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Reducing GP Care home visits


GP’s are always on the lookout for innovative initiatives that will lead to are improving care while driving efficiencies. NHS Calderdale Clinical Commissioning Group (CCG) has pioneered a clinically-led approach to improving the health of care home service users which has, so far, cut emergency admissions of care home service users 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 service users in Calderdale, Yorkshire. The ‘Quest for Quality in Care Homes’ initiative involved 1,300 care home service users 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 has:

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

The Quest team players

So, 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 offers clinical support to ensure the needs of service users are met – for example, advising on ways to prevent falls and incidents that could affect service users.

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 service users to access planned and unplanned care services and ensure that patients are proactively managed to keep them within the care home setting.

The team also works with secondary care staff to support the early discharge, where appropriate, of care home service users who have attended A&E and/or been admitted to hospital.

The role of telecare

To date, more than 1,300 service users 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 service users leave their beds during the night, for example.

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

A key focus of the pilot project was to reduce hospital admissions from care homes, increasing quality of life for service users and reducing demand on primary and secondary care.

This led to the development of the Quest for Quality in Care Homes pilot, which combined a MDT, real-time access to live clinical records for GPs and Quest for Quality in Care Homes matrons, and telecare and telehealth systems to improve the quality of care and help to reduce avoidable hospital and GP visits. It aimed 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 service users 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.

Outcomes

  • 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

Results from the pilot project carried out NHS Calderdale Clinical Commissioning Group show some impressive results. Reducing visits to care homes by GPs by up to 45%. While this is no doubt welcome news to GP’s who are grappling with the problems of scarce resources, I trust that this is not at the cost of regular reviews of the overall health needs of service users. The reduction in falls and falls related incidents can be attributed to the use of technology, and costs permitting we will see a greater use of such technology for the benefit of service users in the future.

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

Concern about Liberty Protection Safeguards


In July 2018, the Government published a Mental Capacity (Amendment) Bill, which if passed into law will reform the Deprivation of Liberty Safeguards (DoLS), and replace them with a scheme known as the Liberty Protection Safeguards (although the term is not used in the Bill itself). Ministers say it will save councils £200 million a year and give ‘swifter access to assessments’.

The Bill draws heavily on the Law Commission’s proposals for reforming DoLS, but generally does not address some of the wider MCA reforms that the Law Commission suggested. So proposed reforms around supported decision-making and best interests are not included, although the omissions have proved controversial, and may be challenged as the Bill goes through Parliament.

Key features of the Liberty Protection Safeguards (LPS)

include:

  • Like DoLS (but contrary to the Law Commission’s suggestion) they start at 18. There is no statutory definition of a deprivation of liberty beyond that in the Cheshire West and            Surrey Supreme Court judgement of March 2014 – the acid test.
  • Deprivations of liberty have to be authorised in advance by the ‘responsible body’
    • For hospitals, be they NHS or private, the responsible body will be the ‘hospital manager’.
    • For arrangements under Continuing Health Care outside a hospital, the responsible body will be the local CCG (or Health Board in Wales).
    • In all other cases – such as in care homes, supported living schemes (including for self- funders), the responsible body will be the local authority.
  • For the responsible body to authorise any deprivation of liberty, it needs to be clear that:
    • The person lacks the capacity to consent to the care arrangements
    • The person is of unsound mind
    • The arrangements are necessary and proportionate.
  • To determine this, the responsible body must consult with the person and others, to understand what the person’s wishes and feelings about the arrangements are.
  • An individual from the responsible body, but not someone directly involved in the care and support of the person subject to the care arrangements, must conclude if the    arrangements meet the three criteria above (lack of capacity; unsound mind; necessity and       proportionality).
  • Where it is clear, or reasonably suspected, that the person objects to the care arrangements, then a more thorough review of the case must be carried out by an         Approved Mental Capacity Professional.
  • Where there is a potential deprivation of liberty in a care home, the Bill suggests the care home managers should lead on the assessments of capacity, and the judgment of necessity    and proportionality, and pass their findings to the local authority as the responsible body. This aspect of the Bill has generated some negative comment, with people feeling that             there is insufficient independent scrutiny of the proposed care arrangements.
  • Safeguards once a deprivation is authorised include regular reviews by the responsible body and the right to an appropriate person or an IMCA to represent a person and protect        their interests.
  • As under DoLS, a deprivation can be for a maximum of one year initially. Under LPS, this can be renewed initially for one year, but subsequent to that for up to three years.
  • Again, as under DoLS, the Court of Protection will oversee any disputes or appeals.
  • The new Bill also broadens the scope to treat people, and deprive them of their liberty, in a medical emergency, without gaining prior authorisation.

