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Just who is watching the vulnerable?

by Craig Dearden-Phillips 30/10/2014

One recent Friday evening, as part of my research for this The MJ piece, I took the train for an evening drink with a social work manager to chew over some issues. She was on emergency duty, which meant that any urgent social care incident in the city that evening went straight to her mobile.

Ten minutes in, and the phone duly rang. It was the local hospital. A 91-year-old woman with dementia – let’s call her ‘Eileen’– had been brought in by paramedics who were concerned about some bruising on her leg. They had been called by paid carers who had put Eileen to bed but then had to rush off to their next call.

The hospital said they couldn’t admit Eileen unless she was ill, but for now, were not releasing her to go home, as they thought that she was ‘vulnerable’.

The council (in the form of my companion) said that it had nothing available at that time of night to help Eileen get through the next 24 hours. Nobody could agree whose problem Eileen was on that Friday evening.

When the social worker put the phone down and returned to our conversation, she said: ‘My bosses will want the hospital to admit Eileen; then she’s off our budget. The hospital want the council to find emergency home care at 7pm on a Friday night – which is almost impossible’. Welcome to the world of integrated health and social care in 2014.

Situations like this happen in nearly every town, every day. Different parts of the health and social care system, each with their own qualifying criteria, each with their own specialism, all focused on what is and isn’t their job to do.

Eileen, meanwhile, slips out of view, as social care assessors – like my companion – fearful of overspending, fight their turf with their counterparts in health.

So, when we talk about better-integrated health and social care in England, we are really asking how we might re-tell this story as one in which the call about Eileen to my social worker contact was never made.

We are talking about a in world which Eileen wasn’t admitted to hospital at all that day and was instead looked after by a team that catered successfully for all of her needs – medical or social care – and in which all the funding for Eileen came from the same joint pot.

Unified commissioning makes sense, but seldom happens, often because of the way the NHS and councils are forced to play a zero-sum game.

In a few places, better things are happening. Take Provide CIC in Essex, a £56m mutual spin-out provider. It offers an integrated health and social care service with its starting principle that people always have a mix of needs. It is Provide’s job to design its offer and to bend various budgets around that mix of needs.

Provide can do this because it has the operating freedom as a business to achieve this. As a mutual, it is owned by its employees and nurtures its own version of the ‘John Lewis’ culture of positive, switched-on staff, for which it has won a national business award.

Provide sees itself as accountable, first to customers – not ‘users’ or ‘clients’ – and second, to NHS commissioners and councillors.

Provide is also assisted by a clinical commissioning group (CCG), a council and a local hospital who see eye-to-eye on how to manage an ageing population.

It is accepted by the main agencies that investment in integrated teams, like Provide’s, is a good way to stop incidents like Eileen’s happening in the first place.

Chief executive officer of Provide, John Niland, believes the future lies in a ‘year of care’ model for whole-person care.

‘This incentivises operators like Provide, working with families and communities, to keep vulnerable people healthy and at home,’ Mr Niland says.

Under ‘year of care’, integrated providers receive an agreed ‘capitation’ fee from the CCG and the council for keeping ‘high risk’, frail, elderly people like Eileen well, but which also bear the cost of expensive hospital care if, for any reason, the care Eileen needs to stay at home should break down.

We need this kind of innovation. Evidence that the ‘Eileen situation’ is becoming serious on a national scale is overwhelming.

The NHS has a black hole of £30bn in its annual funding requirement to 2020. Much of this is due to a crisis in social care that is pouring thousands of ‘Eileens’ into the NHS every day.

While mutuals like Provide, with their ‘John Lewis’ culture, are only part of the answer, the 100-odd spin-out mutuals from councils and the NHS that do exist have shown, time and again, that they are quicker than the traditional statutory providers to reshape their offers around the requirement for integrated care.

This is particularly true when local commissioners can also see the sense in paying for these kinds of service.

Back to last Friday. It’s an hour later; my companion is now off-duty. The phone rings again. It is a courtesy call to inform her that the emergency care place for Eileen has just been found by the duty team at the council.

Eileen will be taken, by blue light, to an emergency respite bed, an hour away from her home. The rest can wait till morning. ‘Job done’, says my companion, only half-smiling.

Craig Dearden-Phillips is managing director of Stepping Out Ltd

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