Rising demand for urgent and emergency care is not a new challenge. But in recent months, there’s been a scramble among health policy analysts, researchers and now the media to find an explanation for these spikes in ‘demand’ for NHS services.
For the hospital sector, this includes (in descending order of credibility):
* more chronic illness generally across all age groups,
* poor access to out of hours GP services,
* a lack of non-acute alternatives for care,
* ignorance or confusion on the part of patients about how to access urgent care, lack of stoicism in the face of minor ailments, and
* a dislike of waiting for anything anymore.
The list often includes the cuts to adult social care budgets, but it is very difficult to know where to place this on the credibility spectrum.
Many current policy initiatives, including the Better Care Fund, are predicated on an assumption that preserving levels of social care funding, better targeting of social care (particularly at the prevention stage) and more integration between health and social care will ease the pressure on the NHS. Put the other way around, an unknown number of older people are arriving at A&E and/or getting stuck in hospital because of a ragged social care system, rather than because of underlying health problems which are unrelated to social care.
The latest analysis of Better Care Fund proposals from NHS England shows that investment worth just over £2 billion will be going into social care. The biggest portion of the projected £532 million of ‘benefits’ are expected to accrue from reducing non-elective admissions (£283m from a reduction of 163,162 ‘stays’ in hospital) while reducing delayed transfers is expected to raise £30m and a reduction of just under 2000 individuals admitted to care homes will save £31m.
It’s easy to see why the logic might flow in this direction: large cuts to social care budgets since 2010 have seen falls in the numbers of people eligible for social care services (most strikingly in the community but also in residential settings). This is likely to have led to problems getting older people out of hospital who need some sort of support to live independently.
The official discharge data relating to delayed transfers of care do not, however, tell a very clear story: there has been a 44 per cent increase in the numbers of patients delayed in hospital between 2010/11 and 2014/15 but over the same period the delays solely attributable to social care have fallen by 11 per cent, while delays attributable to NHS services are up by 25 per cent. In relation to the reasons for delay, the biggest growth has been due to people waiting for a nursing home placement (up by 40 per cent) and for home care to be put in place, (49 per cent) but there has been a fall of 34 per cent in those delayed awaiting public funding.
It is difficult to interpret these trends: it could be a reflection of more people having to self-fund (and therefore delays due to individuals and families having to mobilise savings -intensive home care can be shockingly expensive - or scramble to put in place informal substitutes) or lack of capacity on the care provider side: no spare beds, regardless of who is paying, or shortages of care workers to go into people’s homes.
On the admission side, again, it is plausible that poor nutrition or dehydration caused by lost services (or underfunded, rushed care) could lead to a deterioration in health and therefore precipitate a fall or other medical crisis that leads to hospital. The big problem here is quantifying this.
Research using national level data shown that there is a ‘substitution’ effect for social care, namely that users of social care are less likely to use hospital care, a finding replicated by our own research using linked social care data in four PCTs, which showed lower use of hospital services, including A&E attendances, among users of social care than among those who did not.
This suggests that if funding can be protected, there should be pay-offs for health. But there are two snags with this: firstly the ‘substitution’ effect was never large and secondly, (and more importantly), our research suggested that the substitution effect applied to residential care rather than intensive social care in the home, where rates of hospital use were actually higher than other groups.
It is not clear how care homes help people manage health crises better, leading to lower emergency hospital use, but it is potentially problematic because the direction of travel in social care has been away from institutional-based social care: to encourage and support people to stay in their homes, to live independently, for as long as possible. Reducing the number of permanent admissions to care homes is now an outcome measure for the Better Care Fund and for local integration projects, alongside reduced hospital admissions.
There is a further complication, to the ‘it’s all the fault of social care’ argument. We have a brutally rationed social care system, but it was brutally rationed before the cuts began from 2010. Councils have always had to manage the challenge of balancing the limited public funds with need and the gap has always been wide and growing. A recent study by the Strategic Society Centre estimated that 1.4 million older people ‘who struggle to look after themselves do not receive community support’ while ‘up to 3.4 million older people living in the community whose day-to-day activities are limited by a longstanding condition, have little contact with the local authority’.
It is striking that many local authorities faced with the some of the biggest reductions in budgets have set themselves a much more radical task: changing the expectations of their communities, promoting the idea of independence from state social care as an explicit goal and diverting people away from formal care for as long as possible.
This coincides with calls to reshape the objectives of health services for older people around what older people themselves articulate as being important to them. Research with older people conducted by National Voices and UCLP partners found that older people wanted above all to be as independent as possible, even if they had multiple health problems. The authors of the report note that ‘the older person’s perception of what constitutes good health or frailty is often very different to the clinician’s perspective’.
All of this suggests that the search for the ‘impact of social care cuts on the NHS’, while an important question, might be missing the point. What if the question were to be turned on its head? What is the impact of the patterns of investment in the NHS over the last decade on older people’s ability to be independent and well? What if a large proportion of these admissions were the result not of social care deficits, but inadequate health care - continence services or district nurses- or enough intermediate community services?
Research based on an in-depth review of 131 acutely ill older people in a single hospital concluded that between a fifth and a third of these admissions were potentially avoidable, but of these the absence of ‘more responsive social care’ would have prevented admission of a total of two patients (1.5 per cent of the whole sample). The remainder were judged to be deficits in intermediate care, primary care and hospital care.
Of course there have been many initiatives across health and social care that have attempted to build services around the wellbeing goals of individuals, but considerable challenges remain in measuring gains in wellbeing on a systematic scale: NHS data is used to capture proxies, such as survival from individual conditions or usage of hospital services.
In the absence of routine measurement of wellbeing in older people, there are clear risks in judging the success of reforms in terms of avoided admissions, or speedier discharge if this leaves people feeling fearful, vulnerable and isolated. As David Oliver has so eloquently argued, there are many situations in which an admission to hospital is entirely appropriate, and is the safest place for an older person to be at that moment.
The Nuffield Trust is proposing to conduct research to explore these broader questions, that go beyond a narrow focus on the impact of reductions in state-funded social care on the NHS. We are looking to work with two or three local authorities for a qualitative-based study that would explore the realities of balancing limited social care budgets with the need to promote independence and wellbeing among older people, and the role played by local providers, including health services and the voluntary and community sector.
I would really welcome views and feedback from readers in local authorities on the issues raised above, and particularly interested in hearing from those who might be willing to shape and contribute to this research, which we plan on doing later in 2015. I can be contacted at firstname.lastname@example.org
Ruth Thorlby is Senior Fellow in Health Policy, Nuffield Trust