Issues in Integration

Twelve weeks ago I went over on my ankle, it hurt. The swelling and bruising was pretty nasty but I just put it down to a twisted ankle that would clear itself up. Unfortunately, after a couple of weeks it was still intensely painful so I went to the nearest A & E where they x-rayed it and told me I had a fracture, they gave me a pair of crutches (no other treatment) and told me they would get me an emergency fracture clinic appointment and I could expect a call on the next working day.

Two days later I finally got through to the clinic who mentioned they had seen something with my name on and could I come in later in the week.

At the fracture clinic I was told I didn’t have a fracture (they used the same x-rays) and it was severe wear and tear, even though I protested that my ankle was fine before going over on it, I was summarily dismissed with a piece of paper to give to my G.P. to arrange for physiotherapy.

When I got to the G.P. I was asked what the piece of paper was because hospitals do not normal send that bit of paper to G.P.s! However I had a telephone consultation arranged and was referred to the Physiotherapy Dept.  I then had to visit the G.P. because the pain was still intense and I was simply given a co-codamol prescription, again with little other advice.

It then took six weeks to get a physiotherapy appointment. While, of all the different elements of the NHS involved, the physiotherapy team have, undoubtedly, been the most helpful, once at my first appointment I had to relay all the details of my injury as they had no notes on my fracture clinic appointment or the history so far.

Because of the time lapse between referral and getting a physiotherapy appointment I had a follow up fracture clinic appointment after my second physio session. Again this was another frustrating experience, quick chat with consultant who I told I was still in pain, hour wait for x-ray, then back to consultant who told me there was definitely no fracture just evidence of an old injury. What old injury, I exclaimed, only to be dismissively told, “oh it might have been something minor” and then told to come back in six weeks.

Following week back to physiotherapy, who had no knowledge of fracture clinic appointment and I had to explain what had happened there.

That was last week and I still have bursts of intense pain

The point of this story? We have this long running debate on integration between health and social care yet it is evident within the health service alone there is no real integration and, while mine is a relatively minor injury, I have no doubt people with much more serious conditions suffer from the same frustrations of the lack of ‘joined-up’ care in the NHS.

Social care itself is not a ‘whole’; it is a combination of public sector and private sector services that because of those different sectors cannot fully be bought together efficiently. The bottom line is most of the private sector works for profit and the public sector works toward bureaucratic efficiency.

Integration: The act of combining parts to form a whole.

When we talk about integrated services for health and social care is this what we mean? For those who use services yes it is. Anyone who needs services wants an holistic approach, seamlessly receiving care and support from all aspects of the ‘system’, support with health, social care, housing etc. is, idealistically, delivered in a joined-up way that involves everyone responsible for delivering the services knowing exactly what everyone else is doing and working together toward a single purpose.

From a public sector point of view the issue is different. Technically speaking, integration would mean combining all the parts of the system into one and that is not likely to happen, so the key word here is collaboration rather than integration and this is where the difficulty often arises. Who is responsible for this collaboration, who takes the lead to ensure the individual needing services gets a seamless service?

Naturally people are territorial about their domains, and certainly ‘professionals’ can often give the impression of others not really knowing enough to give a valid opinion, so there is inevitably some tension between ‘professionals’ of different sectors. Yet this approach does not benefit the individuals who need the services which is why there must be clear, defined leadership.

Before there can be talk of, and delivery of, integrated services for those who need them there must be a clear demonstration that those services are themselves integrated as until that happens it means they will be unable to deliver on that which is truly desired.

The Challenges of Social Care Inspection

The appointment of Andrea Sutcliffe as Chief Inspector for Social Care at the Care Quality Commission is a highly commendable one. Not only is she knowledgeable about the care sector (see for example http://www.guardian.co.uk/social-care-network/2013/jul/15/what-good-homecare-looks-like) but she also has her own personal experiences to draw upon (http://www.whentheygetolder.co.uk/finding-care-for-older-relatives/) and that combination, along with her naturally open approach, bode well for the future inspection of social care.

Yet that future is strewn with challenges that Andrea first needs to tackle. The general perception of social care is not great and trust in the Regulators has been severely dented over recent weeks. The first challenge will be defining a model of inspection that will ensure poor provision is identified and stamped out yet this model must also reflect the nature of the care sector and the huge variations within it.

