NICE Guidance Calls for Better Integration of Social and Medical Care for Older People

A more person-centred approach to the provision of care for older people with complex social and medical needs has been called for by NICE.

The number of people with long-term conditions, such as dementia, diabetes, heart disease, and cancer, is set to rise by around 1 million in the next 3-5 years (in line with a rise in the number of older people in the population) and pressure on existing services is set to grow.

There has been much debate within the NHS, social care and the wider public, over how best to serve both the social and medical needs of this group and now NICE has joined the debate, publishing new guidance on the management of older people with multiple chronic condition and social care needs.

The guidance is aimed at social care providers as well as health practitioners, managers and commissioners and aims to improve quality of life, increase independence, choice, dignity and control, through a more person-centred approach

Key recommendations include:

·         Ensuring that each patient is treated as whole, rather than on a symptom by symptom basis, and that they are treated with dignity and respect at all times.

·         Having a single, named care coordinator for each patient, who acts as their first point of contact.  Leading the assessment process, liaising and working with all health and social care services (public, private and voluntary services).  Ensuring referrals are made and actioned appropriately.

·         Ensuring that care plans are updated regularly, to recognise the changing needs of the patient, recognising the progressive nature of many conditions.

·         Ensuring that patients are given choice and control over decisions made about their care.

·         Bringing together specialist teams to review and manage care, including community pharmacists, physiotherapists or occupational therapists,  mental health social workers or psychiatrists, and  community-based services liaison workers as appropriate.

Bernard Walker, Independent Consultant in social care, health and management, and Chair of the guideline development group, said: “When social care and health practitioners work together well, it helps both people using services and their carers to have choice and control over their care. It also avoids unnecessary duplication of services.

“As a committee, which brought together a knowledgeable group of experts including practitioners, carers and people who use services, we recognised how critically important this issue is. Better integration of health and social care services is best practice to which everyone involved in the care of older people with complex care needs and multiple long-term conditions should aspire.” 

Professor Gillian Leng, Deputy Chief Executive for NICE, added: “An estimated 6 million people in England aged 60 and over are living with more than one long-term health condition.

“As the number of older people in society increases, this figure is expected to rise too. A recent report by Age UK warned that a further one million older people in England could be living with multiple long-term conditions by 2020. This will inevitably put pressure on health and social care services and our new guideline highlights ways to best address the growing needs of this group.”

Evidence Suggests Patients Are Not Interested in Weekend Opening for GP Practices

7 day opening for the NHS is a key aim for the UK government, and it is not restrict to secondary care.  The government wants to see GP practices open 7 days a week to meet demand and provide a more flexible service.  

In October 2013 the Prime Minister’s Challenge Fund was established to help improve access to general practice and increase innovation in primary care.  Results from the first 20 pilot schemes, released this autumn, suggested that whilst non-urgent appointments on a Saturday were welcomed by some parts of the community, Sunday opening was not supported by the general public.

The British Journal of General Practice has now published a paper echoing this finding. 

John Ford and colleagues, from the Universities of East Anglia and Oxford, sought the views of over 880,000 patients from across England, through the GP patient survey in 2014.  80% of those who completed the survey did not report any problems with current opening times.  Of the 20% who would like to see changes, approximately three-quarters said that Saturday opening would make it easier for them to see someone, but only 36% (6% of the total sample) thought the same about Sunday opening. 

Younger people, those who work full-time, and those who could not get time off work were more likely to report that weekend opening would help.  Those with complex needs such as those with Alzheimer's disease, learning difficulties or significant mobility issues did not report week day only opening as an issue.

Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust under Investigation

The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust is under investigation by the health sector regulator, Monitor, following a deterioration in its financial position.  

The Trust is responsible for services in Bournemouth, Christchurch, East Dorset and part of the New Forest, and looks after over half a million people.  It has forecast a deficit of over £10 million for the current financial year.

Monitor will be reviewing financial management at the Trust, examining the reasons for the deterioration in its financial position and considering what can be done to improve the situation.

Paul Streat, Regional Director at Monitor, said:

“Patients rely on the services provided by Royal Bournemouth and Christchurch and we want to make sure the trust gets to grips with its finances as quickly as possible.

“We will examine what has caused the deterioration and find out what needs to be done to improve things.

