Make social care free to save NHS

The government should make social care free to everyone who needs it to take pressure off the NHS, former Labour and Tory health ministers have said.

Conservative, Lord David Prior and Labour’s Lord Ara Darzi also called for a “radical streamlining” of NHS organisations to roll back the damaging reforms implemented by former health secretary Andrew Lansley.

Abolishing means testing of social care would end the scandal of people with significant care needs facing bills in the hundreds of thousands of pounds for care, they said.

Cuts to social care funding under the Conservatives have seen the numbers of people receiving state-funded care falling five per cent a year.

But it is costing the NHS £3bn a year to care for people in hospital who are fit enough to be sent home but haven’t got sufficient support, and free services for people with “critical” or “substantial” needs would help.

Elderly people in residential accommodation would still be expected to pay their own housing costs if they can afford to, as at present.

The report sets out how the NHS and social care system could deliver productivity savings which they claim, combined with the extra funding, would release resources to meet the rising needs of an ageing population and enable it to embrace medical and technical advances.

Their plan, compiled with think tank the Institute for Public Policy Research (IPPR), suggests streamlining the NHS by replacing 244 commissioning bodies and other organisations with up to 10 new Health and Care Authorities

It also puts forward the case for a long-term funding settlement which guarantees NHS funding will grow at its historic annual rate of 1.5% above overall economic growth, for a total of around 3.5% a year.

Reform would require annual spending on social care to double, from its current level of around £17 billion to £36 billion, by 2030.

The report recommends funding this during the current parliament by putting a penny on National Insurance Contributions (NICs) for employers, employees and the self-employed, as part of a wider settlement for the NHS.

They suggest the creation of up to 10 new Health and Care Authorities (HCAs), to replace the current 195 Clinical Commissioning Groups (CCGs) and five NHS England regions.

This would mean undoing some of the Lansley reforms, which separated acute and community care commissioning – undertaken by CCGs – and primary care and specialised commissioning – undertaken by NHS England.

The number of national NHS leadership bodies would also be cut from six to three, by merging NHS Improvement, Health Education England and Public Health England with NHS England.

They also suggest the obligation to competitively tender for services – internally or externally – should be scrapped, arguing that the constant churn generated by this process is costly and disruptive to care, with limited evidence that it has improved quality or efficiency.

Lord Darzi said: “The NHS and social care have done well to improve or maintain quality over the last decade. But the cracks are now showing.

“We need bold action to ensure that the NHS is fit for the 21st century. This will mean caring as much about social care and public health as the NHS and embracing reform as much as additional funding.

“The gift the NHS needs on its 70th birthday is a pragmatic plan to secure it for future generations.”

Lord Prior said: “Simply putting more money into the NHS and hoping for the best will not work. With funding must come radical reform. We need a shift from ‘diagnose and treat’ to ‘predict and prevent’.

“Care must be joined up around – and tailored to – the patient. A universal service should be there for everyone, not the same for everyone.

“At the heart of our plan for reform is a radical simplification of the NHS and a properly funded social care system to make this happen.”

It is disgusting that people were misled into believing that the insurance payments they made to government – which are compulsory – would cover the cost of care in their old age have been ripped-off – with many being left without proper care.


The Lords David Prior and Lord Ara Darzi proposals to reform the NHS and to make social care free at the point of entry are designed to stimulate the debate on the way forward for these services which are critical to the population of the UK.

Whether making social care free would take the pressure off the NHS is debatable. It could be argued that it will only encourage greater use of social care. Those who work in the NHS will dread the thought of another reorganisation, and there is no mention of how much this would cost. I guess we will need to wait for the publication on the Green Paper on social care which has now been delayed, to see if any account has been taken of the proposals made by the lords.

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

NHS Community Services Providers: Take Centre Stage

A report from NHS community services providers suggests that their services are at the point of taking centre stage. For many years now, successive national NHS policies have stated that community services should play a more central role in the future health and care system than they do at present. The most recent iteration of this ambition was the Five year forward view (FYFV) (NHS England, October 2014), but this initiative was only the latest in a long line of NHS strategic plans that sought to strengthen the position of the community sector and deliver care closer to people’s homes.

