House of Commons Joint Inquiry by Communities and Local Govt, and Health Select Committees, on long-term funding of adult social care
Submission by the British Geriatrics Society (March 2018):
The British Geriatrics Society believes that the current divide between health and social care budgets must be addressed, and a funding mechanism based on need is key as part of any long term funding solution. Below we set out some of the key features that we believe would support a sustainable funding model that enables all older people to receive high quality, patient-centred care when and where they need it.
1. The British Geriatrics Society (BGS) is the professional body of specialists in the healthcare of older people in the United Kingdom. Our membership is drawn from doctors practising geriatric medicine including consultants, doctors in training and general practitioners, nurses, allied health professionals, researchers and scientists with a particular interest in the care of older people and the promotion of better health in old age. BGS has 3,500 members who work across England, Scotland, Wales and Northern Ireland.
2. BGS welcomes this opportunity to present a written submission to the Committee’s Inquiry into the long term funding of adult social care.
How to fund social care sustainably for the long term (beyond 2020), bearing in mind in particular the interdependence of the health and social care systems
3. Patient-centred care. Our view is that sustainable funding of social care can only be achieved through a system that has patient-centred care at the heart of its design. Older people’s health and social care needs do not neatly divide into two and the current funding model, based on these divides, mitigates against person-centred care. The consequence is older people having to go through multiple assessments of need to access services that have different funding sources, and experiencing the much-discussed ‘delayed transfers of care’ from hospital to home or care home. We strongly believe that any future funding model for social care must be based on the needs and wishes of older people themselves, that it should be focused on maximising independence, and that there is no avoiding the need to recognise that this will require financial investment
4. Integrated funding. The NHS Five Year Forward View and the remit for Sustainability and Transformation Plans focus on the need to move to an integrated health and social care system and already have patient-centred care as a priority.
However, our view is that a sustainable model of social care funding must involve a
restructuring of the way in which social care is currently funded via local authority budgets, so that the funding divide between health and social care is bridged, and the consequences of older people’s health deteriorating because of problems in accessing timely social care are avoided.
5. Evidence-based funding. There is a vast amount of data and evidence on predicted levels of need as the size of the population of older people living with multiple long term conditions rapidly increases. As a membership body of health professionals it is not our role to prescribe a specific model, but we strongly advocate for a new model to be based on evidence-based assessment of current and future needs, both at a macro and micro level, making better use of patient assessment tools at an individual level (for example, by using an electronic frailty index, and Comprehensive Geriatric Assessment ). We believe this is one of the keys to ensuring the sustainability of social care funding.
6. Affordable. Our submission is based on a belief that the most effective way of ensuring a sustainable and equitable health and social care system is likely to be through a model paid for by general taxation. Our view is that taxation needs be at a level that fully covers the care costs of those who need it and that self-funders of social care should be that; self–funding rather than subsidising the cost of care for those who can’t afford it, as is increasingly happening at the moment.
7. Equitable access. We support equitable access to timely care that is sufficiently funded to meet the needs of all older people with moderate to severe frailty, both now and in the future. This requires full account to be taken of the large numbers of people who are never going to be in a position to self-fund. We are concerned about the impact on the health of older people should the principle of general taxation be eroded. We are also concerned about the risks of focusing too much on the ‘intergenerational divide’. Creating a fair and effective system for all generations is in the long-term interests of improving health and care for older people.
8. Place of care. A particular concern we have, that has the potential to impact negatively on older people’s health, wellbeing and independence relates to the current differences in charging for social care. The risk of unintentionally introducing perverse incentives is one which we are keenly aware of. We say this because our members’ experience is that it is not unusual to find that when an older person and their family realise the cost of care home fees will come from the value of the person’s home if they are a home owner, they sometimes (not unnaturally) change their minds about where they would like to live and receive care; sometimes leading to conflict in families. We want all older people to receive the right care at the right time and in the right place. We are concerned about changes that might have the effect of increasing demand for care home places, particularly in circumstances where an older person is still capable of living in their own home but their family’s preference is for a care home.
9. Ensuring sustainability of social care funding by investing in better health outcomes for older people, which include:
9.1. Intermediate care provides a critical link between home and acute hospital for older people who need rehabilitation, re-ablement, or sub-acute treatment. This is essential in supporting older people in regaining independence after they have had an acute health issue. The National Audit of Intermediate Care shows that intermediate care services are key to reducing pressure in secondary care and the care sector. It provides evidence showing that 92% of people maintained or improved their dependency score when they accessed intermediate care in community settings, and 93% maintained or improved their dependency score in bed-based intermediate care (people who remain in acute hospital beds experienced a reduction in their level of independence). The critical role of the occupational, physio and speech therapists need to be prioritised in order to support the effectiveness of any re-design of social care.
