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An integrated health and social care system
With so much coverage pre-election about both the social care sector and the NHS, Nadra Ahmed, chairman of the National Care Association, discusses health and care integration
The challenges we face in health and social care are a direct result of the fact that, nationally and globally, we have made great leaps in supporting people with complex health conditions to live longer – something we as a society should celebrate. Medical research and pharmaceutical advancements have enabled people to conquer debilitating conditions, which in years gone by would have ended their lives. What we have failed to do is to plan for the help and support they need as they age and their health care needs increase.
In fact, we have systematically failed to plan for the future needs of an ageing population despite the fact that we have been predicting it for the past two decades. It should come as no surprise to anyone that we would be facing a challenge which would put pressure on health and social care services, but for some inexplicable reason the people who were making the decisions around services ‘fit for the future’ failed to do anything to plan for it. Instead what we have managed to do is to systematically dismantle any form of support to keep people independent and created pockets of deprivation for some of the most vulnerable people in our society.
The fact that these are the very people we promised we would support from cradle to grave and all they had to do was to pay into an insurance scheme which would fund it, is neither here nor there. We have taken their money, which was their investment for old age and now want them to fund themselves! How on earth can there be any justification in the logic behind this? I understand that the NHS was not originally set up for the numbers it is currently servicing but actually, that is not the problem of the generation that bought into it, it is the problem of the generation that needs to keep it sustainable.
Unsustainable solutions to ongoing challenges
The reality of it is that as healthcare needs have grown we have found ourselves in the midst of challenging financial budgets. In the name of austerity we have created unsustainable solutions to ongoing challenges. Public services have been cut in favour of more favourable privately funded services which have then been commissioned at unrealistic expectations at nominal costs. The result is the crisis we currently face, the NHS under severe pressure and social care at the brink of collapse.
We must not be blinded by the fact that this is only a funding crisis, because actually the challenges we face go much deeper. We could get all the money we ask for but without the health and social care professional to deliver it we will not be able to meet our obligations. We have a severe shortage of nurses and health and social care auxiliary staff which will no doubt be compounded by the impact of Brexit. The image of health and social care is such that attracting staff into the roles is becoming a greater challenge than everyone anticipated.
We have an opportunity to take remedial action to stem the tide and make sure that we do not continue to fail our citizens at their most vulnerable. In order to do this we need to have an honest discussion with all partners around the table. Health and social care have to work together to create sustainable solutions to a growing challenge; a challenge which brings with it great opportunities.
Social care has many masters but health care has one and that in itself creates tensions but this should not be seen as a barrier. When we look at the fact we know that bed-blocking is costing the NHS an unsustainable amount of money from an ever decreasing pot. Social care has to be the answer and actually it quite easily could be.
We only have to look at the financial factor i.e. - Mr S in an NHS bed is costing the state £2,125 per week because he has some complex physical needs and has onset of dementia; in a residential care setting he will only receive funding of about £500, if eligible, or through local authority funding could be cared for at home for about £250 for 14 hours a week and community health care support for an undetermined amount depending on what unpaid care support he may need.
All three options must look at what Mr S’s actually care needs are and how they can be met, but what is important in this is that a hospital bed should be the least favoured option based on the fact that all acute care needs will have been met at the point of a care assessment ready for discharge.
The reality is that once we have met the acute care needs of an individual we should be working together to ensure that they are no longer left in an inappropriate setting, which is going to disadvantage someone else who may need that bed/care. The social care market has evolved in such a way that we are now looking after people who were, two decades ago, being cared for in NHS long stay wards receiving medical support from clinicians and support staff. These people were highly skilled and trained to meet the physical and mental health needs of vulnerable people at different stages of their lives.
Social care provision
Social care on the other hand was set up for people who were mildly confused and no longer able to manage daily tasks without support; home helps would feel that they were now at risk living alone. We did not cater for incontinence or indeed any other physical or mental health condition and usually end of life care meant that they may need to be transferred if their needs became of a clinical nature. However, as costs from the public purse spiralled so ‘austerity’ measures tool a hold and long stay wards were closed pushing people into social care provision at a fraction of the cost.
The entrepreneurial nature of the social care provider began to develop services to meet growing healthcare needs and so the challenge was taken. The traditional care home resident was moved into a home care setting with nominal support despite their frailties and nursing care clients came into social care settings. The impact of this was that social care staff needed additional skills and knowledge to deliver care which was appropriate for the needs of the people coming into our services.
With this in mind we need to create a dialogue which acknowledges the fact that social care provision is now undertaking health tasks which the NHS receives funding for. We must look at what a care setting delivers and map it to traditional health tasks and then look at how we actually commission care. Individuals should have an equal amount of funding available to them whether they are in a health or a social care setting if their assessed care needs are the same. Clearly, if those needs decrease as a result of social care intervention in the short term then that should be reflected but a stroke sufferer or someone with MS or Parkinson’s etc. has the same care needs whatever setting they are in. The dichotomy of the current system is that once they leave hospital and are admitted into a social care setting we assume that the same quality of care can be delivered at less than a quarter of the cost.
We must also look at equalising the training of the workforce who deliver the care. We have had a huge drive to upskill the social care workforce and raise their status. We must stop believing that nurses in social care settings are less skilled; they must be allowed to use their skills as they would in a clinical setting. Surely, the time has come for us to invest in the workforce in such a way that it is a long term investment one which builds confidence in health and social care and sees free movement between the two. Both areas would benefits; we see many social care staff go on to become excellent nurses and we see nurses who leave hospitals come into social care and turn services around. We must promote this and enable people to make the transition in a positive way and so create domestic options to recruit staff into health and social care settings.
The important thing to remember in all that we do in health and social care is that at the heart of all decision, whether financial or clinical the person we care for must not be let down. If we are saying that we cannot fund their care at an appropriate level then we must have an honest conversation with the public and not raise expectations to such a level that people then feel let down. The NHS was the envy of the world for acute care and remains a torch of hope, but what we must recognise is that it needs partners in delivery and social care has to be an equal partner not a side issue, a solution not the problem. We could start by making sure that government appoints a Minister for Social Care and Health!