Health Foundation and The King’s Fund report lack of progress on social reform


A new report by the Health Foundation and The King’s Fund have highlighted a worrying lack of progress on social care reform, in extensive new analysis of funding pressures and options for change.

The authors point to low public awareness and lack of agreement on what should be done as major barriers to progress, despite political consensus on the need for urgent action.

They conclude that reforming the current system will be expensive, but that if reform is chosen, England is now at a clear ‘fork in the road’ with a choice between a better means-tested system and one that is more like the NHS; free at the point of use for those who need it.

Mind the funding gap

The report finds that the current system, which sees fewer people receiving publicly-funded care every year, will lead to a funding gap of £6bn by 2030/31. Returning to levels of access and quality last seen in 2009/10, before the current period of austerity, would increase the gap to £15bn.

More fundamental reforms would also significantly increase the cost of social care. Introducing free personal care for all older people with needs above the current threshold would be an extra £14bn.

Protecting people from having to sell their homes by implementing a cap on the lifetime costs of care would require £12bn. With the population over 75 set to double, demand for health and care is projected to rise dramatically over the next 30 years.

Public perceptions findings from the British Social Attitudes survey reveal extremely low understanding of how social care operates, with 34% believing the government pays. When asked who should fund social care, 41% felt it should be entirely tax-funded. At present only those with assets below £23,250 qualify for any publicly funded care.

Boosting social care funding

With taxation the most likely option for boosting social care funding, the findings of separate deliberative work carried out by Ipsos Mori show most people would prefer a dedicated tax to stop the money being diverted elsewhere. Options that include the possibility of people selling their homes to cover care costs, as exists now, were found to be deeply unpopular.

Anita Charlesworth, director of research and economics at the Health Foundation, said: “We have reached a fork in the road and reforming social care is now urgent. Despite the obvious challenges, the government’s Green Paper must build wide consensus on which direction reform should take, and lead to real progress and improvement. More and more vulnerable people will suffer if bold action is not taken to sustain this vital public service.”

Simon Bottery, senior fellow at The King’s Fund, said: “The case for change is overwhelming – patching up the current system would be costly and would not tackle its fundamental flaws. As the government prepares its forthcoming Green Paper, at least two alternatives should be on the table – a better means-tested system and one offering free personal care, which would cost similar amounts to implement. However, there is no silver bullet – the road to reform will be difficult and costly, whichever option is chosen.”

Green Paper on Social Care

The long awaited Green Paper due to be published this summer has been delayed until the autumn. One suspects because of the difficulty in arriving at a financially acceptable and political solution.

The government is considering the introduction of an inheritance exempt Care Isa in a bid to halt the social care crisis. The proposal is being assessed as part of the government’s social care Green Paper

Under the scheme, the Care Isa would be in capped in line with care costs, with the funds remaining being passed onto the family when the holder dies.

Summary

The authors of this report shed light on the lack of public awareness and agreement on what should be done as major barriers to progress. Historically, all the major political parties have recognised the need for social reform but failed to reach any agreement on how it should be achieved.  Much is being talked about what might be included in the forthcoming Green Paper including funding levels for social care and a possible ISA to help contribute towards it. It remains to be seen if the promise of the Green Paper will fare any better than the initiatives that have gone before it.

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

Care home resident’s emergency admissions to hospital of cut by 45%


We continue to hear of the pressure endured by GPs. Time is seen as a chronically depleted resource in general practice and those in the care industry are constantly on the lookout for innovative initiatives that are improving care while driving up efficiencies.

It was refreshing to learn NHS Calderdale Clinical Commissioning Group (CCG) has pioneered a clinically-led approach to improving the health of care home residents which has, so far, cut emergency admissions of care home residents by 33% and reduced GP care home visits by 45%.

NHS Calderdale Clinical CCG – in partnership with Calderdale Council and Calderdale and Huddersfield NHS Foundation Trust – has pioneered a telecare-supported programme to improve the health of care home residents in Calderdale, Yorkshire. The ‘Quest for Quality in Care Homes’ initiative involved 1,300 care home residents over five years, with a multi-disciplinary team (MDT) – the Quest team – and care home staff working to improve care and prevent avoidable emergency attendances and admissions.

Since 2013 the care home teams involved have used Tunstall Healthcare technology to support individual care plans for residents, enabling the prevention of incidents.

In the launch phase – 2014 to 2016 – following the introduction of the Quest multi-disciplinary team, NHS Calderdale CCG:

  • cut emergency admissions of care home residents by 33%;
  • made savings equating to approximately 7,000 hospital bed days;
  • reduced GP care home visits by 45%.

How does the Quest MDT work with GPs to reduce the amount of care home visits?

