Unrecognised system risk: the care sector

June 2020

COVID-19 has amplified and hastened many underlying issues. In so many areas, what seemed to be taking years to progress suddenly materialised in three short months. One such issue has been the inter-relationship between the NHS and other parts of the care spectrum.

Primary care is often discussed; less so its interface with care homes, other forms of social care and indeed informal care itself. Most NHS boards are under-informed about these key determinants of their own success.

Board assurance frameworks tend to focus on things boards can directly do to mitigate risks. Risks within the local care system are often expressed in ethereal language, and in some key areas the consequences of these risks materialising are hidden as they have become normalised. Perhaps the most significant risks to front-door performance of NHS hospitals are weaknesses in local primary care, while the back-door risks relate to care homes.

The care home business is often opaque to NHS boards, and their own local pattern of provision not reported systematically. Yet the care homes are where many of the most vulnerable members of society live – and it is to them that those with complex needs are discharged.

Shrinking capacity

In 2018 in England there were 10.1 care home beds for every 100 people aged 75 years and older. In that same year there were 4.9 nursing home beds for every 100 people aged 75 years and older. The trend for both over the last five years is decreasing and vacancy rates in skilled roles are high.

Care homes residents are those most likely to find themselves admitted to hospital as an emergency. Around 4% of the population aged over 65 live in care homes and they are 40%-50% more likely to find themselves being admitted to their local hospital in an emergency than the general population aged over 75.

The ‘back-end’ of hospitals poses even greater issues. Older people experience what is known as ‘de-conditioning’ which is physical and mental deterioration through being removed from the routine and movement of ordinary life. For example, every ten days a person aged over 85 spends in a hospital bed they experience ten years of muscle wastage. Retaining people who are medically fit for discharge in hospital beds of course has an effect on hospital capacity. Everyone is a loser in that scenario.

The COVID-19 effect

The brewing-storm over the rapid decanting of hospital patients into care homes as the COVID-19 emergency struck will not go away either – and NHS boards need to be sure of their oversight story.

Regardless of whatever the facts turn out to be, the issue has now become potent in the public imagination at the least. Care homes are now reported as being so anxious about the safety of their residents that they are unwilling to accept referrals from hospitals.

In any case and COVID-19 issues aside, we also know the care home market is unsustainable. The Competition and Markets Authority published a market assessment in 2017 that found that ‘The current model of service provision cannot be sustained without additional public funding; the parts of the industry that supply primarily local authority (LA)-funded residents are unlikely to be sustainable at the current rates LAs pay. Significant reforms are needed to enable the sector to grow to meet the expected substantial increase in care needs.’

The national response is slow burn, with the government’s ideas for social care reform losing them their parliamentary majority in the 2017 general election. Any subsequent policy remedy is being continually delayed. So local systems retain significant structural risks to the wellbeing of many vulnerable citizens, and NHS services are inevitably affected by such an important part of the care continuum being permanently compromised. NHS organisations and their boards thus need to manage this serious, significant and ongoing risk.

Imaginative response

Some trusts, including East Lancashire Hospitals NHS Trust, have run imaginative programmes to buoy up their local care homes through supporting care home nursing services in various ways.

North Staffordshire Combined Healthcare NHS Trust has led on the development and implementation of a new Care Home Coordination Centre with the primary aim being to support people living in care homes to remain in their homes where safe and appropriate.

In Essex, the Pimp my Zimmer scheme supported local care homes through using quality improvement methods. These are all laudable local schemes, but overall the risks are neither reported to nor managed systematically by NHS boards.

Call to action

While boards appreciate that the success of local care homes is critical to their own success, the actual line of sight to this significant and enduring risk is not being systematically reported or managed.

Boards need to develop simple metrics for remaining aware of risk and other issues in their local care home market and to understand what they can do to control these.

We recommend a standard quantitative and qualitative board report on the local care home market to include bed numbers, occupancy, admissions within month (number and timeliness) and global skilled-staff establishment. Qualitative information could include highlight reports from discharge and liaison teams.

In relation to discharges to local care homes in the COVID-19 period we recommend that boards ensure that management have reviewed discharge details since 1 March 2020 and collect any supporting narratives.

If this bulletin prompts any comments or questions, please contact us by calling on 07732 681120 or emailing advice@good-governance.org.uk.

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