By Debbie le Quesne

Archive for the ‘NHS’ Category

Memories of year where care reached crisis point

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Taking a look back is always dangerous. Nostalgia of ‘better days’ and being transfixed with what has been is never good for moving on efficiently.

But we really can’t escape the fact the 2016 put up some of the bleakest headlines for care that I’ve ever seen.

Funding gaps in community services for older people, which could increase to £2.6bn by 2020; delays in discharging medically fit patients from hospital; regular breaches of safe hospital bed occupancy levels;  and the government and the health and care sectors misaligned (what ever happened to the single budget for NHS and social care?).

It should have been the year that social care and healthcare finally start working together effectively . . . but we’re still waiting. There are, however, some green shoots of promise where the integration model has been pioneered.

As for funding for the future – the 6 per cent council tax rise announced in December is a start, but it diverts funds from housing and will leave some taxpayers  out of pocket.

More significantly it will do little to solve the ageing population problem and overstretched care system.

Currently there’s a lot of behind the scenes talk of more joined-up care between the NHS and social and it’s this hope that keeps me motivated. Indeed, 2017 could be a year of promise (but only if you catch me on a good day).

Obviously, by melding the two streams of care – something that had never happened since the NHS was founded in 1948 – care can become the seamless experience our elderly population deserves.

Despite the protests over who is taking what out of combined budgets, there are already promising signs – local authorities should look to Greater Manchester which, in April 2016, became the first locality in England to merge its health and social care sectors and control its budgets.

In the west Midlands there have been snippets of joint funding news, but not always good as I hear of health always having the upper hand and snatching monies back into its pot.

Without change, social care as we know it will inevitably die and so will those for whom it cares. Reinventing budget mechanics can be achieved, I believe, and bring harmony between social and NHS care. Bring it on – the sooner the better.


GPs’ NO vote on care home calls – it’s not all bad locally

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According to the stats care home residents are an estimated 50 per cent more likely than the average older person to be admitted to hospital as an emergency case.

Now there’s a desperate push to improve on these figures, but the latest stance from the GPs’ Local Medical Committees where delegates voted to not do residential home calls has thrown a serious spanner in the works. I have long been a supporter of improving conditions under which doctors work, but this I perceive as a gross dereliction of duty of care and I know there’s a legal groundswell supporting this stance.

‘Blue light’ cases are costly to the NHS and there are various initiatives afoot to cut back on the numbers of elderly admitted this way.

The financial burden on NHS Trusts appears to have sparked a response that is appears contrary to wishes of the Local Medical Committees’ recent vote.

Wolverhampton Clinical Commissioning Group (WCCG) is proposing a system where 12 GP-led practices work together in supporting care homes which have residents with long-term health conditions such as asthma, COPD, and diabetes. Primarily the aim to prevent any unnecessary admissions to hospital.

Under the name Primary Care in Reach Teams (PITs), the service pledges to provide hands-on support to residential care homes in the clinical management of chronic conditions.

These GP practices will work in co-junction with the Rapid Response service, pharmacy and community teams to “enhance the level of care to patients provided by registered GPs.”

This new service will run from this month (February) as a pilot until January 2017. In the first instance to test how beneficial it is to you and therefore a pilot. In a letter sent out to patients, benefits anticipated by WCCG are:

  • “Improving your health and wellbeing by ensuring that you are receiving the most appropriate care
  • “Reducing ill health by intervening earlier
  • “Reducing unnecessary admissions to hospital. “

Care home patients who fall outside of GPs delivering the scheme can register with a participating practice.

In Dudley, a senior CCG spokesperson told West Midlands Care Association a comprehensive response to the doctors’ vote will be announced, but pointed out that the news broken by the Daily Mail “neglects to state that patients will remain registered with the GP practice and therefore the doctor will continue with the responsibilities that fall under primary care.”

In other words, despite the apparent willingness to leave care and nursing homes to their own devices, doctors’ surgeries will still be bound by a legal duty of care responsibility.


GPs’ NO vote on care home calls – the national scene

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A landmark decision by GPs affecting their commitment to residential care homes and nursing homes is another crippling blow to the care sector. In this blog I want to look at the national scene and then post a second piece on the local picture.

Recently the BBC announced that the plight of care home residents “has pretty much slipped below the radar in recent years.”

It noted while there is “close scrutiny of everything from A&E waiting times to access to the latest cancer drugs, the support – or rather lack of it – care home residents receive from the NHS has gone almost unnoticed.”

