“Don’t dabble” with social care. That was one director of adult social services’ plea to hospital chief executives at our recent event to discuss the ways in which hospitals are responding to a lack of capacity in social care.
Tensions between the health and social care systems visibly present themselves in hospitals. Increased demand for services and delays getting patients out of hospital are but a couple of these consequences.
So how should hospitals respond? Invest in upskilling the care workforce, set up a discharge to assess scheme, create a hospital at home service, integrate commissioning functions with social care?
Each of these initiatives comes with a level of risk for the local care economy if not implemented properly. Two of the most commonly cited risks related to the recruitment of new staff and managing the rates of pay given to social care providers.
Our attendees included hospital providers, social care providers, health and social care commissioners – selected because of their first-hand knowledge of implementing one of these schemes. Below are three of their top tips to mitigate against these risks and create positive change.
Collaborate with the experts
Some attendees shared positive examples of hospitals and social care providers who had collaborated over upskilling or increasing capacity within the care workforce.
However, hospitals who “dabble” with the provision or commissioning of social care services – who make a decision without consulting local partners – were described as risking the stability of the local social care market.
For example, one attendee told us about a hospital that had increased the number of intermediate care beds it bought from local social care providers. The hospital paid social care providers a higher rate than normal in an effort to secure beds over those being placed by the local authority. It was a high-cost, short-term solution that ultimately failed – the ‘step down’ beds purchased by the hospital became full of users waiting for ongoing local authority services, whose reduced capacity meant they were unable to meet demand. Delayed transfers of care in the hospital began to rise once again.
A similar case was cited by another local authority representative, whereby a hospital had recruited its own home care staff in an effort to speed up discharge but had taken from the same pool as those targeted by local providers. Capacity in the area did not grow, it simply shifted sectors.
Look beyond delayed transfers of care
Everyone agreed that delayed transfers of care receive a disproportionate amount of attention to the detriment of the entire patient pathway.
The warning from one local area – renowned for having reduced its delayed discharges – was to be careful of shifting the problem to another location. While this hospital reduced the number of delayed transfers of care and managed to close some acute beds, a closer look at the data showed that some people had been simply moved to community hospitals where they were still awaiting social care packages. As with other quick fixes, a year after these changes, the number of delayed discharges in the hospital had increased once again.
Others talked about specific schemes that try to speed up discharge - such as the ‘trusted assessor model’ and ‘discharge to assess’. The risk here is that there isn’t a clear understanding of what these schemes mean. As one attendee stated, “if you have a waiting list for your discharge to assess scheme, it’s not a discharge to assess scheme”. Similarly, if you don’t have the community capacity to provide care at home, your early discharge schemes leave you ‘squeezing the same balloon which is about to burst’, as one attendee described it. The problem is not solved. It has simply moved.
Evolution not revolution
A final piece of advice was around taking the time to bring the workforce with you. In cases where this involved the mergers of health and social care staff – for example, the transfer of social care assessment staff into the hospital – hospital leaders talked about how long they had spent working with trade unions, and presenting a united voice across all the local leaders.
Others noted that expectation should be realistic; impact and benefits are not immediately available. One hospital chief executive was asked, “How has co-locating your staff made a difference to your patients?” The response was “Well, not much, for the moment.” Progress can’t happen immediately; changing behaviours takes time.
The overriding message was that collaboration is essential. Hospitals should utilise the knowledge and experience of their local partners in order to avoid implementing something that has negative consequences for other parts of the local health and care economy.
This still leaves some wondering about how to balance the options available to them. At the Nuffield Trust, we are launching a project which aims to share learning from hospitals and their local partners in their efforts to improve the interface between health and social care. We will publish learning as we go along and aim to produce a full report in autumn 2017.
Holder H (2017) ‘How hospitals can collaborate with social care’. Nuffield Trust comment, 20 April 2017. https://www.nuffieldtrust.org.uk/news-item/how-hospitals-can-collaborate-with-social-care