Yesterday, for example, the new Chief Inspector for Hospitals, Prof Sir Mike Richards, outlined a model which he frequently referred to as ‘an army’, 20 or more inspectors marching into a hospital to inspect all aspects of care provision and ensure the meeting of standards. Unfortunately, in social care that will not work as, in many instances that many inspectors would outnumber both residents and staff!

The variation in social care is completely different from that of hospitals. Social care covers care homes and home care, it covers care and support for the elderly and care and support for those with learning disabilities, it covers large care providers with 100’s of homes as well as micro providers with just a few beds. Finding a model of social care inspection that fully encompasses the variation while ensuring consistency is, in itself, a challenge.

The Care Quality Commission has recently stated that it intends to have more specialist inspectors and social care could really benefit from this approach. For example recent reports have highlighted training and development issues with Health and Social Care staff and having learning and development specialists as part of the inspection process can help raise awareness of the importance of staff development, encourage providers to focus on training and development and help identify failings where providers fail to implement staff training and development. Similarly specialists in infection control or nutrition could have a significant impact.

One thing that would be good to see, and may well happen given Andrea’s former job, is a focus on best practice information and its application both by providers and inspectors. Resources, for example, from the three main national bodies, Skills for Care, National Skills Academy for Social Care and, of course, the Social Care Institute of Excellence should be routinely be embedded in care practice and those who inspect should also be fully familiar with this in order to ensure inspections are informed. One challenge has always been getting best practice information through to all providers, it is easy for providers to say they don’t have time to look at these things or, in the worst cases, believe they know what they are doing and don’t need any advice. If providers know their inspectors will look at this then they are far more likely to make to time to look at and use this information.

The regulatory framework has increasingly moved toward an outcome based approach, if providers and inspectors do not access the knowledge of what excellent outcomes look like then that system fails.

Undoubtedly, Andrea Sutcliffe has a challenge ahead, one that I am sure she will meet head on, and, ultimately, social care can only benefit by having such an effective leader at the helm.

Health and Social Care Training: The Real Issues

“There is no minimum standard of training for healthcare assistants before they can work unsupervised, an independent report has found” http://www.bbc.co.uk/news/health-23246066

Actually that’s not true!

Back in March Skills for Health and Skills for Care launched the National Minimum Standards for Healthcare and Social Care workers – see http://www.skillsforhealth.org.uk/about-us/news/code-of-conduct-and-national-minimum-training-standards-for-healthcare-support-workers/ . In addition the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 state quite clearly the Health and Social Care providers must ensure employees are “appropriately supported in relation to their responsibilities, to enable them to deliver care and treatment to service users safely and to an appropriate standard, including by receiving appropriate training, professional development, supervision and appraisal” (Regulation 23)

So, the issue is not whether those standards are in place but how those standards are applied, implemented and inspected.

The first area that needs real scrutiny is the induction process.

Imagine that time when you first started in a new job, there is always an element of nervousness as you enter a new environment, have to learn new routines and adapt to working with new people. Now imagine how much information you are likely to retain when you are bombarded with DVD’s or reading material which is supposed to make you competent in the role you are about to undertake!

While we have, in social care, the Common Induction Standards, it has to be remembered these only form a part of the induction process. Induction must be as much about ensuring that new employees learn about the workplace, its routines etc. and how the induction standards apply to the workplace and the individuals receiving care and support there. A tick box approach to the induction standards will not work and there needs to be a greater understanding by managers and leaders in the home of the importance of mentoring new employees to ensure the induction standards are embedded in work practice.

Learning and development must not stop after a successful induction. Professional development is a regulatory requirement and continuous training is important. Even if you have been on endless health and safety courses the chances are going on another will spark something in your mind that you had forgotten or prompt you to think about a bad habit you have got into and encouraged you to change it. Training, aside for giving us new information, can also make us think about how we do things right now, it brings us into ‘conscious competence’, always a good thing to do on occasion.

Supervision and appraisal also serves the same purpose. It helps us question why we do things in certain ways and can make us consider better ways of doing our work. Too often supervision and appraisal are seen as a means to be critical of an employees work but they should be seen as a means of encouraging employees to think about their own role and how they perform it.  

