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

12 July 2016
  • Media

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.


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Last updated:
29 May 2017

Notes to editors

  • Inspectors visited eight health and wellbeing board areas between October and December 2015 as part of the review. These were Bristol, Cambridgeshire, Camden, Central Bedfordshire, Hammersmith and Fulham, Portsmouth, Stockton-On-Tees and Wakefield.
  • Each fieldwork team was led by CQC inspectors and most site visits were supported by an Expert by Experience (a person representing the general public with personal experience of care) and a specialist professional advisor (a senior clinician or professional who supports CQC inspections). The team reviewed care records and spoke with people, their carers and the professionals providing care. It also worked with a range of organisations to gather further feedback from older people and held focus groups with a range of staff involved in older people’s care.  
  • The inspection team used a detailed assessment framework to structure interviews and discussions with people, carers and staff during fieldwork. The assessment was built around four keys questions which were:
    • How are older people with complex needs or at high risk of deterioration in their health or social situation identified?
    • Do older people always have a person centred, holistic assessment that forms the basis of a care plan that meets their physical, emotional, spiritual, social and practical needs and is the plan regularly reviewed and updated?
    • Is care coordinated effectively to ensure that the older person is at the centre of their care – including when they have multiple or complex needs or vulnerabilities?
    • Do services and professionals recognise when the care required for an older person changes and how do they manage this change in an integrated way?  
  • CQC uses the definition of integrated care produced by the charity National Voices “I can plan my care with people who work together who work together to understand me and my carer/s, allowing me control and bringing together services to achieve the outcomes that are important to me.” You can find a link to National Voice’s guide to integrated care here.
  • *The report contains many best practice examples, including NHS Camden Clinical Commissioning Group’s ‘Care Navigation Service’. Provided by Age UK Camden, it supports patients in accessing voluntary and community services that help them to self-manage their conditions. It also supports vulnerable people to get the right health and social care to meet their needs. Aimed at the over 60s who are either frail or identified as being at risk of becoming frail, patients have long term conditions, had an emergency admission to hospital in the last year or are not engaging with health and social care services. Six care navigators offer support with case management, multi-disciplinary team meetings and complex referrals. In less than a year since its inception, it has had referrals from over 30 practices and seen almost 600 patients. The service is highly rated, with 83 percent of users saying they would recommend it to others.