As well as articles specifically to discuss, I thought it would be useful to use this space to bring in policy and consultation documents as well as journal articles which we come across which might be useful to others.
The Department of Health launched a consultation last week on ‘improving health and care for vulnerable older people’.
I’m not enamoured generally with the Dept of Health and their knowledge and understanding of social care and the feeling I get from looking at the initial consultation is that there is a lot of confusion about what exactly ‘care’ means. This is a ‘health’ consultation that doesn’t seem to have a consideration of social care or its place in the lives of ‘vulnerable older people’ but if we are, or have been, involved in or used social care, it’s important that we do contribute. Not only for ourselves but for those we have worked with who may not be able to contribute directly. The Department seem undecided on whether ‘care’ includes a broader understanding of the team but I’m going to share my consultation response in the hope it urges more people to contribute.
There are six ‘domains’ to the consultation and they seem to focus on primary care. Coming from a position of working with rather than working in health services, gives a particular perspective on how things can, should and most importantly, do work – to focus on how they can work better.
STAYING HEALTHY FOR LONGER
Of course the language is one of ‘incentive’ which makes me cringe. But I accept that I don’t have a lot of experience in the health service and none at all in primary medical care. The world is oiled on incentives, apparently. Flexibility and capacity though is an issue I have come across working with a lot of GPs in the community, particularly with older people. I’ve worked with some fantastic GPs and some – less so. My concern is around GPs attached to care homes – and again, this is by no means a universal impression – but certainly there have been some who have shown a lack of care to those in the area. I’d like to see much better, embedded connections between health and social care for a start, including a stronger understanding of the way these links between community and residential care are managed.
Speaking as, very much, a layman, I’m a great fan of more information and peer support groups. Generally, there is no reason ‘vulnerable’ (I don’t like that word because it is so vague and lacks any purposeful definition) older people are any different from any other group in terms of extending self-understanding, knowledge and management of their conditions. The issues though that remain are, perhaps, increased lack of mobility.
Better uses of technologies can help people to link with others. I don’t want to see this dismissed because people are ‘old’ or ‘vulnerable’. That’s a whitewash because the potential cost could be high but if people can’t come to peer support groups, they can be linked through forums and voice conferencing. There are also more mobile tools for self-management available. We can’t assume that everyone has a carer. Again, rather dull, but I refer back to using the communities around people too – if they are involved in lunch clubs or day centres (dying out now) the tools and groups should base there. If they have formal care going in to them, use those people to share information and give information, same with district nurses. People generally want to be better.
I’m going to pass on this for the moment but I hope people take the opportunity to present back where things work although it’s important that those within the govt take account of what hasn’t worked too.
NAMED CLINICIAN: PROVIDING A SINGLE, NAMED CONTACT TO COORDINATE AN INDIVIDUAL’S CARE
I wonder if anyone finds it as odd as I do that Hunt has announced this as a policy aim even as its out to consultation. To me, that typifies ‘consultation’ in the NHS sense of the word. Let us tell you what we are doing. You can tell us what you think. If you like. But it won’t make a blind bit of difference. We are doing what we want anyway.
Enough of my cynicism and on to this ‘idea’.
This is a question based firmly at primary care clinicians so it seems a bit foolhardy to respond genuinely and with seriousness because I don’t actually think the DH wants my opinion but I’m going to go with it anyway. Firstly I wonder what on earth they mean by ‘vulnerable’ older people. When does an older person become ‘vulnerable’. Certainly in London, in terms of safeguarding, we have moved away from use of the word ‘vulnerable’ in consultation with service users who did not like it. However this is a different use and shows the difficulty of a Dept that doesn’t know it’s own language or definitions. Equally ‘people at risk’ doesn’t define what ‘people’ are at risk of. People at risk of deteriorating health? People at risk of being ignored by society? I’d like some better definitions to understand exactly what is being asked for.
