“Care homes are care homes – and we’re determined to make a success of them”

Not all the world is in financial distress.

The good news is – McDonald’s third-quarter revenue has topped analysts’ estimates, helped by international markets like Britain and Canada, as well as the expansion of its all-day breakfast menu in the US.

When it comes to English politics, you can be pretty certain that social care will be shunted to be bottom of the pile. Occasionally, privatisation of the NHS surfaces to the top.

Integrated care is a Pandora’s box. Once you begin to look into it, you get a sense of the parts of the health and social care systems being intimately inter-connected with one another. While it might be a political priority ‘to make a success out of Brexit’, there seems to be less enthusiasm about sorting out intermediate care, GP access or delayed transfers of care/discharges.

I feel that the various models of care can get bewildering, but the idea of a ‘person-centred co-ordinated care’ definition that focuses on the individual as the organising principle for services is useful to me. I find less interesting all the minute details about the operations and processes needed to make integration work.

Care homes should indeed be what ‘it says on the tin’ – i.e. pass the Ronseal test, i.e. homes where high quality care takes place.

Becoming a care home resident is meant to be a positive choice, and not symbolic of failure by anyone. It could be a time to meet new people, and have someone help you with mealtimes, making you take your meds on time, doing your washing, for example, if you could benefit from the help.

Part of the aim of ‘opening up care homes’ was so that care homes were not adopting a prison or fortress mentality – and likewise residents aren’t to be expected to want to feel as if they’re in hospital. It’s not meant to be like living in a hôtel either – it’s your home.

Residents should be entitled to the best possible health care as part of a community of a care home as he or she could expect from being in his or her own home. But this is all part of the complicated web that has been weaved about ‘avoidable admissions’ – there clearly has been a knock on effect not just from swingeing cuts in social care, but reductions in ease of GP home visits or community nursing.

There are a number of things going wrong simultaneously, which are not just to do with the total spend on the NHS and social care (inadequate though they are). For example, we have payment systems that reward organisational activity rather than collective outcomes; regulation that focuses too heavily on organisational performance rather than system performance; and the lack of a single outcomes framework to promote joint accountability for integrated care. Promotion of wellbeing of residents in a care home, who like their genealogy tree, or like their cat v dog competitions, should be a valid outcome in itself, in the same way that staying out of hospital might be?

This evening I signed a petition that all dementia care should be free at the point of use. The rationale behind me signing this (“Frank’s Law”) is that I feel there should be no fundamental difference between your eligibility for funding streams in NHS and social care. And we know what the major issues are. The King’s Fund Barker Commission established that the case now for change, for a single point of commissioning of health and social care, is overwhelming. Given that the end point of dementia care should be examined for whether it is health or social care, which can be a somewhat arbitrary decision, it would be helpful if the collection of monies for health and social care were amalgamated at source. Promotion of private social insurance system might be political dynamite, but the discussion of social insurance systems across different jurisdictions is an important one. The care (and housing) sector are in desperate need of financial long term stability, which cannot all be left to market forces, and needs some national infrastructure State guidance.

The present day situation, however, is that commissioning is more fragmented than ever, at a time when the obligation must to integrate around the needs of an ageing population with a mixture of co-morbidities that truly defy service boundaries in a complex way. It would be easier to organise care around a group of providers who agree to take responsibility for providing all care for a given population for a defined period of time under a contractual arrangement with a commissioner. Providers are held accountable for achieving a set of pre-agreed quality outcomes within a given budget or expenditure target.

There are ways of rewiring the system better. Bundling payment for services that patients receive across a single episode of care is one way to encourage doctors, hospitals and other health care providers to work together to better coordinate care for patients, both when they are in the hospital and after they are discharged. Also, in the 2013 Spending Round, the government had announced a new pooled fund of £3.8 billion to try to encourage health and social care organisations to co-ordinate their services. This came to be called the Better Care Fund, and built on the government’s commitments in 2010 to pool some local funds for developing integrated services. Pooled budgets in some form are likely to continue to be important.

But merely bundling the payment is not enough. More needs to happen, including reductions in unnecessary care, reductions in readmissions, lower risk and complication rates for patients, and improved patient function and outcome, for example through the mapping of bundled care payments to a coherent system of valus-based commissioning.

Integrated care was not originally a major part of the coalition’s plans for NHS reform. Yet, as a result of its troubled passage from White Paper to law, Lansley’s diabolical Health and Social Care Act 2012 turbo boosted competition propping a legal framework where integration could be framed as uncompetitive. The Care Act 2014 also placed a duty on local authorities to promote the integration of care and support services with health services (and health-related services like housing) where this will benefit patients and quality of care.

There’s now a genuine concern about rushing the change. The speed of strategic change describes how fast firms are able to implement a new strategy. The resource management perspective suggests that firms need to orchestrate their resources to create new capabilities that are then used to implement strategies. But with Government borrowing still in turmoil, and limited funds to kickstart the ‘sustainability and transformation process’, the political will to drive enhancing health and wellbeing in care homes may be seriously lacking. The danger is if virtually all the money in the Sustainability and Transformation Fund is going into sustainability and deficit reduction there is not much to support transformation.

To enhance health and wellbeing in care homes, I believe in a new set of 5 Cs. Outcomes in the following could be used to produce a structured framework for promoting quality in an extended network involving hospitals, GPs and care homes in an extended network, and help to resolve the problem where commissioning is done from the perspective of the bottom line not quality of care.

(a) care planning

Care planning is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future care. Frequent users of healthcare services are a vulnerable population, often socioeconomically disadvantaged, who can present multiple chronic conditions as well as mental health problems. Case management is a collaborative approach used in parallel with care planning to assess, plan, facilitate and coordinate care to meet patient and family health needs through communication and available resources with the intent to improve individual and health system outcomes.

(b) caring for health

There’s clearly a policy issue of who and how this will be provided, but the aim would be to deal with problems in physical health e.g. falls, fractures, infections, sensory impairment or mental health e.g. apathy, depression, of residents at the first available opportunity. This might be done through an extended GP service or some form of interface geriatrician, for example.

(c) caring for wellbeing

Wellbeing is a multi-faceted phenomenon, and could be promoted in a number of ways, e.g. gardening, arts, music, sporting memories sessions. But the trick is to focus on the person not the task; framing the narrative as “activity rounds” embues unnecessarily a biomedical twang on something which is supposed to be pleasurable and creative. “Dementia Care Mapping” will undoubtedly be invaluable tool for bridging service and research in this area.

(d) continuity of care

People tend to experience the worst care at the transitions of care. Ideally, people should have the best care wherever they are, e.g. at home, hospital, hospital or care home, and there should be smooth interoperability of key health and care information between different settings. At some point, a person might need to shift from living well with a condition to preparing for a good death with a terminal illness, and ideally everyone needs to be familiar with palliative care and end of life. Also, clearly delayed discharges and delayed transfers of care are factors which worsen social care outcomes and NHS outcomes of patient or user “experience”.

(e) care enablement

Whether through a medical intervention, social care or therapy services (physio, OT), for example, a critical feature of living with long term conditions is community based rehabilitation whereby people are given help to live life to the full. Such a package might be intensified, for example, when a person is discharged from hospital.

It’s clear that a long view is now needed.

There are many outstanding examples of care homes currently, but in universalising the best we should be aware that there are wider problems with the health and social care systems which need attention.

The care home sector itself is about to get squeezed through #Brexit and is already squeezed financially in a number of different ways, but somebody somewhere has to have the political will ‘determined to make a success of it’. A critical part to this is financial stability, staff recruitment and retention, and fostering links between caring and housing.

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