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Older people denied personalised, effective and responsive care due to poor integration across local systems

The Care Quality Commission (CQC) has reviewed how well different health and care services work together to support the needs of older people in England. 
In its report, Building Bridges, Breaking Barriers, it warns that despite a widespread commitment for integration across the sectors, substantial progress is needed to better support people who use a number of services, reduce hospital admissions and avoid confusion about where to go for help. The report concludes that with a growing elderly population, now is the time to act.

People in England are living longer with the number of people aged 65 and over in the UK projected to rise by 40 percent in the next 17 years to nearly 17 million. Older people typically have the most complex needs and consequently receive care from more than one service and often across multiple locations; for example from an acute trust, a community  trust, a GP, and a home care provider.

  
As the population grows, the providers of health and social care need to find more efficient ways of delivering care and reducing costs, the report says. The Government and health and social care organisations have identified integrated care as a key step in responding to an increased number of people who have complex needs. 

People with complex needs who use a range of services will often say they are satisfied with  individual providers but when they move between different services, their care can become fragmented and have an adverse impact on their experience of using care, the report says. 
When staff from different services talk to each other and share information effectively, people experience better, safer care. When they do not care can become disjointed.  

An example of how integrated care can improve the experience of patients is with effective multi-disciplinary working, planning and information sharing, such as the Care Navigation Service that CQC identified in Camden*.

 
To carry out this review, CQC inspectors gathered evidence from a range of sources, including speaking to older people and their carers to understand their experiences. They inspected services within eight areas across England to look for examples of effectively coordinated care and to identify barriers which prevent care from working well.

The report concludes that substantial progress is needed to achieve the collective ambition that individuals receive joined up personalised care and support. 
While there is widespread commitment to deliver integrated care, local leaders such as directors of adult social services, health and commissioning managers, appeared to lack the knowledge about how to put it into practice. Other findings include: 

  • Where CQC found health and social care was not integrated, the individual services lacked a culture which supported collaboration.
  • There are organisational barriers that make it difficult for services to identify older people at risk of deterioration or unplanned hospital admission in a timely manner, including a lack of consistency in the use of assessments and sharing information. 
  • Many initiatives to encourage and enable joint working were inconsistent, short-term and reliant on partial or temporary funding and goodwill between providers rather than part of mainstream service delivery. 
  • The monitoring and evaluation of integrated care was insufficient or not carried out.
  • A lack of connection between services often resulted in older people and their families or carers taking responsibility for navigating complex local services and this could result in people falling through the gaps and only being identified in a crisis.

 
Inspectors also found that where care was integrated, local leaders were working closely across health and social services to share information, reduce duplicated efforts and use resources more effectively. A number of initiatives, strategies and systems offered a real opportunity to deliver coordinated care in local areas. 
CQC’s chief executive, David Behan said: ‘Older people who use health and care services tell us that they want their services to be joined up and work together. 

‘This study found examples of effective integrated care but these small steps need to become significant strides to move joined-up services into the mainstream. Everyone deserves seamless quality care, regardless of how many services are involved in delivering it and regardless of how complex your needs are. 
‘Local leaders should build on the opportunities offered by initiatives such as the new care models vanguard programme to deliver joined up care.’

The report recommends that local health and social care leaders should agree a shared understanding and definition of what integrated care means for their communities and then work towards delivering this, which means collective and individual leaderships demonstrate ownership and responsibility for integrated care within their areas. 

It also urges NHS England and the Association of Directors of Social Services (Adass) to develop an agreed methodology at a national and local level across health and social care to identify people at risk of admission to secondary care or deterioration, underpinned by a clear data set. Older people should also be meaningfully involved in making informed decisions about their care – in particular about the outcomes that are important to them, the report says.