POLICY BRIEFING. Health, public health and social care round-up: August 2013

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1 Health, public health and social care round-up: August 2013 Author: Christine Heron, LGiU associate Date: 2 September 2013 Summary The health, public health and social care round-up summarises new policy, research and publications that are relevant to elected members and officers interested in health and social care. It is intended to be a digested read and provides links to the source documentation of major reports for further consideration. The briefings are organised in the following categories: major developments in August health and social care reform and finance public health reform and practice health and social care quality and practice. Briefing in full Major developments in August In a quiet month there were no major media concerns about NHS quality and safety. The Berwick review of patient safety in the NHS reported its conclusions - acknowledged some commentators as not providing great new insights into how to improve delivery. The drive to reform primary care continued with the appointment of Dr Steve Field as the new Chief Inspector of General Practice at the Care Quality Commission (CQC) and NHS England launching a consultation on models for change. The national move towards enforcing minimum wage payment for care staff developed further with the Department for Business, Innovation and Skills (BIS)

2 supporting Her Majesty's Revenue and Customs (HMRC) to name and shame organisations that get round the law by, for example, not paying for travel time. Health and social care reform and finance Developments in clinical commissioning groups (CCGs) Innovations Health Service Journal (HSJ) reports on various innovations in the work of CCGs. Contracts in which a lead provider receives an outcomes based payment to integrate an entire care pathway. For example Bedfordshire CCG has identified private firm Circle as prime contractor for an integrated muscularskeletal service which previously involved 20 contracts across primary, secondary and community services. Staffordshire is considering this approach for cancer and end of life care and Oxfordshire for maternity, mental health and older people's services. Alliance contracting in which a single contract binds several providers into cooperation in complex service areas such as multiple long term conditions. Thirteen CCGs in the North East and Cumbria have formed a collaborative for joint commissioning and contracting, and easier communication with NHS England local areas teams. London CCGs have formed a clinical commissioning council. Commissioning support units (CSUs) Guidance from NHS England has put the deadline for CCGs procuring support from CSUs back by 18 months to April CSUs are currently hosted by NHS England but are expected to become independent organisations. NHS England is looking at a range of options for CSUs - social enterprises, the private sector and being owned by CCGs (previously not an option). HSJ reports on a letter circulated to CCGs referring to 'teething problems' and the need for better relationships so that CSUs can respond to CCG concerns. A procurement framework will be published in the autumn giving CCGs an opportunity to shape the direction of CSUs. Many commentators on the HSJ article made the link CCG + CSU = PCT. Developments in primary care Improving general practice - a call to action NHS England is seeking to stimulate national debate amongst GPs, area teams, CCGs, health and wellbeing boards and other community partners about how to develop GP services. It has provided a slide pack covering the case for change and an evidence pack with information about current general practice and growing problems such as patient dissatisfaction with access, inequalities in access in areas of deprivation, and inadequate urgent care. NHS England indicates that new model of primary care is needed, such as GPs forming larger provider organisations or linking together into networks. Another suggestion is for CCGs and councils to jointly

3 contract primary care plus services incorporating GP community health and social care. NHS England will publish more detailed plans in the autumn. Similar frameworks will be developed for dental services, pharmacy and eye care. Appointment - chief inspector of general practice Steve Field has been appointed to the new chief inspector post at the Care Quality Commission. He is currently a NHS England Deputy Medical Director responsible for health inequalities and previously headed up the NHS Future Forum whose work contributed to NHS reforms. The role will include introducing quality ratings for primary care providers. Integration transformation fund (ITF) NHS England and the LGA have provided initial information on how councils can access the 3.8 billion pooled integrated services budget in Conditions include: CCG and council joint plans to be produced by March 2014 and agreed with the health and wellbeing board. access to social care not restricted in compared with the previous year some allocation for councils' new responsibilities under the Care Bill in 2015 joint assessment and care planning for people with health and social care needs and an accountable professional for integrated care packages 7-day service to support hospital discharge and prevent weekend admissions improved data sharing based on the unique NHS number. 1 billion of the funding will be held back, dependent on areas meeting a set of local and national targets in the second half of and the first half of Some of the fund can be used to protect social care from cuts to council budgets. The LGA, NHS England and the Association of Directors of Adult Social Services will start working with councils and CCGs to help develop plans. NHS England and the LGA have indicated that the transfer of funding from CCGs to integrated services is likely to need reduced spending on existing NHS services, particularly acute hospitals. There is some nervousness within the NHS, particularly providers, about the impact on health services. Support programme for the Care Bill and ITF Community Care indicates that the LGA and ADASS have been given DH funding to help councils prepare for the ITF and Care Bill responsibilities in 2015 such as the increase in assessment, and seven day a week social care for those leaving hospital or at risk of admission. The programme will be led by Andrew Webster in an expanded role as Director of Health and Care Integration. There will also be an assistant director of adult social care reform, due to be appointed next month, and a number of LGA officers will move to support the programme. The new post is likely to be filled by a council senior manager and will be responsible for negotiating with