This argument in favour of stronger, expanded community services has been made for three overarching reasons:

  1. The NHS must radically improve its ability to prevent illness and support people to ensure their own wellbeing if it is going to be financially sustainable. Strengthened community services are crucial to bringing the right focus on preventing ill health, improving the population’s health and wellbeing, and tackling health inequalities.
  2. The disease burden is shifting as people are living much longer with multiple long-term conditions that cannot be permanently cured by hospital intervention. Conditions such as diabetes and hypertension require a very different type of interaction with patients and the public than, for example, a traumatic injury. Community services offer the most appropriate way to promote good health and prevention and provide joined-up care for an ageing population.
  3. Acute inpatient services, in both hospitals and mental health services, are under huge pressure and they are currently being used unnecessarily and inappropriately for patients who could and should be treated closer to home. It is better for patient care, better for performance outcomes, and better for the NHS budget to treat as many patients as close to home as possible, with community services once again at the heart of provision.

However, while the burning platform for this shift in the provision of care is the financial and operational pressures in the acute sector, the real driver for community services lies in good population health and prevention at scale. Too much time has been spent making the case for community services in relation to “moving care closer to home”, when it is the combination of all three reasons that makes the case. Concentrating solely on this defines community services in relation to what they are not, rather than what they are. This then colours the debate around community services, which continues to be acute-focused and about shifting services between settings rather than acknowledging the positive reasons for strengthening community services.

The analysis for this report is informed by an online survey of NHS trust chairs and chief executives representing 51 trusts that provided community services and 20 that did not. The contribution of these 51 trusts. This means over half of all trusts that we are currently providing a substantial amount of community services.

To complement the survey a number of interviews were carried out to gain a richer understanding of the issues facing community providers.

Despite the potential of community services, the survey and analysis found seven reasons why ambitions for the community sector have not yet been realised. And, in doing so, the report provides a clear manifesto for what needs to change if community services are going to take up a more important role: The seven reasons are:

  1. There is insufficient understanding of community services and the community provider sector among the national bodies, the Department of Health and Social Care, commissioners, politicians, patients and the public.
  2. Community services have been, and continue to be, an inconsistent national and local priority.
  3. There needs to be greater financial investment in community services.
  4. Demand for community services is outstripping capacity and supply.
  5. Structural inequity means that competition and procurement disproportionately affect community service providers.
  6. There are worrying staff shortages in key roles.
  7. There is a lack of national-level data and a national focus on an improvement approach for community services.


The report from NHS community services providers puts clearly the overarching reasons for more investment in community services. However, change is unlikely to come about unless there is a major shift in the policy of NHS to recognise the value and contribution of community services, who will then move more closer towards centre stage

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


CQC Driving Improvement Report

This month CQC published its Driving Improvement Report. The report sets out how services who had previously been graded as inadequate improved to achieve a good grading.

Andrea Sutcliffe Chief Inspector of the CQC has stated that their work is guided by a simple principle – is this a service I would be happy for my Mum or anyone I love to use? If it is, that’s fantastic; but if it’s not good enough for my Mum, it’s not good enough for anyone’s Mum and we’ve got to do something about it.

Lots of services have taken up that challenge and improved. We wanted to share some of their experiences to help others to improve too. In the Driving Improvement Report a number of different services were approached who had been given an inadequate grading by CQC.