In terms of my experiences in social care and mental health we were alerted through a number of sources, sometimes GPs, sometimes hospitals, sometimes self-referrals, friends, families, neighbours. Sometimes we’d be alerted by the police or the ambulance service. How did this information move? In the Mental Health team, as a secondary health services, all information would be channelled through GPs. This didn’t happen as a matter of necessity in adult services. Should it? I’m not sure. What I am sure of is sharing information is better than not. Maybe we can go back to the idea of having GPs and Social Work collocated. I think there has to be a link between health and social care but with social care being ripped apart, this probably isn’t the ‘answer’ the government want.
This is a bit of a leading question in my opinion as it’s assuming that this is a good idea and the focus is on the primary care setting which immediately moves us into the territory of health rather than any hope of looking at joined up health and social care coordination. I’m biased because I’ve been a care coordinator and had to work with trying to build links across health and social care and in my opinion it isn’t something that can be just tacked on. I do though, think social work is specifically well-placed to be a link between sectors however in the question asking for a ‘clinician’ (and social workers not being clinicians), it seems my answer isn’t one that the Dept of Health want – which is a shame. I am curious how this role differs from the GP role? What will this ‘named clinician’ actually do? Will they ACTUALLY coordinate between primary/secondary/social care because if they will, I think the lead needs to come from social care. If they are there just to coordinate between primary and secondary care, I have to ask, isn’t that just what GPs do now? Then, I haven’t even mentioned community matrons. Weren’t they supposed to have a role in this? This question makes me angry by the amount of ignorance it displays of what actually happens now and the way it ignores the skills and role of social care in providing a cohesive connection with medical care. Surely this is an opportunity for more ‘integration’ if I believe (ha ha ha) what noises Lamb makes about more integration. Surely this is an opportunity for that. But no, the question asks for ‘clinician’. Hunt doesn’t remember that social care is a responsibility of his as its less interesting and needs more money but giving people lots of ‘lead people’ responsible for them – one ‘named community clinician’, one social worker, one community matron, one occupational therapist, one or two outpatient consultant – and yes, one person could ‘coordinate’ all that – but if we ignore the social care aspect then we don’t really make things less complicated.
Aha. This is the crux. It’s a question that isn’t even a question. It’s a statement. So what is the Dept asking us for? To tell them it’s a good idea. Here’s what I’d tell the Dept. LOOK AT WHAT HAS ALREADY HAPPENED!!! Look at the Community Matron model. Look at the social care-led care coordination and management role. Look at how we tried to implement the Single Assessment Framework in adult services across health and social care and please please, learn from what has already been done, what’s worked (personally, I found collocation and working in teams with district nurses worked well) and what didn’t (trying to pretend ‘health’ and ‘social care’ can exist without each other) and they wouldn’t need yet another consultation with statements instead of questions.
IMPROVING ACCESS: MAKING IT EASIER TO BOOK APPOINTMENTS AND GET ADVICE
Here, the govt/dept are asking for ways that technology might be able to improve access. I’m probably far from the best person to advise on this but would encourage those with ideas to contribute.
This is beyond my experience so I probably won’t comment extensively except to say we need to get the basics right and not all ‘innovative’ solutions need to have a technological base.
Again, I probably am not best placed to respond although interesting that the questions don’t necessarily relate to the heading about ‘booking appointments’. For me, personally, it isn’t technologies that would assist me although I do think that being able to book by email would be a nice start, it’s more about capacity of GPs and not having to wait 4 weeks for a regular appointment. Not feeling like the doctor’s surgery was doing me a favour by fitting me in sometime next month might be a start about making it easier to access appointments.
OUT OF HOURS: ENSURING A SAFE AND CONSISTENT SERVICE
I honestly think this discussion needs to move beyond the ‘vulnerable’ older people and towards a general understanding of what makes a good and reliable out of hours service because I’m far from convinced (I know, I’m bright like that!) convinced its where we are at the moment.