4 government to ensure that Care Bill regulations are shaped by sector knowledge and expertise. The programme will also support the integrated care pioneer programme when up and running. A panel has been set up to choose the pioneers with representation from the Nuffield Trust (chair), University of Birmingham, Kings Fund, National Voices, DH, PHE, NHS England, ADASS and LGA. Plus international partners from the USA (Kaiser Permanente), Sweden and New Zealand. Exploring the system-wide costs of falls in older people in Torbay The Kings Fund has used Torbay's unique patient-level linked data set to explore the NHS and social care costs of the care pathway for older people in the 12 months before and after being admitted to hospital as a result of a fall. It found: on average the cost of all services for each patient who fell were almost four times as much in the twelve months following admission as the costs of admission comparing the twelve months before and after admission, the most dramatic increase was in community care costs (160 percent), compared to 37 percent increase in social care costs and 35 percent increase in acute hospital care costs there was evidence of significant under-coding of co-morbidities for falls patients, particularly for dementia. The Kings Fund concludes that since the majority of costs were outside the acute hospitals setting, commissioners should consider the system-wide costs of providing integrated services for falls patients. Under-coding co-morbidities is a major barrier to identifying and targeting patients and needs to be addressed. Personal health budgets: challenges for commissioners and policy-makers This report from the Nuffield Trust outlines the challenges of establishing personal health budgets within the mainstream NHS. While learning has come from the personal health budget pilots, complexities will have to be worked out through implementation. Issues for commissioners include: determining the value of the personal budget decommissioning existing services to fund them developing the provider market to support them finding the money to pay for infrastructure. Issues for policy-makers include scope, impact on quality, longer-term financial sustainability and avoiding a postcode lottery. Evaluation of right to control pilots An independent evaluation of the seven trailblazer areas in which funding streams including adult social care, supporting people, independent living fund, disabled facilities grant, work choice and access to work were pooled found that there had

5 been no improvement in choice or wellbeing for people involved. 29 percent of people in the pilot said they had as much control as they wanted compared with 31 percent in the comparison group. The average wellbeing score for people in the pilots was 43.4 percent, compared with 43.5 percent in the comparison group. The evaluation indicates that the quality of support planning varied considerably across the pilot sites. For example only one area had single multi-disciplinary assessments. Disability Rights UK has responded that the trailblazers took some time to set up, had a complex task to achieve and 'were barely up and running by the time the evaluators came along'. They also indicate that, 'Since the evaluators left, positive stories have emerged and all trailblazers have decided they want to continue with their work after the end of the pilots.' Carers and personalisation The Social Policy Research Unit at York University surveyed the work of 16 councils to identify how social care practice balances the interests of service users and carers in assessment and care planning, particularly in service users with communication problems where the carer helped in the assessment. It found that while managers and practitioners said carers were routinely asked about willingness to continue providing care during the service user's assessment, carers could not remember being asked about their needs in detail. Few full carers' assessments took place and there was little evidence of carers having their own support plans or reviews; in the few instances where these took place the relationship between the user's support plan and budget and the carer's was unclear. The research calls for: closer links between carer assessment and reviews and those for the service user separate regular reviews for carers clarity over whether support for carers should be delivered as part of a service user's personal budget or a separate carer's personal budget. Supporting working carers: the benefits to families, business and the economy The final report of the carers in employment task and finish group found that many carers struggle to combine work and caring responsibilities to the detriment to individuals and the wider economy. With the ageing population the situation will deteriorate. While some progress has been made there is much more that can be done to The report recommends a range of organisations including national government, local authorities, employers and their organisations, local enterprise councils and others should work together to carer-proof policies, promote flexible working, signposting to support, and flexible social care provision which supports their ability to work. The national carers' strategy action plan is due to be updated this year and the report recommends that that their findings should be reflected in this. Compliance with minimum wage in adult social care provision