  • “The MDT supports the work of GPs in care homes but mainly offering clinical support to ensure the needs of residents are met – for example, advising on ways to prevent falls and incidents that could affect residents’ health,”

Dr Cleasby, clinical chair of NHS Calderdale Clinical Commissioning Group explains:

  • The MDT is made up of dedicated Quest matrons, a Quest nurse, a Quest healthcare assistant, consultant geriatrician, pharmacist and mental health practitioner, and has links to other areas such as the district nursing and community matron teams and palliative care. “The MDT works with the key stakeholders including care homes, Calderdale Council and primary and community care staff to minimise the need for residents to access planned and unplanned care services and ensure that patients are proactively managed to keep them within the care home setting,” Dr Cleasby says; the focus is on preventative care that is sustainable and connected.
  • The team also works with secondary care staff to support the early discharge, where appropriate, of care home residents who have attended A&E and/or been admitted to hospital.

The role of telecare

  • To date, more than 1,300 residents have been supported through the Quest for Quality programme using technology, including bed occupancy sensors, fall detectors and movement detectors; the technology is in operation 24/7 and alerts staff when residents leave their beds during the night, for example.
  • “In Calderdale we have found that using telecare in care homes gives users continuous, discreet support and enables carers to respond quickly to any incidents or alerts, which can prevent incidents”.

Reducing GP care home visits by 45%

While GPs don’t directly work with the technology on the project, they work with the Quest MDT and the care homes and, ultimately, benefit from the project and technology. The Quest programme has meant GP call outs to care homes have been significantly reduced – by an impressive 45%; this is because the Quest MDT works directly with the care homes and, given the additional support and quick response to incidents and incident prevention, they call for a GP less often.

Gauging the impact on workload, quality of care and cost savings

The Quest for Quality initiative aims to:

  • Reduce avoidable ambulance call outs, A&E attendance, hospital admissions and GP visits
  • Improve resident/patient care and safety
  • Respond more effectively to urinary tract infections, respiratory infections, falls and fractures
  • Support staff to feel confident in providing high quality care
  • Improve quality of life for residents

More than 1,300 residents have been supported in 38 homes as part of the Quest for Quality over the last five years, and the project has achieved significant financial efficiencies and associated cost savings since it was introduced.

Comparing 2016/17 to 2017/18:

  • Emergency admissions relating to falls have decreased by 7.7% resulting in an annual saving to the Quest programme of more than £200,000.
  • 50% of care homes saw a reduction in falls of at least 10%.
  • Fall-related incidents as a percentage of total incidents decreased from 25.7% to 23.7% year-on-year

Summary

Calderdale is one of the care home initiatives demonstrating what impact clinically-led technology-enabled models could have on a national scale. The outcomes achieved are impressive in terms of a reduction in emergency admissions and cost savings. But are we in danger of losing service user choice and preference, mantras of the CQC and the rights of service user choice. As patients are proactively managed to keep them within the care home setting. Should we be sacrificing their independence and choice in order to receive a medical service appropriate to their needs?

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

 

Why are care homes not full?


Given the current state of bed blocking in the NHS it would be easy to think that some of the cause could be put down to the availability of beds in care homes. But according to a new Laing Buisson report market-defining report, Care Homes for Older People it says care home occupancy is lower than previously thought with people being turned away from services due to staffing shortages and providers not being able to cover additional costs.

The Care Homes for Older People report says care home occupancy stands at 85%, which is lower than previously thought, and calls for ways of levering “latent provision” back into use.

William Laing, report author and data director at Laing Buisson, said: “These findings call for a realignment of how we think about how future demand for care home places will be met.

“Ally this to the predictions for demand based on proximity to end of life rather than age, where we have adopted the methodology originally proposed by the Brookings Institute in the USA, and the issues the market faces are more manageable and resolvable.”

The report throws new light on care home supply and demand, reporting that net capacity rose by 900 beds in the year to March 2018, which the majority of this gain being driven by nursing homes.

Laing Buisson also highlights the contrasting fortunes of self-pay and state-pay focused providers.

William said: “Where state-pay prevails, there continues to be significant pressure on providers’ prices and margins from council and CCG commissioners, putting into question the sustainability of the model.

“Where self-pay prevails, the sector remains robust and the private pay funding model, based on liquidation of owner-occupied property value, looks likely to remain sustainable for at least the next three decades, so long as there is no collapse in property values.

“The importance of this to the market as a whole is reflected in the fees paid by ‘pure’ self-payers who account for 52% of the market by value but only 45% by volume.”

New information from CQC reports has led to a reappraisal of the impending ‘care home crisis’. Laing Buisson has collated and analysed the data from individual care home reports and these show that overall occupancy of care homes is lower than previously thought, at about 85% when measured as occupied beds as a percentage of registered beds.

William Laing, report author and Data Director at Laing Buisson said:

“If the new information is correct, and we have no reason to doubt that it is, it sheds a whole new light on the balance between demand and supply for care homes. Derived from CQC inspection reports, it shows that the aggregate numbers of residents as a percentage of registered beds are, at 85%, much lower than the widely accepted occupancy benchmark of about 90%. At the same time, there seems to be a lot more ‘latent provision’ – mothballed capacity where the care home provider has chosen not to admit residents to full capacity, for example because they don’t want to incur additional staff or other costs.