I couldn’t have put it better myself.

  • Now for a few facts to set the scene of the latest bombshell to drop on the private care sector:
  • There are 16,500 care homes in England, looking after more than 300,000 residents
  • If nursing homes are included, the number of residents exceeds 400,000 (500,000 across the whole UK)
  • Nursing homes have to have a registered nurse on staff
  • Both care homes and nursing homes work with local GPs, hospital doctors and district nurses

Given the figures, it is obvious any major shift in the way NHS primary care is delivered into this clinically need-laden sector, would have major repercussions.

Announced by the Daily Mail on its front page, I discovered at the beginning of the month “GPs vote to axe care home visits”.

Up to 300 GPs’ representatives from powerful regional bodies voted at a crisis summit to end being responsible for care homes. Simply put: They want to ditch this responsibility.

The British Medical Association union may now lobby the Government to remove the responsibility of looking after residents from the GP contract.

The implications are huge to both service providers and users.

Historically, the care sector has had patchy service from GP practices.

In 2012 the Care Quality Commission reported 81 care homes looked at were not receiving regular visits from GPs. But now that frail commitment is going – or at least going in the way we have come to expect.

These patients are among the frailest, most vulnerable members of society. Many are living with a complex range of conditions, including dementia, heart disease and diabetes, with residents, according to the BBC, on an average of nine medications each.

Like many problems not given the media attention they deserve, the issue has been developing gradually over time.

What concerns me greatly is how quickly this news has dropped out of media interest. Anyone seen anything in the last couple of weeks?

It’s a ‘given’, isn’t it, that many of the people who decant into care and nursing homes are there because of clinical needs.

Doubtless, before that move, these people would probably have been among a GP’s most frequent visitors.

West Midlands Care Association has been flagging up the problem for years along with other representative bodies such as Care England and Age UK.

The bottom line, as with most problems in social care and the NHS, is money and the problem is two-fold, adding unbearable weight to care providers’ responsibility and costs and potentially subtracting essential care from our elderly.

I’ve seen reports of care homeowners paying GP retainer fees of £20,000 a year to provide regular doctor visits for residents. These figures are prohibitive to most providers within my region, but about a third of homes are in expensive surgery retainer agreements.

My fear is that again it’s our most vulnerable who get the worst of deals by default as our GPs push for the right to opt out of being responsible for frail, vulnerable and highly dependent people.

Issues like continuity of care immediately spring to mind and doubtless the cost of bringing in private providers will be loaded. But we have a legal responsibility to register every resident with a GP, and what’s more, my members want to care for their residents properly.

There’s a trend of moving seriously ill patients out of hospitals into care homes and nursing homes, what will happen to them?

Who are their advocates? Increasingly, it’s our care homes who are taking up their causes, but there must be a limit on just how much fighting we can do . . . Fighting to stay open, fighting to pay bills, fighting to fund the living wage, fighting to change a broken system, fighting . . . fighting . . . fighting. Sometimes I just get tired.




How the Government is saving £132bn on care

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No-one these days appears to be arguing that carers should not be paid more for the invaluable work they do. The exchanges are more about where the funding will emerge to reward this valuable social asset.

As head of the West Midlands Care Association, I’ve campaigned with many others for the Government to throw a lifeline to the industry. I am aware good care saves our nation an absolute fortune.

Our media man has some great carers for his ailing wife on a direct payments arrangement. The care is so good nursing calls have been reduced form an average of 4.3 x2 visits per week, averaging eight hours of clinical time, to 1 x1 every three months for a catheter change.

Saving to the NHS in this single case are awesome. Do you know the majority of care for ill, older and disabled people is provided not by doctors, nurses or care workers but by family and friends. More people are caring for a loved one than ever before, with one in eight people providing unpaid care to loved ones. From taking a partner with an illness to hospital appointments, to helping a disabled sibling with washing and dressing, to caring full time for an elderly parent, we are, increasingly, a nation of carers.

New Carers UK figures show that this help is worth £132bn per year – more than double its value in 2001.  This figure is calculated by adding up all of the care provided by carers and working out the cost of the state providing the same amount of support.  And this unprecedented figure of £132bn – more than the value of HSBC Holdings, or Visa plc – does not appear to reflect nursing costs.