9.2 Better support for people with dementia. As many as 40% of hospital admissions are for people over 75, and 1 in 4 beds in acute hospitals are occupied by someone with dementia. They may not have an acute reason for admission but may have reached a crisis and find that there is not sufficient support outside a hospital setting to manage the crisis. Once admitted to hospital they are more likely to experience an overall deterioration. BGS calls for all people living with frailty, dementia, complex needs and multiple long-term conditions, to have access to comprehensive geriatric assessment, personal care plans for treatment and long-term follow-up. We believe that this will support efficiencies in health and social care; for example by reducing unplanned hospital admissions and ensuring that transfers of care, to and from home, hospital and to care home are timely, reducing distress for patients and their families, and pressures on services through a lack of identification of needs and provision of appropriate support.
9.3 Community and tertiary provision. The roles of community geriatricians, community nurses and other specialist health professionals, are key to enabling people to remain independent and living in their own homes for as long as possible. Prevention strategies can reduce (but not remove) risks of falls and fractures. The benefits of helping people to re-gain their previous level of mobility following a fracture are key to maintaining independence. We highlight this here as another example of the interdependence between health and social care which demonstrates the need for investment in health if a sustainable funding model for social care is to be achieved.
10. Greater recognition of and investment in the voluntary sector. BGS fully recognises and appreciates the role of the voluntary sector in promoting better health for older people. Volunteers coordinated by organisations such as the British Red Cross and the Royal Voluntary Services as well as a huge range of other charities of all sizes, play a critical role in supporting the patients our members work with. We know that they are increasingly providing greater levels of support that require close working with local authorities and health providers. The importance to an older person who has multiple long term conditions and lives alone having someone with them or waiting to greet them when they are discharged from hospital cannot be overstated. We warmly welcomed the report published earlier this year by the British Red Cross, In and Out of Hospital which provides clear evidence of the positive impact of volunteers on improving patient flow.
11. Addressing wider inter-dependencies. At BGS our members are regularly seeing older patients with frailty who are well enough to be discharged from an acute hospital ward, but whose lack of appropriate housing means that their discharge is delayed and their likelihood of re-admission increased. “Discharge to Assess services” can reduce length of hospital stay, with some suggestion that this reduces longer term requirement for social care. The availability of transport home from hospital and support on discharge for older people living alone, as well as appropriate housing are key factors in ensuring that older people can remain independent and living in their own homes for as long as possible.
The mechanism for reaching political and public consensus on a solution.
12. Public awareness and understanding. Our members’ experience is that there is an urgent need to raise awareness and understanding of the current system. They frequently find themselves in the difficult position of explaining to a family member that their parent or partner will continue to have care needs that are significant enough to require long-term social care support whether in their own home, or in a residential or nursing home. Often it is the first time that the older person and their family become aware that social care, unlike NHS healthcare, isn’t free to all at the point of use.
13. Building public consensus. We are mindful of the concluding comments in the recent report by the National Audit Office, which suggests that ‘while the public accept the need for more funding in social care, they are sceptical about the current terms of debate’ and their evidence that people may be willing to pay more tax if this can be overcome . Our view is that the first step is to increase public awareness and understanding of the definitions of health and social care which in our experience are poorly understood.
Our experience tells us that it is crucial to engage the public and build public awareness, understanding and trust in the system before reaching the point of use. We believe that greater understanding of what it means to use social care, either at home or in a care home and how it is funded, will have a positive effect on public support for changes to the current system of funding. Testing the public appetite for any models of funding that Government propose in the Green Paper that is due to be published this summer could be very helpful.
14. Political consensus. Given the funding and demographic pressures faced it is vital that a political consensus is reached and that there is no unnecessary delay in developing and introducing a more sustainable way of funding adult social care. The care of older people is an issue which concerns everyone and we hope very much that political agreement on the way forward can be reached. We recognise the challenges and therefore believe a person-centred approach based on evidence of need is one the key to building consensus.
Reform is essential in order to ensure sustainability of social care. We have outlined briefly here some of the ways in which better integration of health, social and voluntary sector care has the potential to reduce social care demands (by Comprehensive Geriatric Assessment, falls prevention programmes, intermediate care services, discharge to assess services and voluntary sector support for discharge). We are optimistic that in the reform will result in better health outcomes for older people. We hope that the forthcoming Green Paper will provide an opportunity for Government to proactively seek to engage the public in debate about how social care should be funded in the long term. Whatever model is used, it requires financial investment at a level that is sufficient to deliver high quality, patient-centred care.
We welcome the serious consideration being given to the challenges that changes to the current system will bring. We hope very much that these will be overcome and that we can move to a system that better supports the needs of our older population.