“No decision has been taken on whether further regulatory action is needed, but Monitor will announce the outcome of its investigation in due course.”

Monitor has also voiced concerns about A&E waiting times at the Trust, and managers have already been tasked with taking the necessary steps to improve its A&E performance.

Delayed Transfers of Care: Flexible National Frameworks Required

Delayed transfers are recognised as one of the main pressures on today’s NHS; reducing its ability to meet targets and patient expectations. Some patients are kept in hospital settings long after it is appropriate, distressing many patients and carers, and reducing capacity for new patients coming into the system. 

After a significant period of stagnation in delayed transfer days, the total number of days discharges were delayed by in 2014/15, increased by 15% on the previous year, to over 210,000.  In the first 5 months of 2015/16 this rise continued, with a further 11% increase.  In response to members concerns, NHS Providers set up a commission to look into the causes of delayed discharge and route out best practice. 

Over 4 months the commission, chaired by Paul Burstow, captured evidence from across transfer of care settings, and the final report draws on good practice in health, local government, social care and housing settings.

The report does not attribute the problem of delayed discharge to any one issue or party, or find a single ‘one size fits all’ solution.  It highlights a range of complex challenges within the patient journey that can result in delayed discharge, with issues around workforce capacity, skills mix, and the flow within and between organisations all identified. 

The report recognises that only by bringing all sectors together, from health to social care and housing, can this issue be resolved.  The report goes on to demonstrate how national frameworks, systems and processes can, unintentionally, undermine local progress, and calls for the introduction of flexible frameworks, that support both best practice and local differences.

The commission recommends that Trusts consider adopting process engineering and data analytics as valuable tools to help surface out the root causes of problems with transfers of care, and the sharing of data across sectors to support this work.

The report concluded that:

 “Simply adding initiatives to already complex pathways is likely to exacerbate problems of flow. In contrast, by making the process leaner, understanding it end to end, designing change in partnership with the frontline, and making sure the patient’s perspective is held at the centre of everyone’s practice we can reduce length of stay, speed up the process of discharge, ensure adequate ongoing support and most important, improve patient care and health outcomes.”

Commission chair and report author, Rt Hon Paul Burstow, said "Local collaboration is key to improving transfers of care. It is also vital that patients, carers and service users are at the centre of developing personalised care that works for them."

Prime Minister’s Challenge Fund to Improve Access to Primary Care Gets Off to a Strong Start.

The £50 million Prime Minister’s Challenge Fund was established in October 2013 to help improve access to general practice and increase innovation in primary care.   Twenty pilot schemes started work in April 2014, and the first independent evaluation of their work has now been published.

Key Findings

·         The pilots have given over 7 million patients access to a new or enhanced primary care services.

·         During the week, outside core working hours, 4.9 million patients have had access to a new or enhanced GP appointment service, with approx. 400,000 appointments provided. 

·         Access to core hour appointments has also increased, with approx. 520,000 additional appointments made available within core hours across the pilot schemes.

·         At weekends 5.4 million patients have had access to new or enhanced GP appointment services.

·         As of May 2015, there had been a 15% reduction in minor self presentation at A&E in pilot scheme areas, compared with the same period in the previous year; representing 29,000 attendances.

·         It was noted that the take up of Sunday booked appointments was low, and it was suggested that these might best be reserved for urgent care.

·         Pilots that built on joint working with ANPs, pharmacists, the voluntary sector, care homes, physiotherapists and paramedics released local GP capacity and more appropriately matched the needs of patients with practitioners.

·         Based on the evidence from the pilots the report recommends that 41-51 total extended hours per week are required per 100,000 registered population in order to meet the levels of demand experienced, of which 30-37 hours should be GP hours.  

Notes of Caution

·         The report stresses the need to tailor solutions to local demand and demography, in order to provide relevant services and value for money service for patients.

·         The achievements that pilots have made have not been without challenges. Many of these challenges have been process related and have caused mobilisation delays and had cost implications. IT interoperability, information governance, securing indemnity insurance and CQC registration are the most commonly cited process barriers. Acknowledging these issues, NHS England has established support for wave two pilots to ease and expedite mobilisation of their programmes and minimise duplication of effort in resolving common problems.