The outpouring of caring is indeed something to be proud of, but I’m equally appalled that such a huge burden is placed on so many without any professional, paid carers on the scene. For some, that will be a choice. For the majority, I fear, it’s because the bar is now too high for them to warrant a funded care package.

The figure is confetti money – the cost of a second NHS service. So, what is driving the increase in the value of care? Demographic change now means means that the numbers of those in need of care and support is beginning to exceed the numbers of working age family members able to provide it.  But more critically is the fact that cuts to social security and local care services means people are receiving less support. It’s ticking time bomb, I fear, for surely this amount of ‘unofficial’ caring cannot be sustained indefinitely without some major support.

One wonders how long it will be before the carers crumble and their charges are, by default, neglected. I know of family carers who are struggling to make ends meet financially. Ordinary people, fighting to balance their domestic books, they are desperate for social services’ funding, but the pool of money to fund such intervention has evaporated.

Government has broken too many promises on the care issue to mention, but I will bring your attention to the hypocrisy of David Cameron. Did you know he protested about frontline cuts to public services suggested by his own Conservative local council?

A leaked letter shows Cameron chastised Ian Hudspeth, leader of Oxfordshire County Council, for considering cuts to elderly day centres and other services. ‘Not in my back yard,’ springs to mind.

A whopping £132bn . . . the yield for zero investment. It surely doesn’t take a lot of imagination to envisage more savings longterm if monies could be poured in to social care to fund a more professional approach. Goodness knows, those heroic and stoic people who care for their loved-ones out of a seemingly endless pool of compassion and love deserve it!

Intermediate care – please light the touch paper

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Caring Times Editor Geoff Hodgson recently blogged about the value of intermediate care – an election firework, I suspect, that’s not yet seen a box of matches.

He writes: “Several years ago I visited a privately-run rehabilitation centre in Germany. The clientele was varied – a lot of older people recovering from strokes and hip operations, middle-aged people getting over their bypass surgery and young motorcyclists and skiers with an assortment of fractures, all tended by a small army of specialist physios, OTs and highly trained care workers.”

He was left in no doubt that this model works, one official telling him: “We get people back home or back to work very quickly.

“The intensive rehabilitation we deliver means we maximise the benefit of the hospital treatment they have had, reducing the risk of complications and greatly minimising readmission to hospital.”

This is a model that, according to Geoff’s German health service people, wins financial support from the state because it had proved its worth both economically and in terms of clinical outcomes. Sensible!

I recall, like Geoff, that a decade or so ago ‘intermediate care’ was a buzzword. It seems to be on the back burner now, though any politician with an eye to getting publicity may want to resurrect the concept. As Geoff points out “whatever the outcome of the General Election, it is to be hoped that ministers will start banging some heads together. Health and social care integration remains a dream. A commitment to intermediate care would go a long way towards making it a reality.” Well said.

Gulf between private fees and authority fees ‘increasing’

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Market reports often tell us what we already know: The gulf between Social Services and private fees in the south continues to grow. What a surprise!

In the winter market appraisal by healthcare property consultants ES Group, it notes, however, that “we are also seeing homes in all areas achieve more private fees, with some operators being more successful at grasping the nettle.”

Some operators apparently are now seeing the rewards of capital expenditure investment – good news!

ES states: “We remain of the view that for many homes some Social Services fees will be unavoidable and there is no harm in that, but clearly operators need to have a strategy of investment in physical standards and marketing to maximise their share of private fees.

Figures show that in purpose built accommodation for the elderly bed yields before tax and other outgoings rank from £15,000 – £25,000; in older purpose builds the figures range from £8,000 – £15,000; while other non-purpose accommodation is as low as £4,000 – £7,000.

Specialist care beds are showing returns between £30,000 – £45,000.

It must be noted this in not a localised summary of economies, but despite regional differences, it must add to a general feeling that things can only get better.



Joseph Rowntree Foundation: Indeed, worthy reading

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I have plenty of regard for Geoff Hodgson, editor of the Caring Times. He appears to have a balanced overview of the care sector and, more importantly for me, is in touch with the realities of life.

I’m also equally impressed by the many findings of the Joseph Rowntree Foundation and its recent report on social care. Geoff blogged that the document was worthy of an enthusiastic response. Indeed it is.

In particular, there’s a section on what should be a bedrock of principles for all care whether providers, regulators, local or central government or the NHS.

Written by JRF’s director of care services John Kennedy, the report (simply titled John Kennedy’s Care Home Enquiry), used social media to harvest the broadest possible comments.

