Growing pains – health and social care bill debate in the House of Lords

The Health and Social Care Bill has its second reading – a debate on the general principles of the Bill – in the House of Lords on Tuesday 11th and Wednesday 12thOctober. More than 90 Members of the Lords have put their names down to take part in the two-day debate. Two Peers have tabled amendments to try and force extra scrutiny of the Bill because of concerns that the Bill was rushed through the House of Commons. Labour peer Lord Rea, a former lecturer at St.Thomas’ Hospital Medical School and GP, has tabled a motion that, if passed, would mean the Bill would go no further in the House of Lords and could not pass into law in this session of Parliament. Lord Owen, a Crossbench peer, physician and former Parliamentary Under-Secretary for Health, has tabled a motion that would have the effect of sending certain clauses of the Bill to a select committee. In particular Lord Owen wants to see extra examination of changes the Bill makes to control of the NHS, the role of the secretary of state and the plans for Monitor, the new NHS regulator.

 The Bill, which has completed its progress in the House of Commons, aims to change how NHS care is commissioned through the greater involvement of clinicians and a new NHS Commissioning Board; to improve accountability and the involvement of patients in their care and to give NHS providers new freedoms to improve quality of care.

 Age UK wants to see the Bill act as a catalyst to improve health services for older people. Throughout our work with parliamentarians during the course of this bill we have been pointing out the problems older people face in accessing health and social care services. Too many older people in the UK experience poor practice and ageist attitudes when it comes to care which can put their health at risk.  Older people often struggle to access the basic care they need as the NHS continues to under-commission essential preventative services such as falls prevention, continence care and audiology. These types of services make a huge contribution to keeping older people well, independent in their own homes and helping to maintain a decent quality of life.

 NHS reforms will impact on everyone to a greater or lesser extent but they are likely to be most keenly felt by older people; patients over 65 account for around 60% of admissions and 70% of bed days in NHS hospitals. Our ageing population means it is more and more important for the NHS to meet the needs of older people. We want the new NHS commissioning board to instigate a fundamental review of how the NHS and local authorities assess, prioritise and commission services to meet the needs of an ageing population to make sure NHS structures, particularly the new commissioning bodies understand and know how to meet the needs of older people across the UK.

Read our Health and Social Care Bill briefing



Regulating health: can the CQC do more for less?

The Care Quality Commission (CQC) certainly has its work cut out. As the independent regulator of the health and social care sector, it is responsible for ensuring every hospital, mental health trust, social care provider, care home (and many more settings beside) are safe and delivering a minimum standard of care for patients/residents.

This is undoubtedly a big job and some people accuse the CQC of not doing it very well.

Last week, the House of Commons health select committee published its report on their recent performance. While accepting there had been additional pressures placed on the CQC, one of the committee’s headline findings was that inspections were down 70% on the previous year.

So that means that the body ensuring safety and standards in health and social care settings carried out 70% fewer inspections to make sure that care was being delivered properly.

Age UK has also challenged the quality of healthcare inspection with its campaign Hungry to be Heard which raised awareness of malnutrition in hospitals. We believe it is a serious failure of care that people are not being supported to eat in hospital and some of the responsibility for this failure must arrive at the door of the CQC.

The campaign did result in a series of spot-checks examining nutrition and dignity in hospital. The outcome has been a number of settings being found to be non-compliant with “essential standards”, so CQC should take credit for responding positively to these issues. Arguably, it shouldn’t need a charity to highlight them in the first place.

The CQC does, however, find itself between a rock and a hard place. On the one hand, the Government is seeking to reduce so-called bureaucracy in the health service and wants to offer greater freedom from centralised control.

There are also the perennial issues of what is proportionate and what can guarantee standards which challenges any system of regulation. The Government’s wider efforts to cut “red-tape” and its ideological bearings will always send the message that less administrative burden is better.

At the same time, failures of care persist. The Health Service Ombudsman’s report Care and Compassion? is an obvious recent example of where the lesser seen elements of care relating to dignity and compassion are simply not up to scratch.

In a system that relies on data returns and fewer inspections, whether or not someone is treated with dignity can fall through the gaps. Put simply, it is much more difficult to capture compassion in a spreadsheet.

Unfortunately, older people are most commonly subject to such failures of care.

The CQC told the health select committee that the number of inspections will start to return to previous levels. It has certainly been under a lot of pressure to register a huge amount of providers since it took on its responsibilities in 2009. This came at a time when their budget was cut from £240 million (the combined budget of its predecessor organisations) to £161 million.

And life is not going to get easier for the CQC. The NHS reforms currently going through parliament foresee an expanded, vibrant market of healthcare providers, all of which must be licensed by the CQC. More than this, having more providers is at the heart of these reforms.

Do we believe, in this age of austerity, that the CQC will have more money to meet the requirements of a growing healthcare sector? To say very unlikely would be generous.

The Government anticipates that choice and competition will be the main driver of quality in the NHS in the future. The message will be: if you’re concerned about the care you’re receiving, go somewhere else.