For each service interviewed a range of people, including people who use services and their families, registered managers, providers and owners, care staff, administrative and other staff, commissioners and social workers. CQC staff used the following questions to interview providers and managers, and adapted them when interviewing people who use services, staff and others:

  • What was your reaction to the service being rated as inadequate?
  • How did you approach improvement?
  • What support did you ask for and what support did you receive?
  • What were the obstacles to improvement? How did you overcome them?
  • Did the inspection report help you improve your service and outcomes for people?
  • How did you involve staff and support them further in their work?
  • How did you involve people, their families and carers and volunteers, who use the service?
  • How did you involve and work with local partners?
  • Could you give us some examples of tangible improvements?
  • Could you give us some examples of improved outcomes for people?
  • Looking back on the improvement journey, what have you learned, and is there anything you would do differently?
  • What are you doing to ensure improvements are sustainable? What’s next on your improvement journey?
  • To summarise, what would you say are the top five actions you took that helped your service improve?

Key Themes

Reaction to the initial inspection report

Most providers, and not just in the adult social care sector, react to a report highlighting failures with shock, surprise and disappointment. But usually when people stand back and have time to reflect, they understand the failings. As one care worker told us: “In the report we recognised the failings and could see the truth in what was said.” For committed staff the report can come as a relief, as in some of our case studies staff were struggling – doing their very best but unable to deliver the care they wanted to. Several case studies highlight the impact that a rating of inadequate and report of poor practice can have on a service’s reputation.


The value of a good leader cannot be underestimated. In most of the providers we spoke to, a new manager had come into the service to deliver the improvements. They engage with staff, people who use services and their families; they are open to suggestions but set parameters and take tough decisions where necessary. Staff and family members in some of our featured providers commented about a manager’s door always being open.

Cultural change

Leadership and culture go hand in hand. It’s the leader’s job to shape the culture of an organisation. Failing organisations tend to have cultures in which staff are afraid to speak out, don’t feel they have a voice and are not listened to. Involving staff is one of the best ways to drive improvement.

Person-centred care

Typically, when a new manager took up the reins, they wanted to see care plans. And in most cases, these were lacking in detail and did not demonstrate that the care being provided was person-centred. It is simply not possible to provide good care if the care staff do not understand the needs of the person being cared for.


A range of issues to do with staffing contributed to the low rating in most of the providers featured in this publication. Too many providers were struggling along without having enough staff to deliver safe and effective services. It wasn’t generally because the staff didn’t care; it was because they didn’t have the time to care as well as they should. And that put a great deal of stress on staff as well as putting people who used services at risk.

Working with partners

Most of the services we feature received support to help them improve – mainly from the corporate provider, if there was one, or commissioning bodies. The starting point was having a manager and staff who were willing to ask for support, were honest about the issues they faced, and were open and transparent about their plans for improvement.

Building a community

Providers that are good and aspire to be outstanding look beyond their own walls and seek to be part of the local community. We saw great examples of providers opening their doors to local groups, working with local schools and bringing the families of the people who use their services.


The CQC Driving Improvement Report raises a number of interesting questions regarding inadequate social care. Most managers of care services will now be fully aware of the key themes identified in this report which constantly appear in literature produced by CQC. This does not demean their importance. It would appear however, there are still too many providers graded inadequate who have still not taken on board their importance.

The services who took part in this study must have been committed to improvement when approached by CQC, otherwise they would not have agreed to it. The elements of good practice identified in this report can be followed by all providers with the same level of commitment.

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

Communicating with someone with dementia

The Alzheimer’s Society have published some useful tips on communicating with people with dementia, which may be useful to staff in adult social care services.

Before you speak

  • Make sure you’re in a good place to talk – quiet, with good lighting and without too many distractions (e.g. no radio or TV on in the background).
  • Get the person’s full attention before you start.
  • Position yourself where the person can see you as clearly as possible (eg with your face well-lit) and try to be on the same level as the person, rather than standing over them.
  • Sit close to the person (although not so close you are in their personal space) and make eye contact.
  • Make sure your body language is open and relaxed.
  • Have enough time to spend with the person. If you feel rushed or stressed, take some time to calm down.
  • Think about what you are going to talk about. It may be useful to have an idea for a particular topic ready. You can also use the person’s environment to stimulate topics.
  • If there is a time of day where the person will be more able to communicate (eg in the morning) try to use this time to ask any questions or talk about anything you need to. Make the most of ‘good’ days and find ways to adapt on ‘bad’ ones.
  • Make sure any of the person’s other needs are met before you start (eg they’re not hungry or in pain).