“This shifts the whole debate. Rather than looking at care home occupancy levels being close to their practical maximum, commissioners might want to look at whatever levers they have to bring the ‘latent provision’ back into use.”

It also casts a new complexion on the impact of openings and closures and, in addition, there appears to have been a reversal in recent trends in the year to March 2018. During this period, net capacity has risen by around 900 beds, with a greater part of this gain coming in registered nursing homes, allaying fears that capacity is being lost.

William Laing remarked further:

“These findings call for a realignment of how we think about how future demand for care home places will be met. Ally this to the predictions for demand based on proximity to end of life rather than age, where we have adopted the methodology originally proposed by the Brookings Institute in the USA, and the issues the market faces are more manageable and resolvable.”

Some of the reasons for lower capacity

Elderly people are being turned away from care homes with spare beds because of staff shortages, analysis suggests. Shortages are arising because managers are leaving beds, or in some cases entire floors, units or homes, empty of residents.

“The number of registered but unavailable beds is much greater than previously thought,” the research said. In some cases, it adds, managers “take a conscious decision not to admit residents to full capacity, usually for staffing reasons, either because they cannot recruit the staff or, more likely, the additional revenue from occupied beds is insufficient to justify incurring additional staffing and other costs.”

Summary

The Laing Buisson report market-defining report, Care Homes for Older People throws doubt on the assertion that care homes will struggle because they will reach their full capacity. The analysis based upon CQC information shows they are only operating at 85% capacity rather than previously thought 90%.

It is a sign of the times that some providers are choosing not to admit residents because of recruitment difficulties, or additional revenue from occupied beds is insufficient to justify incurring additional staffing and other costs.

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

 

MP wants cameras in care homes to be made compulsory


Conservative MP Dominic Grieve is pushing for a new law; making cameras compulsory in care homes.

The MP for Beaconsfield wants a new CCTV law to be one of the first issues debated by MPs when Parliament returns this September. He will apply for a debate in Parliament and intends to argue his case for a law that would make it a requirement for all care homes to install recording equipment.

Law will ‘protect carers; it’s not just a spy device’

“If a resident suffers an injury and you can show on CCTV how it happened, residents and relatives are going to be reassured.” Currently, there is no requirement for care providers to use monitoring in communal areas.

Mr Grieve, a former attorney general, said: “I think this is achievable and could become law. Seeing potential problems that exist in care environments, the arguments in favour are very strong.”

“We have large numbers of vulnerable people in care homes and we want to provide them with proper standards of care. Incidents of them being abused are scandalous.”

But he warned: “We are not going achieve this overnight, but it is something we should continue pressing for.”

“There is clearly growing anxiety about the risk of abuse, sometimes from other residents and sometimes staff, so all that seems to me to make it very valuable. It’s there to protect carers, it’s not just as a spy device.”

The use of CCTV in care homes has long been a topic for debate with some families of abuse victims calling for widespread use, claiming it is the only way to catch abuse or neglect.

Mr Grieve made his statements after hearing from campaign group Care Campaign for the Vulnerable.

Jayne Connery who founded Care Campaign for The Vulnerable is calling for CCTV to be installed in every care home following the experiences of her mother who has dementia. Ms Connery has been a carer for her mother since 2016.

‘There will always be areas which cameras do not see’

However, many have argued a CCTV law is not the solution to issues in care homes.

Gary FitzGerald, chief executive of Action on Elder Abuse has previously voiced concerns of “getting caught up in a debate about cameras when they are a symptom of the problem not the problem.”

He added: “I really think it is a red herring and it is deflecting us from the whole issue of quality of care. Cameras are not the solution. We have to force the Government to invest in social care.”

Caroline Abrahams, charity director at Age UK, recently said: “With all the media stories about abuse and neglect in care homes it can be tempting to see installing security cameras as ‘the answer’, but Age UK very much doubts this is the case.”

“For a start, there will always be areas which cameras do not see and we would not want there to be a false sense of reassurance about the care on offer to residents. More profoundly, care homes are that just that – people’s homes – and those living in them have rights to privacy and dignity just like everyone else.”

“Any use of cameras must therefore balance concerns about older people’s welfare with their right to dignity. Certainly, as a matter of principle we think that cameras should only be used with the informed consent of care home residents or their representatives.”

She added: “Above all, we need to raise the quality of care in care homes across the board and ensure that all older people, their families and staff are involved in how the care home is run and are able to raise any concerns.”

Summary

The Conservative MP Dominic Grieve is entitled to his opinion but would the installation of CCTV Cameras in care homes prevent abuse. At the heart of this debate is acceptance and recognition that a care home is the residents home, a place where they live with the right to their privacy and dignity.

Care services will always have to strike a balance between concerns about resident’s welfare along with their right to privacy and dignity. At the very least, residents and their families should be involved in any decision to use CCTV Cameras before their installation. The question needed to be asked; should we be focusing upon CCTV Cameras or more importantly improvement in quality of care?

If adult social care services raise the standards of quality of care, they will not only reduce incidents of abuse, but give the public more confidence in the services they provide and prevent the clamour for CCTV Cameras.

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