Social care in the last year of life

With an increasingly elderly, frail and co-morbid population, the need to coordinate health and social care is becoming more and more apparent. One could argue that integrating health and social care is the big issue facing the NHS and our care services.

The Atlas of Variation in social care published earlier this year, examined the quality of social care services in England. Like our Atlas of Kidney Care and the other health care atlases, it showed high variation in access, uptake, costs and quality – a postcode lottery. The social care atlas mapped its data to the Adult Social Care Outcomes Framework:

-         Enhancing  the quality of life of people with care and support needs;

-         Delaying and reducing the need for care and support;

-         Ensuring people have a positive experience of care and support;

-         Safeguarding adults whose circumstances make them vulnerable and protecting from avoidable harms.

A large read across to the NHS Outcomes Framework don’t you think? Any reasonably minded person can see the link between the various outcome frameworks from Public Health, NHS Outcomes, by which the Secretary of State for Health will hold the NHS Commissioning Board to account, the Commissioning Outcomes Framework to help deliver on those health aspirations and the Social Care Outcomes Framework. If they were all playing in concert, it would sound more like Schönberg than Mozart would. The staff in the various sectors are not working together yet, and we do not routinely join up information. Good health care leads to recovery and return to normal living. Poor health outcomes have their consequences in the lives of families of those affected, in the metrics of the Department of Work and Pensions, along with the social care needs of the individuals.

When it comes to the last years of life, social care needs are clearly as relevant as health care intervention. In conservative kidney care it really is not about the kidney, it is about the individual their experience, their family, carers and friends.

An atlas of variations in social care: an analysis of the quality of social care services in England, June 2012. MNP Health Mandate

What role should social care play to support someone at the end of life to die in his or her own home? In addition, how can health and social care services work together to make this choice a reality?

A thoughtful and groundbreaking study published by the Nuffield Trust adds significant weight to the argument that with the right support people could die at home, as they wish.

The report vastly improves our understanding of the costs of caring for people at the end of life and encourages a debate on what role integrated, coordinated care can play in keeping people at home in their last days.

“Our ageing population and over stretched health service means that the NHS will not be able to meet the rising costs of people being admitted to hospital unnecessarily at the end of life.”    Ciaran Devine CEO at Macmillan Cancer Support and Non-executive member of the NHS Commissioning Board

You will not be surprised to learn that understanding patterns of health and social care at the end of life also, reveals the large variations in access, uptake and costs.

 Understanding Patterns of Health and Social Care at the end of life, October 2012. Nuffield Trust 

The Nuffield Trust work shows that the cost of caring for someone in hospital increases sharply in the final few months of life- especially for emergency care. The costs can be as much as £90,000 per person. Social care costs, however, are more predictable and constant and home care is on average considerably cheaper than hospital care. Note the different scales on the vertical axis comparing the hospital and social care costs in figure 4.4 from the report above.

Care for people at the end of life needs to improve as a matter of urgency. This Nuffield  report chimes with what I have heard from kidney, primary care and social care professionals, about how it is often help with small things, can make a big difference fro patients and families, and is crucial to keeping people out of hospital at the very end of life. We should seize the opportunity of the current flux, we find ourselves in health, the financial challenges our Local Authority, and Health and Wellbeing boards are under to make step change  improvements in end of life care and deliver on the NICE QualityStandards.