Let me quote Geoff: “By far the most emphatic of the findings in the report is that care workers are undervalued, undertrained and underpaid, echoing the sentiment of Baroness Kingsmill in her report earlier this year.” Err . . . yes!

As Geoff adds, reading such reports do taken a determined efforts but among the dross there is pure gold to be found and this is one such gem.

At the risk of repeating the ‘important stuff’ raised by Geoff and being pilloried by my peers for doing so, I find myself almost agreeing with the report’s author that “regulation should be more than inspection . . . it should look at pay and working conditions, staffing levels, mission, commissioning practices and transparency of tariffs, in order to improve the quality of care.“

But before I’m stoned, what better way would there be to expose the government shortcomings on funding?

The report offers other nuggets too and asks its readers to consider the following principles – and I quote:

  1. Be appreciative of the million and a half people who work in our social care sector. They are your friends, relatives and neighbours. They care for us and our own. Judge them by the reality of humanity not by an idealised, unattainable expectation.
  2. Be proportionate about risk. Share the risks, don’t just try and pass it on.

Much of this report is about right attitudes, culture and better futures. Below is a snippet or two lifted from Kennedy’s work and you may even wish to read it (I do hope so).

For care homes:

  • Providing care is not the same as making widgets: it comes with a wider social responsibility of national importance. If your business model is driven solely by profit, you shouldn’t be in the business. The vision, values and attitudes required to run a care home start in the board room and proprietor’s office. Your business has a significant social and community impact. Take responsibility.
  • Be active in your representative organisations. It is time to step up and help create a vision for the 21st century care home. Stop being passive. Care homes will only get better if you are part of creating the solutions.
  • Be open, honest and transparent. Be candid about your strengths and your failings. Resist defensiveness.

For government:

  • Declare the care sector a ‘sector of primary national strategic importance’ for the country, the economy and ourselves.
  • Recognise that social care on the cheap is very expensive. The opportunity cost of low investment in our social care system is simply pushing higher cost onto the NHS. It is also inhibiting our national economic potential by failing to effectively support a modern labour force.
  • Regulate the market, don’t just inspect. We need to take a ‘whole system’ approach. We need proper regulation of the market as a whole. Regulation should encompass pay and working conditions; staffing levels, commissioning practices and transparent tariffs. These are the factors that directly impact on quality of care. Only with firm foundations can the care sector deliver. Regulate the market to compete on quality. Regulate for success not failure.
  • Care managers need a professional body. Managers should be registered and have a licence to practise. The body should set professional standards, have disciplinary powers and provide a voice at a national policy level.
  • To give assurance and to raise the status of the profession, care workers should be registered and have a licence to practise.
  • Introduce a single assessment instrument to provide real data on quality indicators, dependency profile and resource needs. Understand the care home sector. This would give valuable data in measuring quality. It would also provide a national statistical database to inform strategic planning for health and social care.

For the system: regulators, local authorities, the NHS:

  • Ensure that your requirements support the ‘mission’ of the care home. Be mindful that whatever extra you ask them to do takes time away from relationships and people. Find out about your local social care providers. Engage with the care sector in partnership.
  • Rationalise the ‘paperwork’ burden on care. Work together to ensure a proportionate bureaucracy that supports ‘people time’ not ‘office time’. It is people who make the difference in the end, not paper.
  • Share what is good. You need to be more ‘in the game’ – don’t just point out what is wrong; engage in finding solutions too. Listen. Share your experience.
  • Be collaborative and involve the care sector at the inception stage of new requirements and initiatives – not just a consultation at the end of the process. Care homes have a lot of experience to share.
  • Ensure there is someone on your boards with direct experience of working in and running care homes.

CQC new regime: The good, the bad and the ugly

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First the good news: The Care Quality Commission has found “many examples of good and outstanding care” using their new inspection criteria.

And now the bad: As the expert-led inspection model rolls out the regulator is discovering wide and “unacceptable” variations in quality.

The tougher approach also discovered that there are not just big differences in the quality of care that people experience from different providers, in different places but also sometimes at different times of the day or day of the week.

The five-question approach – are they safe, are they effective, are they caring, are they responsive to people’s needs and are they well led? – is bound to bring change to existing ratings and perhaps the findings with a sample of NHS trusts will be mirrored in our care and nursing homes.

