‘Cosy’ health and care relationships should be avoided, says NHSE director

Jenny Keane was speaking at a roundtable organised by HSJ and the National Care Forum to discuss social care’s contribution to NHS winter planning. A range of leading health and care figures were in attendance. 

Part of NHSE’s winter planning includes accelerating the rollout of transfer of care hubs to speed up discharges, while NHSE director for urgent and emergency care Sarah-Jane Marsh recently told HSJ the centre was overseeing a “massive change” of delivering emergency care through community services. 

The roundtable also heard that:

• The health and care sectors believe they are better prepared for winter than last year;
• Some ICSs treat care providers as “unclean” and only out to make a profit;
• The growth of virtual wards was creating “an extraordinary challenging environment” for paid and unpaid carers; and
• The NHS “could win Oscars” for the complicated nature of its discharge planning.

Ms Keane leads the national “frontrunner” programme to explore and spread effective hospital discharge methods. She said the programme had identified the “key” importance of system partners holding each other to account.

The NHSE director told the roundtable she had become suspicious of “cosy” systems where “everybody’s getting on really well and they tell you that they’re all really good friends”.

She added systems need the “edge” that high-quality and transparent data provided if they were to tackle the “really, really difficult” challenge of working through the shared responsibility of dealing with delays in discharges.

Ms Keane was also concerned ICSs had not paid sufficient attention to taking a cross-sector approach to workforce planning. She said the “good progress around joint strategic needs assessments, strategic planning and commissioning” had “rarely been matched by integrated workforce planning. And I think that’s the single thing that could make the difference”.

Better prepared for winter

However, the NHSE director added she had “seen significant improvement in the partnership working between health and social care partners in pretty much every system that I’ve been in contact with” over the previous two years. This, she argued, put the health and care sector in a better place to deal with winter pressures than during 2022-23.

Dan Hayes, chief executive of care provider The Orders of St John Care Trust, agreed there were reasons to feel more “positive” about the forthcoming winter.

He said “workforce pressures” on the care sector had “improved significantly in [the last] five or six months” and added: “Funding is a little bit better on a permanent basis. Local authority commissioners… are pushing as much into longer-term funding through annual fee settlements as they possibly can.”

Joe Coogan, director of operations for provider Essex Cares, agreed with Mr Hayes. “I think social care is more ready this year,” he said, adding that stronger recruitment and retention had boosted capacity.

“In previous years it has been hard to penetrate the ICS and its predecessors, [but] the funding’s helped [and] our ability to respond quickly to it has helped open doors. So, we’ve got more contacts now in more places across the health [sector]. I’ve now got staff working in every hospital in Essex.”

‘Unclean’

However, Mr Hayes said some integrated care boards remained highly suspicious of care providers’ motives, even not-for-profit organisations like his.

When the government released short-term funding to tackle delayed discharge last winter, the St John CEO said he wrote to ICBs to offer the spare capacity in the provider’s homes.

He said he detected “a sense of suspicion about social care provision” from NHS commissioners that on “a personal level, made me feel slightly unclean”.

Mr Hayes said NHS commissioners had wanted to focus on returning patients to their own homes, rather than stepping them down into care homes on a temporary basis.

The importance of involving care providers

The NCF represents not-for-profit care providers like St John and Essex Cares. Chief executive Vic Rayner said she was particularly concerned about NHS plans to keep people out of hospital by significantly increasing the number of “virtual wards”. These involve patients staying in their homes or in a care home while being monitored by technology and visited by NHS staff rather than being admitted to hospital.

Ms Rayner supported the rollout of virtual wards, but was concerned they were being introduced without fully considering the burden they might place on carers.

She said “remote monitoring” could create “an extraordinary challenging environment” in a residential setting or home care setting and added that funding was not being provided to meet the extra staffing and increased technology infrastructure the care sector needed to cope with a significant uptick in remote care.

NCF members were “delivering a whole bunch of additional tasks that might have been done by primary care” without being given the money to pay staff for the additional work it involved, she said.

Methodist Homes Association chief executive Sam Monaghan said the increased acuity of care residents had created a similar misalignment of funding.

“The acuity level of people coming into residential care is at an ever-increasing level. We are viewing our housing care model now as where residential care used to be years ago, and our residential care is now moving towards increased focus on dementia and high-level complex need management.”

The funding needed to support the resulting and necessary “increased nursing capacity” within the care sector was not following this rise in acuity, he added.

Ms Rayner said this problem – and many others – could be avoided if ICSs gave “a proper role to social care providers” in decision-making.

Reflecting on criticisms the care sector was too disparate, she said: “All the stuff about fragmentation is true, but is it not [also] true for GPs? Is it not true for dentists? Is it not true for pharmacists?

“We’ve got care associations in almost everywhere in the country who can absolutely [represent providers]. We just need to properly embed them in that system.”

Frimley ICB chief executive Fiona Edwards acknowledged it was important for ICSs to “hold our nerve on all the multifaceted component parts” of, for example, the system’s urgent and emergency care strategy. This meant having care providers “sat around the table”, she said.

However, maintaining a “whole system approach” was challenging, she added, as “not only are we faced with constant surges [in demand] whether it be through heat [waves] or winter [pressures]… we are also faced with unprecedented industrial action”.

An ‘Oscar’ for complexity

There was widespread agreement among those at the roundtable that discharge care pathways were over-complicated.

Sarah Maguire, chief executive of domiciliary care provider Choice Support, said: “We could win Oscars for making things so difficult… people are lost within all of this.”

Nottingham and Nottinghamshire ICB chief executive Amanda Sullivan said “well-meaning” regulatory requirements have made the process “overcomplicated”, but that it was now time to “strip back” that complexity.

Ms Keane agreed the sector had a tendency to “dress up” discharge pathways “into really complicated things.” She said NHSE was now “focused” on what was necessary to enable “mainly older people, to walk, talk, eat, drink and sleep [well]. And I don’t mind whether that’s at home or in a care home bed or in a community bed.”