The key issue is to ensure that those responsible to managing and leading staff are sufficiently trained themselves in staff development.

One of the vital areas of training, often overlooked, is the quality of training itself. Certainly I have stopped using training providers because of the negative feedback I had from staff (the usual complaint is ‘they were just reading from a script’ – how can a trainer engage learners when they a focused on reading their lines?) yet how many providers actually get feedback from staff about the quality of training. It is important that providers do this, not only to ensure the quality of training but also to ensure they are not wasting their money!

There are schemes in place which accredit training in social care the principle one being the National Skills Academy for Social Care, and whilst their list is somewhat small at the moment, it would benefit all those who provide social care training to apply for accreditation (here’s the link https://www.nsasocialcare.co.uk/training-providers ).

Given that standards and regulation already exists the obvious question is how are these actually regulated and inspected. If there are issues over training and development why are these not picked up in the inspection process? It can only be speculated that the inspectors themselves are receiving insufficient training into what to look for and what questions to ask about training and development. One of the proposals from the Care Quality Commission’s consultation on inspection is the introduction of ‘specialist’ inspection teams – personally I hope that includes specialist in training and development to ensure standards and regulations are adhered to.

The training and development regulations and standards are there, the issue is how these are applied and inspected, if we can improve this we can improve the general quality of care across the board.

The Confusion of Westminster

Last week we had an announcement that £3.8 billion will be given to social care yet official sources cloud this. For example the Department for Communities and Local Government describe it as;

“£3.8 billion, including £2 billion of new NHS investment, to improve adult social care and join up with health services. This will help older and vulnerable people to stay healthy and remain at home thereby avoiding unnecessary hospital admissions or emergency visits to A&E. To stimulate real change, £1 billion of this funding will be paid when local results are achieved.”  (https://www.gov.uk/government/news/eric-pickles-hails-council-tax-5-year-freeze-and-38-billion-for-social-care)

In other words the money is for preventative health support to reduce the need for admissions in hospital.

Obviously this has to be welcomed by preventing a health issue becoming a health crisis the pressure on Accident & Emergency departments can be eased a little and, more importantly, being healthier should lead to a better quality of life for those who need social care services.

But what it does reveal is the ignorance of those in Westminster about what social care is.

Eric Pickles demonstrated this with his quote on the DCLG website saying;

“For the last 30 years all too often the care home, social services, and the local GP haven’t been working together to prevent unplanned hospitalisation of elderly or vulnerable people.”

The last set of statistics from the Health & Social Care Information Care show that care home residents only account for 14.6% of council funded care recipients. How, one wonders, does Mr Pickles think the new investment will help the 85.4% of social care users who are not in care home?

If the role of preventative health is to be transferred to social care then considerably more money will need to be ploughed into the sector. Social workers and social care workers are not health professionals and if it is to be their role to work with the health of an individual then they will need significant training in order to do so effectively. If however the onus is on health professionals then the money is not for social care it is simply transferring health funding!

Following on from the spending announcement we have learnt that the Care Bill will set the ‘substantial’ criteria as the benchmark for individuals to access care funding from the state.

The current ‘substantial’ criteria mentions health briefly, the majority focuses on personal dignity, daily living and family and community life and when the Care Bill final goes through there will be a significant increase in funded care users as many councils are currently only funding those with ‘critical’ needs. Therefore councils will need a staffing infrastructure to cope with this increase if current social workers are not to be totally overloaded with paperwork, especially if they also have to assess health needs!

Westminster seems to be clueless about social care and solutions to support people to live life in the way they want to is lacking as Ministers continue to confuse social care and health.

Social care should be about supporting people and bringing together the services they need. Health is just one of those services. A person’s health needs will vary over time and, where social care support is involved, it is social care’s responsibility to ensure the individual is able to access those health services, but social care also has a responsibility to ensure the individual is supported in every aspect of their life, from adaptations in housing to maintaining community links.

Social care is ever more important in society and demand for social care services will grow as the population ages. We need a social care service that is fit for now and the future and that cannot happen until those in Westminster recognise that they need to recognise the true importance of social care.