In recent years, the challenges facing the social care sector have become one of trust leaders' biggest concerns. Operational pressures including hospital discharge highlight just how interconnected the health and social care sectors are. Both sectors have been grappling with rising demand, squeezed funding and staff shortages for many years. The impacts of the COVID-19 pandemic have compounded these pressures further, leading to the most difficult summer on record and ahead of what we expect will be a particularly busy winter.
While recent social care reforms represent welcome recognition of the need for change from government, particularly around the amount and the way people are charged for social care, there is a general consensus that we are a long way off creating a social care system that is sustainable for the future. Social care faces nation-wide problems which require national solutions. But in the absence of a sustainable long-term funding settlement, or the scale of reform required, trust leaders are working with their local social care partners in increasingly innovative ways to help ensure individuals receive the right care at the right time in the right place, and to facilitate the flow of people through the system.
In this blog, we explore how trusts are supporting social care partners with recruitment and retention, increasing capacity in social care and developing new integrated delivery models. There are already examples of trusts, such as Torbay and South Devon NHS Foundation Trust, which are well established providers of both NHS and social care services. And there is much to learn from other types of providers as well, such as City Health Care Partnership Community Interest Company, which has recently been commissioned by the local acute trust to deliver an intermediate care service in support of elective recovery. However, here we provide several emerging examples of new ways trusts are working with social care locally, to help share learning across the provider sector.
NHS and social care leaders are particularly concerned about the impact of increased demand and complexity of need, which is putting a strain on social care capacity and the already fragile provider market. The gap between capacity and demand means more people are waiting for assessments and support; higher levels of unmet or undermet needs impact on people's wellbeing and can have a knock-on effect on other public services.
This demand-capacity gap should also be considered in the context of the inverse care law: with evidence suggesting that the most deprived local authorities in England have experienced more funding cuts than the most affluent, which compounds the health and wellbeing challenges that already exist in those areas.
In response to these challenges, some trusts are working with social care partners to increase capacity in their local areas, with a particular focus on care at home, while being careful to mitigate any risks of disruption to the domiciliary care market.
Northumbria Healthcare NHS Foundation Trust has recently set up a home care service to help address domiciliary care capacity issues in their local area. The service will focus on the highest volume of demand, to support older people with less complex care needs.
The trust has employed 30 home care staff, who will be employed on NHS terms and conditions. They will be integrated into community teams spanning health and social care to reduce duplication from home visits by different health and care professionals.
The service aims to ensure continuity and higher quality of care, as well as value for money, as the cost of running the home care service is significantly less than a new acute ward. The trust has deliberately kept their intervention relatively modest so as not to disrupt wider social care markets across the patch.
North West Surrey Health and Care Alliance worked with social care partners during the pandemic, at one stage running over 200 step-down beds in a range of settings, including acute and community hospitals and care homes.
They found that patients were discharged quicker and with better outcomes when in high quality social care settings, and that this option was also the most cost-effective.
The alliance has developed a multi-year agreement with CHD Living (a social care provider in the area), to invest in additional capacity (commissioned by the local authority). This has improved the rates of discharge from hospital and enabled people to recover in the most appropriate settings.
North West Surrey Alliance has been able to reduce its net bed base by 70 beds across the NHS acute and community hospital settings, while maintaining hospital flow.
Recruitment and retention
Recruitment and retention of social care staff is one of the biggest concerns for health and care leaders. There are currently 165,000 social care vacancies, with people leaving the sector at higher rates than ever before, and over 132,000 vacancies across NHS trusts.
The rate of pay for social care staff is a key issue, particularly in the context of sharp rises in the cost of living, as care workers are increasingly choosing alternative roles in retail and hospitality. This is compounded by a lack of clear career progression and training opportunities for care staff.
The challenges around recruitment and retention also reflect the fact that staff are suffering from burnout and fatigue due to a lack of support, increased workload and the ongoing impact of the COVID-19 pandemic. Entrenched recruitment and retention problems are therefore impacting capacity and quality of care.
