Last month was ushered in by headlines warning of the coldest December since 2010’s prolonged deep freeze.
The predictions of dire weather were joined, on 30 November 2017, by the latest in a long line of reports forecasting a gloomy future for adult social care.
While snow and sub-zero temperatures have abated in the run-up to Christmas, the unsettled outlook for care services – which usually face their greatest pressures at this time of year – has not.
Councils and NHS trusts have been making progress against targets for reducing delayed transfers of care (DToCs), set by the government last summer. Yet some areas remain a long way from meeting them and face the possibility of financial penalties next year.
Meanwhile renewed alarms have also been sounding about the impact of Brexit on the health and social care workforce.
Community Care spoke to local government and care sector representatives for their views on how things stand.
‘Pulling out the stops’
With deep snow having recently affected sizeable swathes of the country, both care provider and local authority representatives were keen to sing the praises of staff who made sure they were there to support people.
“Everyone in social care pulled out the stops,” says Mandy Thorn, the managing director of Shropshire-based Marches Care and vice-chair of the National Care Association. “We had people in care homes staying overnight so they could be there the next day, and domiciliary care staff doing everything they could to get to clients, even if that meant walking.”
Business continuity planning involved organising lifts, making use of 4x4s, and help from communities to clear paths, adds Raina Summerson, the CEO of a representative of the United Kingdom Homecare Association (UKHCA) Large Provider Action Group.
“It’s about having plans in place – risk assessments, knowing which locations are most vulnerable in terms of access or people needing support, ensuring staff are experienced and able to deliver care in a more pressurised environment than normal,” she adds.
Whether such pressures are triggered by weather or by the outbreaks of illness that peak in the winter months, having to respond to them is nothing unusual.
“During the winter period staff go above and beyond, some coming in even though they are supposed to be on leave,” says Colin Noble, the leader of Suffolk council and health and social care spokesman for the County Councils Network.
‘It’s tougher than last year’
But while discrete episodes of seasonal stress can be mitigated by a committed core of staff members, the wider picture is, in many areas, only getting tougher.
“You hear about the notion of winter pressures, but the social care crisis was here before the snow and is still here after it,” warns Martin Green, the chief executive of care provider body Care England.
For operators in many parts of the country, workforce recruitment and retention – which can have a major impact on DToCs – continues to be the biggest challenge. Last month a judge dismissed a judicial review brought by Care England against Essex Council, which was accused of setting its fees at an ‘unsustainably’ low level for the market.
Providers, especially in areas of low unemployment, are also in continual competition with other sectors such as retail and hospitality in which wages are often better and work is seen as less stressful.
The growing complexity of care packages that staff are expected to deliver is compounding the latter factor, Summerson points out.
“It’s definitely tougher – I think things have got worse over the last year,” says Summerson. “Workforce shortages have been increasing, and spreading from being more evident in domiciliary care to care homes.”
Some providers, Thorn adds, are already struggling as a result of workers from continental Europe heading back to their countries of origin both because of Brexit uncertainties and the pound’s poor performance against the Euro.
North Yorkshire council’s health scrutiny committee recently wrote to the government to flag up fears about workforce shortages. The letter called for clarification over EU workers’ rights – something Noble says he is “deeply concerned” about – as well as extra funding to enable better pay in the sector and action to promote social care careers.
Both care provider and local authority representatives we speak to say the latter factor will be crucial.
“Skills for Care is looking at national recruitment and we, from a UKHCA and Care England perspective, are encouraging central and local government to do what they can to boost the image of social care,” says Summerson.
‘Home first’ models
While workforce issues have been a key reason why some areas continue to struggle with demand for services, there also continues to be a lack of consistency in how well public bodies and care providers work together, according to Green.
“NHS trusts who are having problems with DToCs, very few are going to their care providers and saying, ‘What can you do for us?’,” says Green. “And while some local authorities are putting contingencies in place, others are not. No one is holding a coherent position across country.”
In certain areas, Summerson adds, the system slowed down appreciably in the run-up to Christmas. Last month saw familiar headlines about cancelled operations and makeshift hospital wards beginning to appear.
Yet many authorities also made significant progress on their discharge targets as winter approached, with the overall numbers attributable to social care dipping steadily of late.
Government pressure on health services and local authorities to implement ‘discharge to assess’ (D2A) or ‘home first’ care models have had a significant impact, according to Grainne Siggins, the Association of Directors of Adult Social Services (ADASS) policy lead and director of adult services at Newham council.
Such models depend on getting people out of hospital – where many become frailer or iller – as quickly as possible, before assessing their ongoing needs.
“We’re directly providing care and support for the initial period [out of hospital], supporting people to get a bit better and more independent before we complete a formal assessment,” Siggins says, adding that the capability in Newham has been funded from the borough’s share of the extra £2 billion Better Care Fund allocation.
Authorities that have driven their DToC numbers down, Noble and Summerson agree, have focused on delivering intermediate care beds, improving reablement services and other measures that get people out of hospital and help them recover.
“West Suffolk hospital has worked with Care UK, which took over 16 ageing Suffolk council care homes and re-provided them as 10 state-of-the-art care with nursing homes, and block-purchased rooms to offer intermediate beds,” says Noble. “When you don’t need the medical care of hospital, you move to a setting that allows you to recover and most importantly frees up the other bed and lowers cost to system.”
Going into the first, and coldest, months of 2018, councils, trusts and care providers will continue to find plenty to disagree on. Yet there is a consensus that, with the financial climate also continuing to be hostile, intelligent ‘whole system’ approaches are likely to offer the only prospect of respite.
“It’s about using each other’s resources and skills better,” says Summerson. “There is a spirit behind what works, and that is one of proper partnership, with grown-up discussions, not an adversarial relationship. That sounds simple but it doesn’t happen much.”
There is an “intensive focus” on getting things working properly, Siggins adds. “It’s everyone making sure they can do all they can: seven-day-a-week social workers in hospital being able to broker packages of care and support, equipment being delivered every day, and the increasing use of voluntary-sector support to divert people away from the hospital front door,” she says.
Looking forward though, Noble says, there may need to be a more fundamental shift in perception – as well as funding – of health and social care services, if the system is to function, whatever the season.
“At present the NHS model is about fit, healthy people who episodically get ill and we fix,” he says. “With our ageing population that will dramatically change – we will have a significant number of people who will be living with more conditions. They can’t just be turning up in A&E. We need to make sure that we are properly supporting them in the community.”