This could indeed be a powerful mechanism for getting the type of care you want. But ultimately, most people will want the confidence that when they enter hospital, for example, you will at the very least be fed, treated with compassion and leave there feeling better than when you came in.

The CQC has a vital role in making that a reality, particularly for older people as the NHS’s largest users.

For its faults, the CQC is working to a shrinking budget and growing expectations and there’s a great deal it does for which it deserves praise. For example, their Experts by Experience programme (run in part by Age UK) involves service-users in the inspection of care homes and was used on the nutrition and dignity spot-checks. There should also be no doubt that the CQC helps to ensure safe care in the majority of NHS services.

As I said at the beginning, the CQC have a huge amount on their plate and Age UK believes they need more funding to do their role effectively. In an age of austerity and attacks on “red tape”, the Government needs to remember that there is a cost to being the guardians of patient safety.

The potential cost of weak regulation is substantially higher.

Find out more about our care in crisis campaign

Should relatives be caring for older people in hospitals?

This weekend, Peter Carter, chief executive of the Royal College of Nursing (RCN), said patients’ relatives need to do more to look after their loved ones in hospital. Clare Gerada at the Royal College of GPs agreed. This is what Carter said: “If you have a 24-bed ward and have got five nurses and everybody is having lunch at the same time and half the patients need feeding, it becomes difficult to get it all done,” Carter said. “You get this business of wards, very, very busy people, [patients] dying to go to the loo, elderly people wetting themselves, then they lie there feeling embarrassed — and it is about helping gran get out of bed and go to the loo”.

For many people, the immediate response to this quote will be “so what are nurses supposed to be doing?” This question is even more pertinent when you consider that the majority of inpatient bed days are used by older people. Helping someone to eat and supporting them to meet personal care needs are essential elements of care. To suggest that such can be simply picked up by friends and family is to suggest it is care less relevant to what the NHS is there to do. Peter Carter may be asking the right question, but is coming up with the wrong solution. He is absolutely right in questioning why, in his example, a 24 bed ward is not able to offer an appropriate level of support to it patients.

However, the solution is not simply to defer responsibility onto friends and relatives. The wider question is why a hospital ward in a £100 billion NHS is unable to meet essential care needs for older people. Part of the solution may be more nurses, though this is often a simplistic answer. There are certainly questions around why so-called geriatric wards are generally resourced less than other wards (though “geriatric ward” is something of a misnomer as older people will likely be the majority on most wards). There are fundamental questions about the nature of training, something Peter Carter alluded to at the end of last week.

Age UK certainly believes all medical training most be far more grounded in the care of older people. Many health professionals can be woefully under-prepared for assessing and responding to older people’s needs. This is symptomatic of much bigger issues that NHS needs to resolve. As Carter and Gerada both point out, the NHS will spend an increasing amount of time helping to manage people with long-term conditions, the majority of these being older people. Already, 70% of the primary and acute care budget is spent on long-term conditions. If we continue to picture the NHS as there to simply cure and repair, then it will continue to make the mistake of making its core users second class citizens. In making that mistake, the NHS will remain organised around meeting the needs of the minority, (vital as this is), and framing the majority as an inconvenience. Carter and Gerada’s comments reflect such an attitude.

Age UK absolutely supports the involvement of family and friends in a person’s care. This can make a vital contribution to their wellbeing and sense of control in what can be a distressing period of their life. Some hospitals have even offered low-level training to family members to help with care, and we would support such positive steps to improve older people’s experience of care. However, this must never detract from the fundamental caring responsibilities of nursing and other hospital staff.

Age UK is currently running a commission with the NHS Confederation and the Local Government Group looking at issues of dignity and essential care. The commission will be seeking real solutions to these issues and we welcome the debate that these comments have sparked. However, there must be a must better understanding of what the NHS is for before we can start describing how it can best achieve this.

Caring for our future; shared ambitions for care and support

Last month the Department of Health announced that it intended to ‘co-produce’ the proposed social care reform white paper. This month, on the 15th of September it has launched an ‘engagement’, entitled ‘Caring for our future; shared ambitions for care and support’ which is intended as the first step toward making good on this commitment.

The content of the engagement reveals that the scope of reform is meant to go well beyond responding to the proposals of the Dilnot Commission on long term care funding or the Law Commission review of adult social care law.  However the government does ask for people’s views on the recommendations of the Law Commission and the Dilnot Commission ‘and on ‘how we should assess these proposals, including in relation to other potential priorities for improvement’.  So the DH is still thinking about the extent to which they intend to implement the proposals of the two commissions.

The engagement focuses on six key areas. These are;

  • quality – including improving quality and developing the future workforce;
  • personalisation – giving people more choice and control and helping them to make informed decisions;
  • shaping local care services in order to ensure a wide range of innovative and responsive services;
  • prevention and early intervention;
  • integration, in particular better connections between the NHS and local services; and
  • the role of financial services.