Some trusts are working with social care partners to use NHS infrastructure to support improved recruitment and retention initiatives locally which offer individuals better entry points and career pathways across health and care. Although these initiatives have generated some positive results, they are not a long-term sustainable solution on their own. The social care sector still needs national action on pay and conditions to ensure the sector has the right workforce for the future.
Several trusts are developing health and care academies to enable skills development for all NHS and social care staff. For example, Central London Community Healthcare NHS Trust's academy supports new ways of working across community and primary care by providing staff education and training opportunities.
Through the academy, Central London Community Healthcare NHS Trust is exploring working with partners such as the Prince's Trust to recruit home care assistants, with the trust offering to fund two weeks of training for staff, and support during their first six months.
By ensuring social care staff are fully trained and supported, and by demonstrating possibilities of career progression into a range of care settings, this initiative has the potential to improve the quality of the training available and aims to support recruitment and retention.
The health and care partnership in Leeds has supported the local social care sector by providing advisory and financial support to the local authority as part of the place-based health and care partnership. This support included working together to run city-wide and international recruitment campaigns and funding to mitigate demand increases.
The integrated care board (ICB) in Leeds allocated some funding that was used by Leeds City Council to bring forward the increase in pay for care workers with effect from December 2021, four months ahead of the rise in the national living wage which came into effect in April 2022.
Leeds Teaching Hospitals and Leeds Community Healthcare NHS Trust are also working with the local authority as part of the city's system flow and intermediate care programme. This includes initiatives to increase social work capacity, establish a model of 'active recovery' within community recovery and rehabilitation services, and the establishment of a multidisciplinary transfer of care hub to coordinate discharge from hospital.
These initiatives have shared aims to ensure that the health and care system is effective in supporting people to remain living independently at home, including providing targeted support to enable people to return home swiftly after a stay in hospital.
Integrated delivery models
With the establishment of statutory integrated care systems in July, health and care organisations are increasingly focused on partnership working with the aim of delivering better, more joined up health and care for the benefit of local communities.
In the context of this direction of travel and in response to system-wide challenges, trusts are increasingly looking for opportunities to embed joint working across NHS and social care, including joining up pathways, improving the quality of services, and ensuring best use of collective health and social care resources. Often this involves more integrated approaches to both delivery and commissioning.
Tameside and Glossop Integrated Care NHS Trust is looking at how integrated health and social care teams can reduce duplication and improve quality and continuity of care in their area.
The trust hosts the Greater Manchester blended assessor role, which is the first in the country to train staff working in care homes to administer insulin. Enabling care staff to carry out these tasks reduces duplication in home visits and frees up capacity for NHS staff to dedicate time to those with more complex and acute needs.
Similar initiatives are being carried out in Leeds. For example, Leeds Community Healthcare NHS Trust staff are carrying out tasks that would usually be done by adult social care staff. This in turn frees up capacity for social care staff and prevents duplication of effort during home visits.
Central London Community Healthcare NHS Trust has a rapid response social care service to facilitate hospital discharges while patients await a longer-term package of care.
The 'QuickStart' scheme takes referrals from GPs, hospitals, adult social care and community health services and offers up to four care visits a day to help individuals with daily tasks.
People are referred simultaneously to QuickStart and social care for a long-term care needs assessment. The benefits of this service include reducing the risk of deterioration in hospital beds, facilitating earlier discharge, preventing readmissions to hospital and improving communication between carers and nurses.
Our conversations with trust leaders show the extent to which they recognise the need to support and work with local social care partners. Indeed, many see system working as a chance to think differently about how they can help prioritise and resource services that keep people well and independent for longer.
However, this cannot be achieved through local initiatives alone. Without adequate funding or staff, the social care sector will continue to struggle to meet increased demand – particularly in home care – with major knock-on effects for individuals and wider health services. The adult social care sector needs long-term, sustainable funding and reform which addresses unmet and undermet need, quality of care and innovation, and workforce shortages.
All of this requires clear direction and support from the government, as well as honesty and openness with the public. Local solutions from trusts, social care and system partners are a pragmatic response to current pressures, but they will not prove a sustainable solution long-term.