6 In May Community Care reported that HMRC had been targeting non-compliance in the national minimum wage in the care sector, focusing on 90 of the largest residential and home care providers. Jo Swinson, Minister for Employment at BIS, indicated that the main reasons for non-compliance were non-payment of travel time and training time, incorrect deductions for uniforms and administrative payroll errors. HMRC was carrying out a full analysis which would be shared with BIS and the DH. Care Services Minister Norman Lamb has announced that non-payment of the minimum wage was unacceptable and the government would work to eradicate this, including 'naming and shaming' and possible fines. Research by Kings College London suggests that at least 150,000 social care workers may be affected. In August Community Care reported on the Government's intention to relax the criteria for naming organisations that do not meet the legal minimum wage requirements so that more organisations can be named and shamed, starting in October A report by think tank the Resolution Foundation indicates that some home care workers receive as little as 5 per hour because although their pay rates may be at or above the minimum wage of 6.19 an hour many lost at least 1 an hour because they were not paid for travel time between visits. Also many spent longer with people than they were paid for in order to carry out their tasks properly. It recommends: phasing out 15-minute care slots increasing penalties for companies that break the law clearer payslips including average hourly rates a greater role for local authorities in monitoring legal compliance, greater focus and resources for HMRC's compliance unit and a focus on care work as a high risk sector consider making both local authorities and care firms legally responsible for payment of the minimum wage to care workers ensuring local authorities factor in the cost of minimum wage when calculating the price for care clearer government guidance to the sector on applying minimum wage legislation. Elsewhere, a report by Unison suggests that 97 percent of councils use zero hours contracts for home care. Judicial review challenge rejected Community Care reports that the High Court has rejected the challenge to Worcestershire Council's 'maximum expenditure policy' which would limit the amount spent on supporting disabled adults in the community to the amount that would be spent on residential care. The judge did not agree that the policy would compel people to move to residential care and indicated that there would be ways of meeting eligible needs in people's homes more cost effectively. Lack of competition in private healthcare

7 The Competition Commission has found that a lack of competition between private hospitals is raising the prices that individuals have to pay and the cost of medical insurance, and reducing choice. There is little new provision in the sector due to flat demand, high costs and the response from existing providers. Of the three major groups: Spire, BMI and HCA, charges to insurers by HCA are significantly higher followed by BMI. It is possible that 20 private hospitals may have to be sold to increase competition. Incentives to consultants to recommend patients to particular hospitals may also be banned. Providers will have to give patients better information on quality, fees and services, while insurers, particularly Bupa, need to communicate better with patients about their entitlements. Commission on residential care The Commission set up by Demos to investigate the future and reputation of residential care has published its terms of reference and is inviting interested parties to answer a number of questions such as: how do you define residential care? is extra care housing and housing with care different? what outcomes to people value in care and can existing residential care deliver these? what is the future role for residential care? Evidence needs to be submitted to Demos by the end of May Better procurement, better value, better care: a procurement development programme for the NHS The Government is establishing a procurement development programme for the coming twelve months. The programme will include action such as: establishing procurement development oversight and delivery boards identifying immediate opportunities in the supply chain to leverage purchasing power establish quarterly price comparison on a rolling basket of 15 products launch a procurement data dashboard, with trusts required to publish procurement data establish new multi-disciplinary clinical procurement review partnerships establish procurement development networks at region/trust group level. Public health The socioeconomic gradient in physical inactivity in England The Centre for Market and Public Organisation at Bristol University analysed activity in a million adults through the government's annual active people surveys. It found high levels of association between physical inactivity and dimensions of socioeconomic position such as education, income and local area deprivation. Local area facilities and geographical factors explain very little to the variation in activity and the economic gradient increases with age. Nearly 80 percent of the population fail to hit government physical activity targets. The research concludes that financial as well as cultural barriers need to be addressed when tackling inactivity prevalence.

8 Stop smoking evaluation POLICY BRIEFING Researchers from University College London have praised NHS stop smoking services as a very successful and cost effective intervention. Between 2001 and 2011 nearly 146,000 have been helped to quit, and many of these have been from disadvantaged groups that are likely to be more heavy smokers. However there is room for improvement; if all services had performed at the same level as the best more than twice as many people would have been helped to quit. The research was published in the BMJ. Excess winter mortality PHE has indicated that the excess deaths of last winter are likely to be due to a combination of influenza and cold weather on elderly people. It has decided to halt its regular series of death analyses due to potential methodological weakness and duplication. HSJ reports that an earlier leaked version of the regular death analyses had suggested that links to A and E pressures and reductions in access to adult social care should also be investigated as possible causes. PHE will publish a new series of weekly mortality reports. Health and social care practice Twenty years of hospital food failure The Campaign for Better Hospital Food found a disparity between how patients and trusts assess the quality of food. Three in five hospitals self assessed themselves with the highest rating for food quality, while in the CQC independent survey half of patients were dissatisfied. The Campaign is calling for mandatory standards as for prisons, schools and government departments. The Government has said it supports the principle of food standards but these are decisions to be taken locally. Home care league tables Laing and Buisson have set up a league table of home care providers based on those meeting CQC standards. Home Instead Senior Care were the top performer with 97.8 percent of its 109 branches compliant, followed by Mencap with 93.4 percent. Councils where all branches were compliant include Bolton, Bedford, Bury, Hammersmith and Fulham, Knowsley, North Lincolnshire, North East Lincolnshire, and Redcar and Cleveland. Care Connect NHS England has launched a patient feedback mechanism which uses a website, free-phone, , text or social media to allow patients to comment on NHS providers in real time. All comments are sent to the trusts, but comments are moderated by NHS Direct before they appear on the public website. Care Connect is being piloted in 18 trusts in the North East and London. The target for all trusts to