·         Wave one pilots did experience some capacity issues, which often manifested as difficulties in recruiting or competing with OOH providers for GP time. There also remains some concerns around the availability of ANPs in particular, which are likely to be exacerbated as more local health economies press ahead with seven day services and introduce skills mix.

Further funding of £100m for a second wave of schemes was announced in September last year.  Thirty-seven schemes have been selected for 2015/16 involving over 1400 practices and 10.6m patients.

CQC Survey Reports ‘No notable improvement’ in people’s experiences of out-of-hospital mental health care

The annual CQC patient experience survey into people’s experience of using community mental health services has been published.  It shows no overall improvement in people’s experience of mental health services over the last year, and in some cases a reduction in the quality of service.

The regulator is now calling for NHS trusts to reflect on their findings and improve their care.

Over 13,000 patients in England were surveyed, with conditions ranging from mild depression to psychosis. The survey did not cover the care people had received for their general practice. The survey asks for views on aspects of their care, such as whether they felt they were treated with dignity and respect and on whether they felt involved in decisions about their care.

Key Findings

·         The number of people who rated their experience as poor increased by 3% (28% compared to 25% last year).

·         A slightly higher proportion of people felt they were not feel listened to by staff (7%, up from 5% in 2014).

·         11% of people felt they were not given enough time to discuss their needs and treatments (up from 9% in 2014).

·         7% felt they were not treated with dignity and respect (up from 6% in 2014).

·         70% reported that they ‘definitely’ felt listened to by the person or people they saw (down from 73% in 2014).

·         73% reported that they were ‘always’ treated with respect and dignity (down from 75% in 2014).

The survey also shows some variation in performance between NHS trusts, with a small group performing poorly across many of the questions. Those that scored ‘worse than expected’ for 10% or more of all of the questions are:

·         Coventry and Warwickshire Partnership NHS Trust (inspected by CQC in January 2014 – not rated)

·         Leicestershire Partnership NHS Trust (inspected by CQC in March 2015 and rated Requires Improvement)

·         Lincolnshire Partnership NHS Foundation Trust (to be inspected by CQC in November 2015)

·         North Essex Partnership University NHS Foundation Trust (inspected by CQC in August 2015 – awaiting rating)

·         The Isle of Wight NHS Trust (inspected by CQC in June 2014 and rated Requires Improvement)

Those that scored ‘better than expected’ for 10% or more of all of the questions are:

·         Bradford District Care NHS Foundation Trust (inspected by CQC in June 2014 and rated Good)

·         Cheshire and Wirral Partnership NHS Foundation Trust (inspected in June 2015 – awaiting rating)

·         Mersey Care NHS Trust  (inspected by CQC in June 2015 and rated Good)

·         NAVIGO Health and Social Care CIC (to be inspected by CQC in January 2016)

·         Tees, Esk and Wear Valleys NHS Foundation Trust  (inspected by CQC in January 2015 and rated Good)

Dr Paul Lelliott, Deputy Chief Inspector of Hospitals (lead for mental health) said: “Overall it is disappointing that there has been no notable improvement from last year’s survey. In particular, the fact that over a quarter of people reported a poor experience of their care is worrying and must be acted on.

“Community mental health services play a vital role in supporting people with their mental health problems without needing to stay in hospital.  It is imperative that the NHS gets this right.

“We urge all NHS trusts and in particular those that have performed poorly to reflect on what the survey tells them about what their patients think of their services act on the findings.

“We will consider the results of this survey in our inspections so that we can be confident that people receive the safe, high-quality and compassionate care they deserve.”

Lesbian Bond Girl – Just Needed ‘The Right Man’

Dr Gibson, a dedicated fan of 007 was in regular correspondence with the writer of the novels and in June of 1959 wrote to Ian Fleming complaining that he had changed Pussy Galore from “a criminal Lesbian into a clinging honey-bun (to be bottled by Bond) in the last chapter”.

Pussy Galore, an agent of Goldfinger, in Ian Fleming's 1959 007 novel, is a thoroughly modern, independent woman, equal, or superior, to most of the men around her.  She is the only woman in the USA known to be running an organised crime gang and is 'immune' to James Bond’s charms.  Bond describes her has as having black hair, pale skin, and the only violet eyes that he has ever seen. She is in her thirties, her voice is low and attractive and he is under her spell.

