Getting patients out of hospital quickly and efficiently – either home or into an alternative care setting – has become (perhaps for good reason) a bit of a national obsession, seen by many as a barometer for the effectiveness of adult social care.
Of course, nobody would wish to stay in hospital any longer than absolutely necessary – but while timely hospital discharge is crucial, as an overall metric of social care (and health) effectiveness, we need to be telling a different story. And loudly.
Over the last two winters social care colleagues across England have made considerable in-roads in reducing the number of people delayed in hospital settings by 40%.
Given the pressures on the sector this is a fantastic outcome, and means that social care delays currently account for approximately one third of the total number of hospital delays, or delayed transfers of care (DToC) in England. Yet, perplexingly, national and local discussions continue to focus on the role of social care only in ensuring effective flow through the complexities of a health and care system, centred around our acute hospitals.
This in my view only serves to divert attention, along with precious and increasingly limited social care resources, into a singular approach to the wrong kind of operational excellence – getting people out of hospital quickly, rather than continuing to keep as many people as possible away from unnecessary admission (and let’s not forget that the latter is the ambition writ large in the NHS Long Term Plan).
To bring about collective change in how we measure the success of adult social care, there is an obligation on those of us in the profession to be more vociferous about the huge range of support we provide – day in and day out – collaboratively with partners; challenging the narrow optic which sees social care as simply the recipient of onward business from NHS acute care. This is certainly our shared ambition with NHS colleagues in Hampshire.
Across our local authority area, we support more than 20,000 adults each day – the vast majority living as independently as possible at home, supported by an excellent range of independent, community and voluntary sector providers, as well as the county council’s own direct provision.
This excellent but hard-pressed sector is under intense pressure to maintain the support that keeps people well and as independent as possible. Failure to maintain, or indeed boost, this community support in favour of diverting further resources into hospital discharge would inevitably lead to more people being admitted to hospital. This could be the unintended outcome unless we are watchful and attentive as a sector.
Acute hospitals should, in leading healthcare professor Don Berwick’s view, be a ‘supplier of last resort’. If this is to be the case, then we must question how we better use our resources to avoid admission to an acute setting in the first place.
The answer is to continue to innovate. In this context, our pioneering venture with South Central Ambulance Service – having social workers operating alongside NHS 111 call handlers to avoid ambulance transfer to hospital where better, and perhaps safer, alternatives exist – is exceeding expectations. The 50 or more avoided conveyances per month for one acute trust alone, are saving not only time and money, but ensuring vulnerable people are directed to a setting much more appropriate to their needs. At present, these ‘avoidances’ do not figure on the collective radar. It is time they did.
In the end, unless health and social care can collectively re-imagine how we operate and develop more balanced measures of the approaches we take, the focus will continue to be upon a narrow and somewhat arbitrary measure within the overall world in which we operate.
DToC and patient flow should be part of this world view, but not the only element.
Graham Allen is director of adult health and care at Hampshire CC