9 have the scheme in place by 2015 has been dropped so as to avoid problems of too swift implementation. Physiotherapists and podiatrists to prescribe medication The above healthcare professionals are now able to prescribe medication relating to their areas of expertise such as painkillers and anti-inflammatories. Podiatrists can also prescribe medication relevant for diabetes. The first wave of 'advanced practitioners' will be trained by next summer. Benefits are predicted to be freeing GP time and swifter response for patients. G8 Global dementia summit The UK Government is using its presidency of the G8 to organise a global dementia summit in December. Dementia is a challenge for both the developed and developing world who have nearly 60 percent of the dementia population. A promise to learn - a commitment to act: improving the safety of patients in England The review of NHS safety by former US presidential advisor Don Berwick made a number of recommendations. The NHS should be a learning organisation. All leaders - regulators, political, governance, executive, clinical and advocacy - should place quality and safety at the top of the agenda. Patients and carers should be 'present and powerful' at all levels of healthcare from wards to boards, and the patient/carer voice should be treated as an 'essential asset'. The government, Health Education England and NHS England should ensure that there are sufficient staff available to meet NHS needs and organisations should ensure they have sufficient staff to provide safe care at all times. The National Institute for Health and Care Excellence should develop a tool to allow organisations to analyse and correct their staffing levels on a daily basis. There should be a hierarchy of responses to safety problems; criminal sanctions should be extremely rare and primarily act as a deterrent but in should be applied in cases of neglect or wilful misconduct, including by managers, with up to five years in prison. Comment on the report from, for example, the Kings Fund and the Patient's Association, suggests that the Berwick review has nothing new and is short on detailed solutions. Friends and family test - needs further development to avoid misleading? HSJ reports on July's friends and family figures. In terms of levels of response, at 28 percent inpatient services are well above government targets of 15 percent but on average only ten percent of A&E patients completed the test. There is also a wide

10 variation of response rates between trusts. In terms of results, some correlation over time is starting to emerge with the top five trusts the same as in previous months. HSJ also reports on dissatisfaction with how the results are displayed on NHS Choices hospital profile pages. Hospitals in the bottom fifth are denoted by a large red exclamation mark and the words 'among the worst'. However, all but two scored over 50 for inpatient care, a score that would be regarded as excellent in other industries. For example Yeovil Foundation Trust was in the bottom fifth despite surveying almost 40 percent of its inpatients and only 6 people saying they would be unlikely or extremely unlikely to recommend the hospital. The Western Gazette ran a story saying that the trust was amongst the worst in the country. Other otherwise high performing hospitals, such as Salford Royal and Heart of England, have also ended up in the bottom quintile. The Picker Institute has also called on NHS England not to use data from wards where fewer than ten patients filled in the survey to prevent results that are not representative and which might create 'unreliable impressions, unnecessarily damaging staff morale, and alarming local communities'. A&E funding The government has announced 500 million additional funding over two years for the most hard pressed A&E departments; the use of the funding will be decided by Monitor, the Trust Development Authority, urgent care boards and NHS England local area teams and CCGs and could include more staffing, infrastructure or preventative health or care services. Statement of government policy on adult safeguarding The Government has updated the original policy published in 2011 with additional resources, rewording to make the policy clearer and updating to take into account the Care and Support Bill and a consultation on Power of Entry. (n.b. following the consultation the Government decided not to grant this to social workers; a campaign to reverse this is underway). It is aimed at councillors, professionals, agencies and communities and is intended to be a bridge between No Secrets and the Care Bill. 'It aims to encourage progress and action and avoid the inertia that often accompanies anticipated change'. For more information about this, or any other LGiU member briefing, please contact Janet Sillett, Briefings Manager, on janet.sillett@lgiu.org.uk