In an article on the CQC website, the regulatory body says: “We began applying our new inspection approach to NHS trusts in September 2013. We’ve seen some outstanding care – but we’ve also seen examples of care that requires improvement or that’s inadequate. We have found differences in quality from one trust to another, from hospital to hospital within trusts, and between different services within hospitals.”

Some 38 NHS acute trusts were checked by the end of August 2014; nine achieved an overall rating of good, 24 were rated requires improvement and five trusts were rated inadequate.

Stating the obvious, CQC says good leadership drives up quality and safety overall.

But as CQC “calls time” on unacceptable variation in the quality of care and higher the bar for providers, my fear that you get what you pay for remains.

Indeed, I cannot think of a single WMCA member who does not want excellence in their service, but how, tell me how, are we supposed to achieve such glorious goals when there’s such a tight hold on local authority purse strings for bed purchases?

I applaud the sentiment of the Commission to empower consumers to use CQC’s inspection reports and ratings to make decisions on care choice. I also believe in their advice that “providers of poor care need to look at those who are doing it well and learn from them.”

Quality, however, always has a cost – an ugly word, I know – and I’m let pondering once again where the finance will come from to meet the new CQC inspection challenges

NHS chief’s bombshell comment still causing care home waves

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 A number of weeks ago now, NHS chief executive Simon Stevens said he was looking forward to the demise of nursing homes,

The fallout from his “It would be a disappointment if in 30, 40, 50 years’ time, nursing homes still existed” is still ongoing.

I initially thought I would reserve judgment and his comment was so contemptuous it was not worth putting pen to paper so to speak.

Nursing homes, Mr Stevens? Really? So where do we put the chronically sick, elderly and frail? Who will care for them? The NHS? I think not.

There is a distinct difference between nursing and residential homes, though Mr Stevens was reported after he made the comment at an Age UK conference that had meant all care homes.

Like many, I’m left questioning that there perhaps is an agenda that has not yet been revealed. Whatever, Mr Stevens appears to possess knowledge the care industry is lacking.

It’s been noted in the media that he made the remark after a working trip to the US, where ‘nursing home’ is a generic term.

Maybe a slip of the tongue, but either way a disappointing one.

With the consultation period on the Care Act now complete, it will start taking effect from April. But there is still a chorus of concern that interpretation on some issues is unclear.

Mr Stevens’ comment – I suspect a deliberate bombshell – does nothing to – create the much-needed stable platform from which to launch such legislation.

Meanwhile, a joint submission by the Local Government Association and the Association of Directors of Adult Social Services is warning that the regulations, as they stand, appear to give local councils responsibility for accessing “medical services” when identifying people’s needs.

 Similarly, the associations point out, the regulations require councils to give people information and advice on available services including “effective treatment and support for health conditions”. As the submission states: “This suggests social care staff giving information and advice outside of their knowledge base.”

I can see the boundaries between social care and NHS becoming increasingly sticky ground. No doubt the legal arguments over wordings will emerge soon enough and with them a boatload of cash being sunk with the real winners being the lawyers.

The time to take part in funding consultation is NOW

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Unless a high-speed railway is about to be directed through your garden, why would a member of the public take the time to respond to a government consultation?

Take, for instance, the consultation from the Department of Health on the rules affecting who qualifies for care and support, which was published in June.

Much too long and boring?

Not so!

Independent Age points out that it’s one of the most important consultations for years but is concerned too little is being done to publicise it.

There is a real danger the only people who are responding will already be known to government. Local government will respond no doubt – and rightly so. And charities will be doing their best to present a powerful case for more funding so adults with significant care needs can receive state-funded care well into the future.

Which, according to Independent Age, begs a burning question” Whose consultation is this anyway?

Where are the voices of older and disabled people, those of care and nursing home owners and what more can we do to ensure people with care needs are directly influencing the consultation outcome?

In particular, the outcome will have a huge effect on the level of local authority bed payments being agreed in the future. Dare we miss having our say” No way.

The Care Act 2014 is an interesting piece of legislation which will change the dynamic of the care industry.

Its impact on the South of England where they rely heavily on the public to fund their own Care will be dramatic and will see the cost of care for the Local Authorities go up. There will be less impact here in the West Midlands, but it could mean that homes will need to introduce larger top-ups as localauthorities will cover less. There are other part of the legislation which will affect the industry, but truth be told, it’s what is being consulted on between now and mid-August that really matters, says Independent Age.

We all have an opportunity to a say about how generous the publicly-funded social care system will be and who it should support.