Repeal the legislation that privatises anything the sector can get it’s hands on? I’m not sure that’s the answer they, in govt, want. These questions are, by the way, incredibly leading. Accountability can’t be held to companies which are run on profit, in my, very simple, brain.
Well, clearly there is a need for all services to ‘join up’ but I’d include social care in their too although this is just focused on primary care.
I wish they would ask for examples of where things haven’t worked too – sometimes there can be as much learning in that – particular when there may have been an over-reliance on ‘technology’ and ‘innovation’.
CHOICE AND CONTROL: PROVIDING CLEAR AND ACCURATE INFORMATION TO HELP PATIENTS MAKE DECISIONS
I waver when I see ‘choice and control’ mentioned because I see how it has been done in social care and it has overpromised and under delivered. Hopefully Health can learn from Social Care – when it realises (starting with the Dept of Health) that social care exists. Cynical? Maybe just a little bit.
Interesting that ‘out of hospital care’ is the term used rather than primary care. For me this has to include social care because it’s vital that we join up the choices available both in health and social care sectors. I’m not sure that’s what the consultation is demanding but that’s what it’s getting from me.
The important thing about supporting choice is ensuring that people who may lack the capacity to make particular choices are not subject to second class services because they don’t have the voices of those who are better able to advocate for themselves. I’d suggest that there needs to be a role for independent advocacy to help people to make choices – not the named clnician – who may have a vested interest in promoting ‘cheaper’ options – especially if they are part of a CCG. We need an element of independence in providing options to people.
Where to start..
People who lack the capacity to make decisions and who are not supported to make decisions bout choices
Lack of availability of choice or preference or quality services for that matter.
Geographical barriers – people want good services which are close. Choice is over-rated if we have consistently good quality, responsive services.
Where is the ‘control’ – this question is all about choice and not control? How and who to users who are ‘vulnerable’ older people have a stake in controlling the services that are provided to them?
I’m sure you can all think of more. Please do respond to the above question.
I don’t because I’m not a clinician but I do think that this consultation talks about choice but says nothing whatsoever about ‘control’ so it’s interesting it asks for examples of ‘control’ being handed over without explaining it. I think that’s a fault in the consultation but I hope we will be able to flood with real life examples in the hope that someone listens.
Finally we see some mention of social care although only briefly because the consultation refers to ‘clinicians and carers’ resolutely ignoring social care! It’s funny because we’ve been trying to work on integration and seamless information sharing for, well, at least a decade and this consultation seems to lack understanding of that.
For a start those in policy need to understand and appreciate the role of social care and not completely ignore it as seems evident in this consultation. The main barriers are the lack of conversation between the two sectors and the lack of any incentive and time to create pathways across health and social care. The coordination is better coming from a non-clinician in a social care setting because we have experience in care coordination across health and social care sectors so it’s important that the experiences are learnt from.
I have some examples which I’ll share more fully as a part of the consultation but I’m not at all sure what this consultation means by ‘integrated’ – does it mean primary/secondary care? Does it mean medical/social care? I wish it was a bit clearer but I think there’s a role in feeding information back about what has worked (and not worked) in terms of ‘integration’ over the years so we don’t end up making the same mistakes two, three, four times.
At the moment the systems that don’t allow social care systems and NHS systems to ‘talk’ to each other is a massive barrier to information sharing. We need to look at the basics before getting over-excited about the potential of data sharing. Until the basics of sharing information between local authorities and NHS is solved, anything more imaginative and innovative is impossible.
Um, no – but maybe I’ve just been unlucky.
So that’s the consultation – although it’s based and focused on primary care with a few nods towards other areas, I think it’s important that those who have experience in social care respond to. We need to make our voices heard in order to help the Department of Health understand what life is like for practitioners rather than leaving it to people who sit in rooms deciding to be ‘experts’ on policy without any understanding of the reality of the situation as it occurs.