According to some campaigners there is fear that vulnerable old people face being ‘effectively imprisoned’ in care homes if Ministers press ahead with cost-cutting changes to the way that service users are assessed, campaigners fear. They argue that care home managers will become ‘both judge and jury’ in cases involving the freedom of their clients, many of whom have dementia.

At present the friends or family of those lacking the mental capacity to decide where they live can object to a home’s decisions about their care by applying for an independent review. But the Government is scrapping the existing Deprivation of Liberty Safeguards (DoLS) system because they say it is too slow and expensive.

But critics say the move will strip vital rights from the most vulnerable.

Crucially, the new rules would do away with the automatic right to a review by an independent ‘best interest assessor’. Instead, care home managers will carry out ‘consultations’ about what should happen to a service user.

Judy Downey, from the Relatives & Residents Association, said: ‘Care home managers will become both judge and jury in cases in which they may well be involved. That is neither fair nor appropriate. ‘She added: ‘Staff on our helpline hear far too many examples of people deprived of their liberty, seemingly for no reason except that it’s thought best by the care home.

‘At the moment they or their relatives can challenge such decisions. But under these short-sighted proposals they will lose that right, raising the frightening possibility that individuals will be effectively imprisoned in homes that are totally unsuitable for them.’

The Department of Health and Social Care said: ‘The Bill ensures that authorisations for people to be deprived of their liberty in care homes are determined by responsible bodies such as local authorities or clinical commissioning groups.’

Summary

Although some ministers claim the Liberty Protection Safeguards will save will save councils £200 million a year and give ‘swifter access to assessments’ it is questionable that the proposed changes will prove to be a smooth transition. Service user’s families and carers will not take to kindly to a care home manager determining what is the best for their loved ones, nor would one think that managers would welcome this new responsibility.

My major criticism of the new bill is that it relies on the profession judgment of social care workers and deprives relatives and friends from contributing to the decision making process.

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

Can Alexa improve the lives of those who are lonely?


It came as no surprise to learn that some councils in England are now trialing Amazon’s Alexa in Care homes and services for people with disabilities. Voice control technology is about to become an integral part of many people’s way of daily living. Having heard so much about it my wife bought an Alexa for my birthday. We use it to access music of our choice and to be honest it is much more convenient than streaming music to your phone or computer, let alone playing a CD. I then began to think how Alexa could be of benefit to those who use social care services.

One of the scourges of modern society is the lack of contact people have with each other. This is much more acute in the elderly population, those confined to their own homes and those who live their lives in care homes. For lonely older people, having someone to talk to can be a lifeline. Even, perhaps, if that someone is a computer.

It has been reported recently that Amazon’s Alexa digital assistant is being used to keep elderly and disabled people company in trials that could offer a way for them to stay in touch with the outside world.

Councils insist that Alexa will only ever be used on top of existing care. But campaigners have warned that computers must not be used as a replacement for human contact.

There is so much controversy surrounding the benefits of technology. It is often blamed for exacerbating the atomisation of society. Theresa May once said that “the warmth of human contact risks receding from our lives”. However, this does not appear to have much traction, when her government has singled out the potential of Alexa to help social care in plans published this week.

For those with a degree of skepticism it can be seen by some, that councils struggling with cuts, remote robot monitoring with the £89.99 devices could offer a way to keep care bills under control.

Hampshire county council began a trial of the Alexa technology this year in a pilot of 50 people with disabilities. Early results found 72 per cent said that it had improved their quality of life. Liz Fairhurst, the councilor responsible for social care, said some participants had described it as life changing. “We are keen to look at how we might use this technology . . . to support a wider range of people to live as independently as possible.”

