Making a difference to people’s lives through modern health and social care regulation

1. Making a difference to people’s lives through modern health and social care regulation Alan Rosenbach – Head of Strategy and Innovation CQC SSRG Annual Conference - Manchester 8 March 2010

2. Agenda • Confronting the restraints - together • Making progress • Contribution of regulation • Next steps

3. The ‘iron curtain’ effect between health and social care • Higher use of long term residential care in England compared to • many other OECD • Individuals not supported to die where they wish to • Constant ‘fire-fighting’ - limited investment in prevention, re-ablement • and earlier interventions • High & variable emergency hospital admissions, occupied bed days, • delayed discharges from hospitals – though some areas are getting it • right • Inefficient use of resources

4. Effects of the iron curtain between health & social care – end of life care • The majority of people express a preference to die at home but at present about 60% actually die in hospitals. • Deaths in hospital, having risen slowly to 2005, have begun to decline. Deaths at home, having declined to 2005, have started to rise slowly. These trends, though still quite slight, are a welcome move in the right direction. Where care homes are in effect someone’s home we would also hope to see more deaths taking place there too, as an indicator that people’s wishes are being taken into account and their choices are being better supported. • Taken from Department of Health (July 2009) End of Life Care Strategy: First Annual Report (pg 8)

5. fire-fighting focus • As noted in our state of health care and adult social care in England report, 72% of councils have chosen to focus their funding for social care solely on people whose needs are substantial or critical. • According to the DH and the Audit Commission*, the most likely way that local authorities can release monies for investment in the future is to reduce the proportion of spend on adult residential care. However, LAs are still failing to shift spending away from residential care. Although spending in 2007/08 was 46% higher than in 2001/01, the proportions of spending on different elements of care has remained almost exactly the same * Audit Commission (Feb 2010) Under pressure. Tackling the financial challenge for councils of an ageing population. Local government report.

6. Effects of the ‘iron curtain’ between health & social care – huge variations in care

7. cultural issues “Trust is an issue e.g. not accepting assessments from each other’s organisations. This is not helped by charging; [generally] social care charge for services and health don’t.” (Commissioner of social care services) “I had to ask too many different people for advice. It was too disjointed.” (Carer for husband with long term condition) Recovering from his coma in hospital, ‘Paul’ asked for physiotherapy, which he felt he needed after 60 days in bed, but was told: “This is a neurological ward. We don’t do physiotherapy on this ward” “If we, inside the system, don’t understand how the system works, what chance do the public have of navigating through?” (Provider of health care services)

8. Drivers of change for health & social care • People want alignment in their services • Changing demographics • Increased expectations of good public services • Personalised care • Arctic economic climate

9. Drivers of change for health & social care - economic • Current direct costs are substantial • Over 65s (16% of the population) • 60% of social care spend • 44% of all NHS spend • 2/3 of acute and general hospital beds by daily census • Overall costs across health & social care = £36 billion • Plus broader economic & social costs

10. Making progress in joining up health & social care • Components of sustainable more joined-up care: • practice level e.g. multidisciplinary teams • provider management • commissioning • local corporate governance • supporting policy & performance framework • Need to be aligned

11. Making progress in joining up health & social care • Findings from National Evaluation of POPPs: • For every extra £1 spent on POPP, there has been approx £1.20 • additional benefit in savings on emergency bed days • Total cost reduction of £2,166 per person through reductions in • overnight hospital stays, use of A&E, use of physiotherapy/occupational • therapy clinic or outpatients appointments • 12% increase in self reported health related quality of life for those • receiving practical help and simple aids • prevention & early intervention can work well even for older people with • very high and complex levels of need

12. Making progress in joining up health & social care • Findings from pilots in South West region: • More early diagnosis, prevention and/or early intervention • Quicker hospital discharges • Improved patient/service user experience and feedback • Developed a set of key enablers, “10 Golden Rules”, for the • commissioning of integrated health & social care

13. The best performing areas in the country have less than half the rate of repeat emergency admissions for older people…

14. And while the rate increased across the country, a basket of the best performers reduced the admission rate over 5 years 2+ emergency admissions per 1000 population aged 75+

15. A similar pattern emerges for the bed days used by these patients, only this time the variation is nearly four fold

16. And the difference in trend between the best performers and the average is even more stark OBDs associated with 2+ emergency admissions per 1000 population aged 75+

17. If everyone had the same use of hospital beds for older people as the best performers, this would save over 6 million bed days a year OBDs associated with emergency admissions for people aged 65+ (millions) At £300 a day this would equal £2bn a year

18. Contribution of regulation in championing joined up care

19. CQC well placed to make strong contribution • Statutory Remit Covering ‘consumer protection’ (registration) and tackling ‘information asymmetry’ (assessments of quality) • Particular powers for inspection, data gathering, enforcement • ‘Whole system’ statutory remit – covering health, mental health, adult social care; commissioning & provision • Trust and credibility driven by independence from government and commercial relationships • Intelligent data analysis and risk assessment • Gathering in and responding to user voice • Local intelligence, insight & local relationship from field force • National influence, drawing on comparative view of quality & safety of care • User Groups & Regulated bodies • Other regulatory and oversight bodies (incl, Govt. Offices, SHAs, Monitor, AC, Ofsted, NPSA • Secretary of State & DH Privileged Assets Specific Competencies Special Relationships

20. CQC strategic priorities • ‘Championing joined-up care as one of 5 priorities – impact through: • Provider compliance • Provider assessments of quality • Holding councils & PCTs to account • Reviewing pathways of care

21. Assessing provider compliance with registration requirements • Outcome 6: Cooperating with other providers • When care & treatment of service users is shared with, or transferred to, others we will expect to see evidence of – • appropriate care planning through the cooperation of those relevant • appropriate information sharing, particularly around admission, • discharge and transfer, and coordination of emergency procedures • supporting individuals to access the right health & social care support • to meet their needs

22. Assessing councils and PCTs as commissioners • In 2010/11, we want to test some ideas for how we could look at health and social care commissioning together. These ideas include: • work with the Department of Health and others to develop the same measures on outcomes, to hold councils and PCTs to account for commissioning better joined-up care • joint service inspections of councils and PCTs on safeguarding and joined up care • work with other organisations to develop a joint outcomes framework for assessments of councils’ and PCTs’ performance • We also want to develop our work on assessing value for money which, in the current financial climate, is particularly important for organisations that provide and buy services.

23. alan.rosenbach@cqc.org.uk