensington and Chelsea said its poor ratings were the result of having relatively few homes.

A spokesman said the borough was home to only around ten privately-run care homes and the small number ‘skewed’ the figures.

A report on care homes in Kensington and Chelsea from May revealed it had problems attracting low-paid staff to the most expensive area of the country.

This is another report that casts nursing homes in poor light. It is to CQC credit that they continue to bring to the attention of people, politicians and decision makers the shortfalls in quality care. However, what is surprising is the that those who represent nursing homes are not bringing more into the spotlight, the difficulties in recruiting and retaining nursing staff.

It would be wrong to criticise the efforts of providers in attempting to address the situation, when registered nurses are just not available because lack of funding for nurse training.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

The unfair practice of self-funding residents subsidising residents supported by local authorities

The published report of the Competition and Markets Authority’s market study into residential and nursing care homes for older people makes interesting reading for those working in this sector.

The study found that public expenditure on adult social care of all types (including non-elderly care and care outside care homes) has been under pressure. For example, aggregate expenditure has declined in real terms by 8% between 2009/10 and 2015/16 in England.

The sector has reported facing challenges to its sustainability, due primarily to the low fee rates being paid for state-funded residents – those challenges being exacerbated by increased cost pressures due largely to wage costs. In its annual assessment of the quality of health and adult social care in England (October 2016), the Care Quality Commission (CQC) said that the sustainability of the adult social care market is approaching a tipping point.

The Competition and Markets Authority have undertaken an extensive profitability analysis of the sector using information provided directly by care homes and taken from company accounts. It is understood to be the most complete study of profitability in the sector in recent years.

In their assessment, they found that the average fees paid by Las are below the full costs involved in serving these residents. Our financial analysis of the sector shows that, looked at as a whole, the sector is just able to cover its operating costs and cover its cost of capital. However, this is not the case for those providers that are primarily serving state-funded residents.

Many care homes, particularly those that are most reliant on LA-funded residents, are not currently in a sustainable position. Our analysis shows that while many can cover their day-to-day operating costs, they are not able to cover any additional investment costs. This means that while they might be able to stay in business in the near term, they will not be able to maintain and modernise facilities, and eventually will find themselves having to close, or move away from the LA-funded segment of the market.

This shows that the fees currently being paid by Las are not sufficient to sustain the current levels of care under the current funding model. The implication is that public funding needs to increase if the current model of funding is to continue, or alternatively, if current levels of funding do not increase, the funding model for care will need to be changed.

Our analysis suggests that about a quarter of care homes have more than 75% of their residents LA-funded, and that these are the ones most at risk of failure or exit because of a funding shortfall. We estimate that LA-fees are currently, on average, as much as 10% below total cost for these homes, equivalent to around a £200 to £300 million shortfall in funding across the UK. This finding is based on an average result – there will already be a proportion of operators that are struggling and at risk of closure.

The large majority of care homes offer places to self-funded as well as LA-funded residents. Many care homes are relying on higher prices charged to self-funders to remain viable, even when providing the same services. Self-funded residents in mixed homes are meeting a much greater proportion of homes’ fixed costs. Without this, the public funding shortfall would have a substantially larger impact than it currently has.

Our assessment based on larger providers is that self-pay fees are now, on average, 41% higher than those paid by Las in the same homes. This represents an average differential of £236 a week (over £12,000 a year). We understand that fee differentials for smaller providers are slightly lower but still significant.

This difference between self-funded and LA prices for the same service is understandably perceived by many as unfair. The large majority of self-funders are not wealthy; the current thresholds for support are currently drawn so that practically anyone who owns their property will be ineligible for state funding, regardless of income. Moreover, there is very poor visibility of the size of these fee differences so the public is generally unaware and Las do not have to justify their approach to the fees they pay to care homes.

In addition to this, however, the situation may not be sustainable. Where LA rates are below total cost, those care homes that can attract self-funders are likely to move away from serving a mix of residents. We already observe that nearly all new care homes being built are in areas where they can focus on self-funders. While we would expect that many mixed homes with differential pricing could continue to operate for some time, there will be a need for additional funding to support further care homes that would not be sustainable without the benefits of this price differential.

Our assessment is that if Las were to pay the full cost of care for all residents they fund, the additional cost to them of these higher fees would be £0.9 to £1.1 billion a year (UK wide, and assuming this money is directed specifically to those homes where LAs pay fee rates below total costs).


The Competition and Markets Authority’s market study into residential and nursing care homes for older people, confirms what we have known for some time a seriously underfunded social care sector. However, what is interesting from their analysis is how the care home sector is propping up their services. To remain viable it is asking self-funded residents to pay the real cost of care and thereby subsidising local authority sponsored residents who are paying much less for the same care. This is grossly unfair. It is time for Local authorities to pay the real cost of care. Equaity should mean equality.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy