Key learning points
- Integration between health and social care is vital to look after an aging population
- Care of the elderly is fraught with challenges, including staffing and budgetary constraints
- Demographic pressures mean that many community nurses caring for the elderly are themselves heading for retirement
We all are talking about it and most of us would claim to be doing it already but are we really achieving integration between health and social care for older people? Is it within our grasp or the very essence of what we do? The part that community nurses can and perhaps must play in this issue can be seen as the critical ingredient in driving forward change. This article aims to open up a debate about what role the community nurses can and should play.
The recent Age UK report  Later Life in the UK gives us a stark illustration of the scale of the challenge in how we address the needs of an aging population. The wide spread of data in this excellent report sets out the issues and imperatives both for us today and for the future in how we provide care for our older people. Box 1 (below) illustrates some of its key messages.
- 11.6 million people are aged 66 or above
- 1.5 million people are aged 86 or above
- 2 million people aged over 76 or above are living alone
- 15 million people have at least one long-term condition
- In the winter, there are 200 preventable deaths every day
- 4 million people in older age are living with a longstanding life-limiting condition 40% of all those over 65
- In 2012/13, there were almost 2.25 million emergency admissions of people aged 60 or over, costing 3.4bn
- In 2016, of the 18.7 million people admitted to hospital 7.6 million (41%) were aged 66 or over
The work that nurses do across the previously parallel lines of health and social care has at last recognised the critical connection between the two and the reality that squeezing social care will see a requisite impact on the NHS. Social care has seen a 40% reduction of its budget at local authority level in the last five years to a figure of 18.6bn compared with a current health budget of 126bn.
Nurses, working predominantly in a social care world, see the interchanging headlines between the pressures on the NHS then social care as both troubling but also perversely encouraging, as negative headlines have meant health and social care is now a new interlocked phrase uttered by many in the press, politics and also within services.
The catastrophising of the state of health and care causes great alarm for swathes of the population, but can also hearten us all in giving a more urgent profile for a solution to the pressures we are seeing.
The recent budget announcement of an additional 2bn as an interim bail-out prior to a green paper addressing social care later this year was very much welcomed, though many will wonder how and when this will be deployed to address system overload. Care of older people, we are arguing locally, is the most important part of the health and social care sector and a special concentration should be applied to those aged 80 or over.
The King’s Fund, in its 2014 report that set out priorities for the next government prior to the previous general election, tells us that the average age of hospital patients is now over 80 and we know this remains the case today.
Here are three of the issues needing some focus in this debate:
There is little doubt that we are facing some real challenges in the health and social care workforce. These include:
- The shift from trainee nurse bursaries to loans.
- The demographic pressures that mean the average age of a community nurse is in their mid 40s and many are looking forward to retirement.
- Increased workload demands as well as heightened expectations and scrutiny of the work of clinicians.
- The impact and implications of Brexit.
The responsibility for a culture embedded in a ‘can-do’ attitude rather than ‘yes-but’ attitude must also balance the risk of naivety if we all speak too loud and proud about our work without some level of protest. In respect of skills, knowledge and competence are a must to ensure a confident workforce that is fit for purpose. This is where the real debate must take place at all levels to inspire and reassure all stakeholders in health and social care.
Much understandable unrest is bubbling up about pay, and terms and conditions for health and social care staff, too. Dr Sarah Wollaston, former GP and current MP for Totnes, Devon, talked in her letter in the BMJ  about how health and social care organisations ‘retreat to protect their own budgets’ in times of a financial squeeze on services. In addition to the 1.5 million people who are employed in social care, there is a considerable reliance placed on the 6 million unpaid carers, often aged and looking after a spouse. Many organisations, such as the King’s Fund, fear this is unsustainable.
Commissioning as a term has been around for some time now a lot of frontline clinicians, including nurses, may feel this to be a distant part of management-speak and not something to be terribly concerned about, let alone involved in.
The truth is, however, that although the cycle of change, restructuring and reconfiguration of services is ever fluctuating, the need for strong and credible policy is so crucial that jobbing community nurses must get involved at clinical commissioning group (CCG) and sustainability and transformation plan (STP) level.
I would encourage all nurses to take an interest and speak up about what integration means across the great divide between health and social care. Another system design must recognise the ongoing and significant influence of the Care Quality Commission (CQC) in determining ‘what good looks like’ and how services work and connect.
The CQC’s annual state of care report for 2015/16  gave a cautionary view on how the social care system was ‘approaching a tipping point’ and gave a strong endorsement for more joint working between the two areas of health and social care. The Nuffield Trust  produced a report recently, offering ideas on how integrating commissioning of hospital care and social care can provide better outcomes, suggesting collaborating with experts, addressing delayed transfers of care and taking an ‘evolution-not-revolution’ approach is best to prevent tensions in the system.
I would concur, but we need action right now to get things better connected after many years of talking about integration. NHS vanguard schemes  have also offered a number of excellent and successful projects but at some financial cost to the NHS, with a budget for the 50 projects of several hundreds of millions and a further 101m allocated for this year.
Key themes and principles for community nurses
Words like collaboration, shared care and joint working are used a lot in health and social care. But with a mounting pressures across the system, it is understandable that time spent in meetings outside of multi-disciplinary team (MDT) work addressing patient need must be kept to a minimum.
Add to this what many nurses feel is the onerous requirement for admin functions and paperwork, and there is little time for innovation and industry beyond the essentials.
Our local work has developed a tool to provide a workload distribution framework for our staff. This defines a broad aim that is flexible but is used in gauging and guiding frontline staff. It is worth mentioning that meetings include handover and continuing professional development (CPD) includes a lot of the essential skill training, supervision and room for developing special areas of interest and expertise.
What good looks like
So what does good look like in terms of health and social care integration? For me, it’s to do with trust, respect, leadership, followership, partnership and like-mindedness as well as common cause and belief. Culture is at the heart of our approach. Physically spending time with one another and seeing the world from the other person’s point of view are vital parts of achieving true integration for providers, so empathy must be a key to achieving this.
Whether a colleague in a different organisation, profession or with a different perspective to an issue or a person needing help, it is important that we know each other and our respective roles and demands, strengths and limitations. Then I hope the debate on what matters most can be triggered.
Conclusion and suggested actions
Nursing in Practice runs conferences and events all around the UK each of these offers the opportunity to bring likeminded nurses together to share experiences and ideas to address the pressures and strains in an increasingly challenging health and social care environment.
Exerting credible influence on policy makers should also include direct lobbying of MPs across the country. If we speak with the same voice, we can seek assurances that integration of health and care is on their priority list.
1 Age UK. Later in life in the UK, 2016, 2017
2 Institute of Fiscal Studies. Public spending on adult social care in England 2017. Available from ifs.org.uk/publications/9185
3 Ham C. Priorities for the next government. King’s Fund, 2014.
4 Royal College of Nursing. Unheeded Warnings Health Care in Crisis, 2016.
5 Wollaston, S. Commentary: The Political response has been dismal. BMJ 2017;365:j5.
6 Humphreys R et al. Social Care for Older People Home Truths. King’s Fund 2016.
7 Care Quality Commission. The State of Health and Adult Social Care in England 2015/16.
8 Holder H. How hospitals can collaborate with social care. Nuffield Trust 2017.
9 NHS England. New Care Models 2016. Available at england.nhs.uk/ourwork/new-care-models/vanguards/about-vanguards/
10 NHS England. NHS England announces 101 million of new funding for new care model vanguards 2016. Available at england.nhs.uk/2016/12/vanguard-funding/