Demand for integration series

Winter performance: how did health and social care do and what can we learn from it?

The Demand4Integration series takes a new look at the issues facing health and social care, and the necessity of greater integration to not only deliver better outcomes for citizens, better use of resources and better experiences for the workforce but to provide a way of tackling the increasing demand for services while resources are diminishing.

Managing ‘winter’ demand is at the ‘sharp end’ of the health and social care system. It means working together to ensure older people avoid hospital admission and making sure hospital discharges work well, as such acting as a ‘health check’ for the ‘whole system’.

So what’s been happening? Some key overarching data can give a sense of the range and complexity of the system:

  • More people still coming to hospital – This is a continuing pattern. A&E attendance has increased by around 32% over the last 10 years yet 40% of people coming to A&E are discharged without treatment.
  • More people waiting to be discharged – recently released figures from NHS England shows that the number of people still in hospital who were ready for discharge at the end of January 2016 is the highest since records began in April 2010 with an increase since last January from 150,392 to 159,089 people. On 28 January 2016, 5,799 people were in hospital but medically fit for discharge. 
  • More pressure on adult social care – delays in discharge attributable to social care increased to 32.3% compared to 26.7% a year ago. Ray James President of ADASS attributes this to ‘unprecedented pressures on social care’
  • Pressure on provider capacity in the community – the main reason for adult social care delays is provision of care and support packages. 
  • Continued pressure to meet key performance targets – acute trusts are consistently struggling to meet key NHS targets e.g. four-hour A&E target.

This is undeniably a system under strain and it could be argued that an integrated approach is even more challenging in such an environment.

Learning from experience

Realistically, it’s probably too early to fully evaluate how ‘winter’ has gone this year so perhaps a more reflective approach is helpful, with local organisations learning from experience so far and challenging their own systems. Here are a few key questions to consider when doing so.

  1. Is there visible, strong, system leadership with a shared set of values and principles? Do these embrace an enabling approach for individuals and learning for organisations?
  2. Is there proactive intermediate care, good reablement services, and support for primary care on admission avoidance?
  3. Are there agreed, established care pathways for frail older people and more specialist ones for people with dementia or at the end of life?
  4. Is demand really understood – do information systems focus on the right people with proportionate escalation processes?
  5. Is there shared activity data aligned with financial information across the system – are efficiencies realistic and their impact understood across organisations?
  6. Do shared strategic and joint commissioning plans take the right approaches? Do they make use of market intelligence and innovative service designs? More importantly, are they being implemented and demonstrating improved outcomes for people?

While things aren’t getting easier, analysing information and thinking about these questions is important. Although it’s complex, getting better at managing and improving acute care has a broader whole system impact and improves outcomes for people.

Structural challenges

Don’t underestimate the challenge. There are also structural issues that perhaps go beyond local solutions but impact on them.

  • Are there the right enablers? Is the Better Care Fund (BFC) really the enabler for this activity or is just an opportune funding source with a limited plan. 
  • Will the NHS relinquish any central control? Devolution areas will be watched with interest 
  • Is there a will to challenge the acute health sector’s way of working? There are great examples of integration working well in the community but can there be a sustainable shift? Acute hospitals are beloved by the public and although there is lots of positive debate and action around developments such as acute outreach, this requires the refocusing of services and even closures. It can be a difficult to persuade people that this is a service improvement.
  • Can joint commissioning between CCGs and Local Authorities drive change? Will they really be able to jointly commission the range of services, including acute services, which will make the necessary step change? How practical is this in places where multiple CCGs occupy one local authority area, like the big shires?

What needs to happen next?

Organisations need to recognise and embrace the reality – hospital care will always immediately grab public attention even when we know the solutions must focus on care outside hospital with the associated shift in resources.

This will need to be driven by strong, joint strategic leadership across the local system, supported by health and wellbeing boards. This should show understanding of local demand and be willing to challenge the status quo.

Pragmatic plans that build on what is already working, such as intermediate care and reablement, and that go beyond this with ideas for integrating the health sector with community health and social care organisations, need to be created. The acute sector would do well to learn from colleagues in community health and social care, who in turn need not to be overwhelmed by acute hospital pressures.

It’s important to keep the show on the road, especially through the peak winter period. It’s also important to be realistic and pragmatic and remember everyone, whoever their employer, wants to do the best for people. However, take stock and make time to develop better, innovative integrated plans for the longer term.

Reference: Carter Report Feb 2016 Operational productivity and performance in English NHS Acute Hospitals

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