In the novel she tells Bond that she became a lesbian after she was sexually abused by her uncle at the age of 12.  But by the end of the novel Bond has helped Pussy Galore find her inner domestic goddess, as she turns her back on the world of crime and falls in love with a man.  Bond looks deep into her eyes and says, ‘They told me you only liked women’. He then promises her “a course of TLC”, before she looks up at his “passionate, rather cruel mouth” and it comes “ruthlessly down on hers”.

In response Dr Gibson’s letter, James Bond’s writer, Ian Fleming, wrote that Pussy Galore, Goldfinger’s lesbian love interest, only needed ‘the right man to come along and cure her psycho-pathological malady”.


The letter from Ian Fleming to Dr Gibson will be auctioned on the 11th November, by Bonhams for an estimated price of between £3,000 and £4,000.

Birmingham University’s Student Union Taking on the Tampon-Tax

Daisy Lindlar, a Birmingham University student union officer, has taken action following the recent debate in the Houses of Parliament on the ‘tampon tax’.  Following the debate MPs voted to leave female sanitary products in the luxury category for VAT, unlike crocodile meat and edible cake decorations, which are just two of the items deemed necessary to day to day living, and so are exempt from the tax.

Daisy started a Facebook campaign to describe how periods add to living costs for women, and secured free sanitary products for her fellow students at Birmingham University.  In a blog post for The Huffington Post, she wrote: "I'm fortunate in that although the tampon tax angers me, I would never be actually priced out of a period. But there are many people who aren't so lucky. These people have to resort to unhealthy measures to manage their periods, creating unhygienic, home-made alternatives to traditional sanitary products.

"We should be talking about our bodies, and the associated cost of them, so that we can move towards a society where we do not have to pay an extra charge.

"If we can access contraception for free, why shouldn't the same apply to sanitary products?"

Birmingham university students can get their free supplies from the Student Union Office.

NHS England to Set Up £45m Transforming Care Partnerships Fund

40 Transforming Care Partnerships are to be set up across England, to oversee the implementation of the recently published ‘Building the Right Support Plan’, part of the wider government Transforming Care Programme. 

The plan was developed by NHS England, the Local Government Association and the Association of Directors of Adult Social Services.  It seeks to transform community services for those suffering from learning disabilities and/or autism, who are too often, and for too long, being treated in in-patient hospital settings. 

In England, around 24,000 people who have a learning disability and/or autism are classed as being at risk of hospital admission and three quarters of those admitted stay in in-patient facilities for more than a year. 

Under the plan sufferers will be supported to lead more independent lives, with new high quality community services reducing the need for in-patient care.  The plan predicts a reduction in inpatient beds of between 30 and 50 per cent.  Improving the quality of life for thousands of patients and freeing up hundreds of millions of pounds for investment in community-based support.

Transforming Care Partnerships will have until April 2016 to produce local action plans, and are expected to oversee a smooth transition to new service arrangements within 3 years.  £15m will be made available for capital expenditure over this period, with £30m available on a match-funding basis for local commissioners to ‘double-run’ services.

Bed closures will be staggered, only taking place when suitable alternatives are available. Providers such as hospital trusts will be supported by NHS England and others to adapt to the new model, shifting their own services to the community where possible.

Jane Cummings, Chief Nursing Officer for England and Chair of the Transforming Care Delivery Board, said: “Society has failed this group of people for decades. Now is the time to put things right, and with this far-reaching plan I am confident that we can finally make quick, significant and lasting improvements to their lives.”

Dr Paul Lelliott, CQC Deputy Chief Inspector of Hospitals (lead for mental health), said “As one of partner organisations of the transforming care programme board, we support the vision to create more appropriate models of care so that people with learning disabilities can live more independently and whenever in their best interests, receive the care and support they need outside of hospitals'

“Our inspections are structured around what matters to people who use services and how well they are served – this includes assessing the experiences people with learning disabilities and when they are being cared for as inpatients, what providers are doing to support their discharge. As well as this, we are continuing to look at how we register potential new ‘assessment and treatment’ providers so that inappropriate models of care do not continue. We will publish an update on our plans later this year.”

Budgets will be shared between the NHS and local councils to ensure the right care is provided in the right place and a set of national guidelines will be published, setting out the support service users and their families can expect, assisting commissioning bodies in planning appropriate services for their area.