By overlooking social care concerns and focusing exclusively on health the Keogh review missed out on the opportunities of integrated care, says Billy Boland

Billy Boland

Billy Boland

Sir Bruce Keogh’s investigation into 14 NHS trusts with “persistently high mortality rates” was published earlier this month. Undertaken at the request of the health secretary and the prime minister, the review gathered a “vast array of hard data and soft intelligence held by many different parts of the system”.

Sir Bruce argued that the capability of senior leadership in the trusts to access and use data was a common issue. In setting out the vision for the future, he said the hospitals should have the ambition to become organisations that are “confidently and competently using data and other intelligence for the forensic pursuit of quality improvement”.

Missed opportunity

While the report is undoubtedly thorough, it is a missed opportunity for thinking about integrated care. Sir Bruce’s selection of quality indicators exclusively concerned health, looking at parameters such as infections and serious incidents resulting in death. Not surprising, one might think, given the investigation was prompted by higher than expected deaths rates.

Jigsaw puzzle pieces

‘Surely in inspection teams of that size there would have been room for at least one social worker?’

But Sir Bruce makes it clear that his report was less about demonstrating poor performance and more about creating solutions. Given that “integration” is a current watchword of service reform, should consideration have given to social care?

The sheer quantity of information used for the report was huge. Fifty separate data sources were analysed, as well as information submitted by each of the trusts. Yet none of these directly related to social care, even though good sources of social care data are readily available.

The Health and Social Care Information Centre published their report into adult safeguarding in England in March. Healthcare staff were the second biggest source of referrals after social care staff, making tens of thousands of referrals for suspected abuse in 2011-12. An examination of safeguarding and types of abuse in these institutions could only have added to an understanding of quality in the hospitals.

The full experience

Another key area where social care could have contributed was in the review of “patient experience”. Sir Bruce and his team of investigators interviewed hundreds of members of the public who used the hospital services, and made site visits to understand how care was delivered and staff behaved.

‘By focusing exclusively on health, great swathes of the care provided by these organisations have been overlooked’

Teams of up to 20 people including managers, senior and junior doctors, student nurses, and patient and lay representatives dissected business with a critical eye. But where were the social workers? Surely in teams of that size there would have been room for at least one? A social angle would have helped to describe abuses in the organisations, such as neglect of personal care and nutrition, and given a better understanding of safeguarding to protect adults at risk of experiencing harm.

Opportunity to refocus

By focusing exclusively on health, great swathes of the care provided by these organisations have been overlooked. Social care is intrinsically linked to health, and social outcomes including social harm may be significant indicators of poor quality in acute hospitals.

Other commentators may argue that there are many other health parameters that Sir Bruce could have chosen over those found in his report, and that social care is just one of many factors excluded. But social care offers the promise of untapped solutions that other areas of health do not.

‘Including social care in our plans for the future can only enhance our vision of high quality services’

Politicians from the three major political parties say integration can do much to improve care, including reducing hospital length of stay and preventing admissions. On Radio 4’s Today programme the day after the report was published, two former health secretaries, Stephen Dorrell of the Conservatives and Alan Johnson of Labour, were in an unusual state of agreement about the benefits integration could bring. With such vigorous backing from government, the secretary of state would have had strong support to ask Sir Bruce Keogh to consider what integration could offer.

Without question, the Keogh review’s analysis is astute, and the remedy canny and compassionate. It will do much good and help those trusts reviewed make significant progress. But leaving social care out in the cold is a missed opportunity. Robert Francis has already highlighted the need for information sharing and for organisations to work together. Including social care in our plans for the future can only enhance our vision of high quality services.

Billy Boland is a consultant psychiatrist and lead doctor in safeguarding adults at Hertfordshire Partnership University Foundation Trust