Oxfordshire county council has started to install Amazon Echo speakers in the homes of elderly people. For older people unfamiliar with the internet, it is hoped that a voice-activated assistant will be a simpler way to find information online and keep in touch with relatives.

Ian Hudspeth, leader of the council, said that imaginative ways were needed to deal with isolated older people. “We are experimenting with Amazon Echo’s for older people to see if that provides some ability for them to communicate,” he said. “It’s a simple idea but if it gives the person that bit of respite from loneliness, isn’t that a good thing?”

He hopes that Alexa can also keep a virtual eye on hundreds at risk of falling over or slipping into illness.

Greater potential

Director of adults’ social care at Oxfordshire council Kate Terroni, says the council was especially keen to see how Alexa could support older people and help to connect them with their communities and to see how the technology can reduce loneliness and isolation. So far, Alexa has performed tasks for service users such as setting reminders, providing news updates and playing audiobooks, helping to give service users a greater sense of independence. At the halfway stage of the trial, Terroni says Alexa has had a greater effect than anyone at the council expected.

James Picket, of the Alzheimer’s Society, said: “Alexa isn’t the same as a chat with a loved one. Human interaction is always the gold standard, but unfortunately there simply aren’t enough professional carers to provide the care that people with dementia need and deserve.”

Summary

The imitative taken by Hampshire and Oxford County Councils to trial Amazon’s Alexa digital assistant is to be commended. There appears to be emerging evidence that the voice-controlled technology can engage people and reduce loneliness and isolation.

As with all technology ‘Alexa’ should not be viewed as a panacea that will on its own rid society of its failure to engage with one another. It cannot and should not be a substitute for human contact. Those responsible for social care budgets and care providers must not see it as a replacement for caring staff. That said, and given the aforementioned safeguards, ‘Alexa’ can have the potential to bring some enjoyment and support to people who are isolated and lonely in their lives.

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

CQC receives award to encourage innovation


Through its Regulators’ Pioneer Fund, the Department for Business, Energy and Industrial Strategy (BEIS) has awarded the CQC £500,000 to explore how it can work with providers to encourage good models of innovation.

CQC says this draws on our long-standing commitment to co-production and learning from providers, while upholding people’s right to safe, high-quality care.

The Regulators’ Pioneer Fund was established by the Government to fund unique projects that will help regulators support the development of new products and services. These projects are aligned with particular “Grand Challenges” set out in BEIS’ Industrial Strategy and aim to unlock the potential of innovation to help tackle these issues.

The CQC project being backed will allow the organization to investigate and test new ways of engaging with innovative providers to meet the needs of an ageing population, while making sure that patient safety is kept at the heart of developing services. This could include ‘regulatory sandboxing’, where implementation of technology can be tested against the regulations in a controlled way, to ensure that regulation achieves the best outcome for people using services.

Commenting on the announcement of the award, Ian Trenholm, Chief Executive, said: “We have always been committed to developing our approach to regulation alongside providers”. As technology is becoming an integral part of the way care is delivered we need to make sure our approach supports innovative new services.

Just as people’s needs and expectations of care are changing, so are the innovative ways that providers can support them. Regulation has to keep pace with and encourage progress – whilst also making sure that people receive the safe, high-quality care that they deserve, regardless of how it is delivered.

“This funding from the Regulators’ Pioneer Fund will help us work with and encourage innovative providers at this exciting time, helping regulation to develop effectively and, encouraging technological change.”

In announcing the fifteen winning bidders for the £10m Regulators’ Pioneer Fund, Business Secretary Greg Clark said:

“The UK’s regulatory environment is recognised as being among the best in the world and through our modern Industrial Strategy we are building a business environment in which Britain’s dreamers, developers and disruptors can continue to thrive.

“These projects will further strengthen our regulatory system and ensure that it keeps pace with the innovation and technological advances needed to power our economy now and in the future.”

Embracing technology to bring about change

This award gives an insight in how the CQC sees the future of social care services. There is little doubt that they wish to see more providers making use of the new technology that is constantly becoming available. Providers will be encouraged to make more use of technology, and even if I dare say it, in the not too distant future standards will be introduced to measure the provider’s use of technology.

