Managing the hospital and social care interface: interventions targeting older adults

Given the national policy drive for better integrated care across sectors, what examples already exist of individual hospitals and social care providers working together to reduce delayed transfers of care, length of hospital stay and admissions for older people - and how successful are they?

The health and social care sectors are dependent on one another to succeed. But the boundary – or interface – between the two is challenged daily: care received in one of the sectors has a direct impact on the other. This report focuses on that interface.

Now more than ever before, hospitals are struggling to meet performance targets. Delayed transfers of care increased by 185,000 in 2015/16 compared with 2014/15 – costing a total of £146 million more than planned (National Audit Office, 2017). By the third quarter of 2016/17, just 82% of patients attending Accident & Emergency (A&E) departments were seen, treated and admitted or discharged within four hours (National Audit Office, 2017) – the worst performance since the target was introduced in 2004.

Hospitals are increasingly blaming their local social care sector for playing a part in their deteriorating performance and tensions are rising at a time when collaboration between the two sectors is needed more than ever before.

This report explores the actions and strategies that providers and commissioners have put in place to improve the interface between secondary and social care, with a focus on what hospitals can do. In particular, we look at:

  • collaboration to prevent avoidable hospital admissions
  • the interface between hospitals and social care providers when patients are discharged from hospital
  • the relationship between commissioners and social care providers
  • wholescale organisational integration.

Drawing on the experience of seven case study sites, as well as evidence of what has worked to date, we make five recommendations for national policy-makers. We also make seven recommendations for local hospital leaders.

Recommendations for national policy-makers

1.  Move beyond a focus on delayed transfers of care

A focus on delayed transfers of care is not sufficient to address the wider issues facing health and social care. And requiring local areas to concentrate on this single issue may actually have a negative impact on local relationships.

2.  Consider small-scale as well as large-scale organisational change

The national drive towards certain models of care and accountable care organisations will deliver successful outcomes in some areas, but do not underestimate the potential of small-scale change in bringing about significant results in a faster and less resource-intensive way. One size does not fit all.

3.  Focus on increasing the health and social care workforce

The workforce is the health and social care sectors’ greatest asset. Innovation and growth in the sectors are meaningless without a workforce to deliver the changes. Enable providers to create a positive learning environment for staff where they feel respected and rewarded.

4.  Understand the capacity of community-based services

The strategies highlighted in this report are interconnected with the performance of local community-based services. A mapping of the capacity in these services is vital for an understanding of the pressures facing secondary and social care.

5.  Make use of other sectors where possible

A vibrant and diverse voluntary and community sector will support effective interfaces between hospitals and social care, and should be nurtured. Similarly, making the best use of Extra Care Housing and other such schemes will help people to live independently at home.

Recommendations for local hospital leaders

1.  Think imaginatively about the workforce

We heard many novel ideas to help address recruitment and retention challenges in the workforce, such as paying for travel, helping employees to hire cars, providing priority parking and subsidising accommodation (with advice from HM Revenue & Customs – HMRC – to avoid staff getting tax bills for accommodation).

2.  Do not make decisions about social care, without social care

Hospitals that make decisions about providing or commissioning social care without consulting their local authority or social care providers may risk destabilising the social care market.

3.  Think carefully about different types of integration

Organisational, service-level and patient-level integration all have their own strengths and weaknesses. Organisational integration requires a lot of time and dedicated resources to create the necessary infrastructure. Progress towards integrated working on the ground can be made more quickly via servicelevel integration, but organisational integration can bring other benefits such as helping all members of staff to understand the entire health and social care pathway. It is important to be very clear about exactly what it is hoped will be gained from integration.

4.  Consider pooling budgets to facilitate progress

Most of our case studies benefited from a shared budget to initiate and sustain integration efforts. Some of this came from ‘vanguard’ funding, but most of the case study sites also drew on the Better Care Fund.

5.  Make sure that integrated teams have appropriate processes to support them

Where integrated teams work effectively, they have appropriate processual and managerial support. Shared governance and accountability processes mean that everyone is working to the same set of standards.

6.  Make sure that commissioners are on board

Collaboration and buy-in from all local commissioners and providers, including primary and community care, was a key factor in successful implementation for most of the case study sites.

7.  Collaborate with housing partners

There are good examples of collaboration with housing partners at the local level. A project set up in the North East of England between a clinical commissioning group and a housing association allowed people with respiratory diseases who were living in cold, damp homes to be ‘prescribed’ double glazing, a boiler and insulation. This ‘Boilers on Prescription’ project reported a 30% reduction in A&E attendances and a 60% reduction in the number of general practitioner (GP) appointments needed by people taking part in the project (Burns and Coxon, 2016).

None of this is easy. But as both the health and social care sectors face the biggest challenges that they have ever faced, improving collaboration is more important than ever.

Suggested citation

Holder H, Kumpunen S, Castle-Clarke S and Lombardo S (2018) Managing the hospital and social care interface: interventions for older adults. Research report. Nuffield Trust