This blog is the first in a new series called ‘Fact or fiction?’, where experts from the Nuffield Trust give their take on the data and evidence behind some of the current perceptions of what is happening with the NHS.
Rising demand for urgent and emergency care is not a new challenge. But in recent months, there’s been a scramble to find explanations for the overheating hospital sector.
These include (in descending order of credibility) the predictable effect of an ageing population, more chronic illness generally across all age groups, poor access to out of hours GP services, a lack of non-acute alternatives for care, changes to the way hospitals diagnose and treat patients, ignorance or confusion on the part of patients about how to access urgent care, a lack of stoicism, a dislike of waiting for anything anymore and the impact of uncontrolled immigration.
The list often includes the cuts to social care for older adults, but it is very difficult to know where to place this on the credibility spectrum.
What we know
There have been cuts to social care
There have been large cuts to social care budgets since 2010 . Recent analysis from our joint programme with the Health Foundation, Quality Watch, found a 16 per cent cut in real terms net expenditure on social care for older adults between 2009/10 and 2013/14, resulting in almost 300,000 fewer older adults receiving services in the community over the same period.
These cuts could have impacted on hospital emergency departments in two ways: they could have left older people at greater risk of hospital admission, and/or they could have created problems getting older people out of hospital who need social care support to go home, which creates knock-on effects through the whole hospital.
Evidence on the discharge side exists but is not very clear
The official discharge data relating to delayed transfers of care do not tell a very clear story: there has been a 43 per cent increase in the numbers of patients delayed in acute hospitals between 2010/11 and 2014/15. However, 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.
As for the reasons for delay, the biggest growth has been in reporting people ‘waiting for a nursing home placement’ (up by 40 per cent) and ‘for home care to be put in place’ (49 per cent). 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 or scramble to put in place informal substitutes). Or it could be a 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.
Robust evidence on the effects of social care cuts on hospital admission is missing
On the admission side, it is plausible that poor nutrition or dehydration caused by lost services (or underfunded, rushed care) could precipitate a fall or other medical crisis that leads to hospital. The big problem is quantifying this; the system does not routinely track users of publicly funded social care through the NHS and does not capture any data about those who are providing for social care for themselves.
Research using national, area based data has shown that there is a ‘substitution’ effect for social care. In other words, users of social care are less likely to use hospital care, a finding replicated by our own research, which tracked social care users at an individual level in four primary care trusts and their use of hospital inpatient and emergency services.
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 in other groups). But placing more people in residential care may conflict with the stated aims of both health and social care policy to promote independent living, and with what older people themselves want.
Fact or fiction?
There is no question that reductions in the already limited social care budgets since 2010 have added to the ranks of vulnerable older adults who have to provide care for themselves. What is less clear is the consequences of this budget squeeze on their wellbeing, on the wellbeing of those who care for them, and their impact on hospital emergency departments.
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’. Many current policy initiatives, including the Better Care Fund, are predicated on an assumption that preserving levels of social care funding (and ensuring that it is used wisely), will ease the pressure on the NHS.
But turning the clock back to the levels of social care funding we had in 2010 or 2005 or even 2000 wouldn’t change the fact that most older people would still have to provide social care for themselves, in a health and care system that struggles to support them to be independent and as well as they can be despite their health conditions, calls them ‘frequent fliers’ or ‘bed blockers’ and over relies on proxy measures of success such as avoided admissions.
There are many initiatives underway to change this, from the councils that are aiming to reduce dependence on formal care to the integrated care pioneers attempting to build services around the goals of what people actually want for themselves.
But there are clear risks in judging the success of reforms in terms of avoided admissions, or speedier discharge if this ignores whether older people feel 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 and most efficient place for an older person to have their needs met.