In my experience at one end of the scale it is the larger providers with sufficient profit margins that are able to afford the investment required. While at the other end we have smaller providers, who struggle to make ends meet to keep their services running let alone invest in technology. The number of care home closures in the past year gives us evidence of the struggle.

Summary

This award to the CQC through its Regulators’ Pioneer Fund should be welcomed. Social care services need innovation and providers should embrace technology that can improve their services. However, CQC should take care that they do not drive the smaller provider out of the care industry, because they cannot keep pace, let alone afford new technology.

I am prepared to accept that technology has an integral part to play in the delivery of social care services, but it must be accompanied by staff and Services Users who are able to make the best use of it. We should be wary that we do not take our eye off the ball. Placing too much focus on what technology can offer us at the cost of spending less time on providing a face to face service for Service Users.

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

Quality care services are not just about more money


I recently read an article in the Times that reaffirmed my view that quality care services are not just about money. The article referred to a woman who had spent weeks looking at places for her father, who has had dementia for 12 years and now needs specialised nursing. In her search she came across the average, the diabolical and the inspirational, all within a few miles of his town.

Surprisingly, money didn’t seem to have the greatest effect on quality. The most expensive felt like a prison with the dementia inmates locked in, staff vacancies, grey sloppy food, a regimented timetable and dark, echoing corridors.

Elements of a good care home

The most impressive was the cheapest not-for-profit charity home where even the handyman stopped for a chat while putting up a curtain, there were packets of digestives on tables, the vicar popped by, the Brownies sang a song, and there were signs on each door with instructions such as: “Mrs. Jones likes her tea lukewarm, her hand shaken not squeezed and a cuddle at night”. The staff were motivated, kind and chatty. Everyone wandered freely, couples were welcomed, their bedrooms were covered in cards and photos, the garden was full of benches and bird feeders and when they demanded liver and bacon it was provided instead of pizza. But it has a long waiting list.

Difficulties facing social care services

We all know that financially it’s tough to run a care home. At least 148 businesses became insolvent in 2017, up 83 per cent on the previous year; 2,492 residents were evicted with nowhere to go because their homes closed, up 39 per cent on the previous year. This is particularly harsh for those with dementia who need familiarity. They are also often the ones being charged the highest rates. According to a report this week by the Alzheimer’s Society, providers can add as much as 40 per cent to the bill for dementia patients. About 850,000 people have dementia in Britain and pay an average of £100,000 for their end of life care. Increasingly, families cannot find anywhere that will take them, so they end up on hospital wards.

There are also not enough staff for care homes, with vacancy rates running at 11.4 per cent and 90,000 places unfilled. That’s before Brexit curbs the number of EU migrants. Caring is viewed as “unskilled labour” but the British need to see it as a vocation and a worthwhile career.

The elderly staying at home often aren’t faring any better. According to Age UK, 1.4 million older people are now not getting the necessary help to carry out essential tasks such as washing and dressing, a 20 per cent increase in only two years. There are already 7.6 million people caring for elderly relatives but even with their help the Local Government Association is warning of a £3.5 billion funding deficit by 2025.

When a care home place is not available the NHS fill the gaps. Simon Stevens, chief executive of NHS England, said recently that the equivalent of 36 hospitals were out of action because of a lack of social care.

Funding in the future

This week Matt Hancock, the new health and social care secretary, announced £240 million for the elderly, which could provide 71,000 more domestic care packages to help pensioners stay at home. This will alleviate some pressure on wards but it’s not going to address the long-term issues. Mr Hancock hasn’t been allowed to announce anything more radical, although he has been pushing quietly for a new social care fund where payments could be deducted by employers for future care costs. By the end of this parliament there will be a million more people in Britain over 75 than there were at the start of it.

Summary

We bang-on about the lack of funding for social care services, which it badly needs. But, as this lady found a cheapest not-for-profit charity home in her opinion provided the best service. Reading between the lines what she found was a home, who knew the service users and their preferences. Staff who were motivated and chatty and made everyone feel welcome. These things are not about money, they stem from the leadership of the manager, supported by staff who are committed to a culture based on the values of a quality service.

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