How to speak

  • Speak clearly and calmly.
  • Speak at a slightly slower pace, and allow time between sentences for the person to process the information and respond. This might seem like an uncomfortable pause to you, but it is important for helping the person to communicate.
  • Avoid speaking sharply or raising your voice.
  • Use short, simple sentences.
  • Try to communicate with the person in a conversational way, not question after question (it can feel like an interrogation).
  • Don’t talk about the person as if they are not there or talk to them as you would to a young child – be patient and have respect for them.
  • Try to laugh together about misunderstandings and mistakes – it can help. Humour can help to bring you closer together, and may relieve the pressure. However, be sensitive to the person and don’t laugh at them.
  • Include the person in conversations with others. This may be easier if you adapt what you say slightly. Being included can help a person with dementia to keep their sense of identity and feel they are valued. It can also help to reduce feelings of exclusion and isolation.

What to say

  • Try to avoid asking too many questions, or complicated questions. People with dementia can become frustrated or withdrawn if they can’t find the answer.
  • Try to stick to one idea at a time. Giving someone, a choice is important, but too many options can be confusing and frustrating.
  • If the person is finding it hard to understand, consider breaking down what you’re saying into smaller chunks so that it is more manageable.
  • Ask questions one at a time, and phrase them in a way that allows for a ‘yes’ or ‘no’ answer (eg rather than asking someone what they would like to do, ask if they would like to go for a walk) or in a way that gives the person a choice (eg ‘would you like tea or coffee?’).
  • Rephrase rather than repeat, if the person doesn’t understand what you’re saying. Use non-verbal communication to help (eg pointing at a picture of someone you are talking about).
  • If the person becomes tired easily, it may be better to opt for short, regular conversations. As dementia progresses, the person may become confused about what is true and not true. If the person says something you know is not true, try to find ways of steering the conversation around the subject and look for the meaning behind what they are saying, rather than contradicting them directly. For example, if they are saying they need to go to work is it because they want to feel useful, or find a way of being involved and contributing? Could it be that they are not stimulated enough?


  • Listen carefully to what the person is saying, and offer encouragement.
  • If you haven’t understood fully, rephrase what you have understood and check to see if you are right. The person’s reaction and body language can be a good indicator of what they’ve understood and how they feel.
  • If the person with dementia has difficulty finding the right word or finishing a sentence, ask them to explain it in a different way. Listen out for clues. Also pay attention to their body language. The expression on their face and the way they hold themselves can give you clear signals about how they are feeling.
  • Allow the person plenty of time to respond – it may take them longer to process the information and work out their response. Don’t interrupt the person as it can break the pattern of communication.
  • If a person is feeling sad, let them express their feelings. Do not dismiss a person’s worries – sometimes the best thing to do is just listen, and show that you are there.

Body language and physical contact

  • Non-verbal communication is very important for people with dementia, and as their condition progresses it will become one of the main ways the person communicates. You should learn to recognise what a person is communicating through their body language and support them to remain engaged and contribute to their quality of life.
  • A person with dementia will be able to read your body language. Sudden movements or a tense facial expression may cause upset or distress, and can make communication more difficult.
  • Make sure that your body language and facial expression match what you are saying.
  • Never stand too close to someone or stand over them to communicate – it can feel intimidating. Instead, respect the person’s personal space and drop to or below their eye level. This will help the person to feel more in control of the situation.
  • Use physical contact to communicate your interest and to provide reassurance – don’t underestimate the reassurance you can give by holding the person’s hand or putting your arm around them, if it feels appropriate.


Adult social care services are always looking to improve their ability to communicate with people with dementia. Managers of adult social care services are well advised to bring to the attention of their staff and carers the tips on communicating with people with dementia produced by the Alzheimer’s Society.

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