The engagement runs for three months. There will be a series of events and meetings which will be attended by six ‘discussion leaders’ drawn from the ‘care and support community’ – one for each of the six key areas. The discussion leaders come from a variety of backgrounds representing service providers, local authorities and the NHS. Jeremy Hughes from the Alzheimer’s Society and Imelda Redmond from Carers UK represent service users and carers. There will also be a web based feedback form that people can use to respond directly. This can be found at Written comments must be sent to the Department of Health by December 2nd.

Find out more about our Care in Crisis campaign

Healthy changes to the Health and Social Care Bill?

Photo: Pickersgill Reef via Flickr

The Health and Social Care Bill returns to Parliament this week. MPs will have their last chance to debate the Bill on Tuesday and Wednesday during the Bill’s Report Stage and Third Reading before it is sent for scrutiny in the House of Lords.

Despite the changes the Government made to the legislation after the public consultation earlier this year, the Bill remains controversial with some groups of medical professionals and the Labour Party accusing the Government of privatisation and further fragmentation of the NHS.

The number of people aged 65 and over is expected to rise by 65% in the next 25 years to almost 16.4 million. The population is also living longer with the number of people aged over 85 expected to treble within 30 years. As life expectancy increases, so does the likelihood of more years spent in ill health, with women aged 65 having on average 8.7 years and men 7.7 years of poor health at the end of their lives. And yet, too many older people in the UK experience poor practice and ageist attitudes when it comes to care which can put their health at risk.  Age UK is therefore supportive of the Bill’s aims to bring decision making about treatment and services closer to patients, and to better involve patients in decisions about their care. We agree with the Bill’s central principle which calls for ‘no decision about me, without me.’ However, we are continuing to lobby the Government for improvements to the Bill to ensure the NHS is able to meet the needs of our growing ageing population.

We are asking the new NHS commissioning board to instigate a fundamental review of how the NHS and local authorities assess, prioritise and commission services to meet the needs of an ageing population to make sure NHS structures, particularly the new commissioning bodies understand and know how to meet the needs of older people across the UK. Older people often struggle to access the basic care they need as the NHS continues to under-commission essential preventative services such as falls prevention, continence care and audiology. These types of services make a huge contribution to keeping older people well, independent in their own homes and helping to maintain a decent quality of life.

There is clear evidence that it is never too late to improve health and well-being if people are given the right access to information, support and services. We are also calling for changes to the Bill to improve the regulation of care homes to try and prevent a repeat of the recent crisis which saw the collapse of the Southern Cross network of care homes.

What the Government heard about the NHS

In April, the Government “paused” their Health and Social Care Bill. The reason? The public didn’t seem to like it much, nor did many health professionals.  A number of charities, including Age UK, welcomed many of underlying principles but had deep reservations about how some aspects of the reforms, such as public involvement and accountability, had been expressed in legislation.

Ten weeks later, the Government has concluded its listening exercise. Earlier this week, the NHS Future Forum, a panel of experts and senior clinicians co-piloting the listening exercise, published their recommendations. The Government has now responded, setting out how it now intends to take the Bill forward, taking on board many of the NHS Future Forum’s recommendations.

Age UK had five key things we want to see the NHS doing after the proposed reforms:

  • Delivering better outcomes for older people
  • Better public and patient engagement
  • Ensuring accountability
  • Stronger Health and Wellbeing Boards
  • Promoting integration between services

Continue reading “What the Government heard about the NHS”

Food for thought

A few weeks ago the Royal College of Nursing (RCN) Congress dominated the headlines as nurses overwhelmingly voted in favour of a motion of no confidence in Andrew Lansley. While NHS reform was the main topic of conversation at the 4 day Congress, it was not the only issue being discussed.

Hospital food by celesteh, via FlickrWe attended the RCN congress to talk about a current problem in our hospitals – older patients becoming malnourished. The statistics show that the number of people entering and leaving hospital malnourished has steadily risen each year – in 2008-09 over 185,000 people left hospital malnourished.

The nurses we spoke to all agreed that this is a problem, but they disagreed over the cause. Many nurses believed that it is caused by the poor quality of food: “Have you seen the food they serve?” “The food looks like slop” are two comments we heard time and time again. Their proposed solution is straightforward – hospitals need to spend more on food so patients can have nutrient rich and appealing food.

While improving the quality of food will help, it will not fully solve the problem. Good quality food is important but hospitals also need to ensure that older people receive the help they need during mealtimes. What’s the point of having a five-star meal if no-one helps you to remove the packaging?

Older people regularly tell us they do not get the help they need at mealtimes – this help could be as simple as ensuring the food tray is placed within reach, to removing packaging as well as assistance with feeding. Without this support older patients go without food and often end up leaving hospital malnourished.

Nurses have told us that the biggest barrier to ensuring patients receive help is time – mealtimes are too short and there are simply not enough nurses to help everyone who requires support at mealtimes. There is no one solution to this; mealtimes could be staggered or extended, hospital volunteers could support patients during mealtimes or more nurses could be employed on wards.

What is clear is that immediate action is required to stop this scandal, otherwise the number of people leaving hospital malnourished will continue to rise.

Find out more about Age UK’s Hungry to be Heard campaign, fighting malnutrition in hospitals.