Written evidence submitted by Age UK
Age UK is the country's largest charity dedicated to helping everyone make the most of later life. The Age UK network comprises of around 150 local Age UKs reaching most of England. Each year we provide Information and Advice to around 5 million people through web based and written materials and individual enquiries by telephone, letters, emails and face to face sessions. We work closely with Age Cymru, Age NI and Age Scotland. Local Age UKs are active in supporting and advising older people and their families in the care market.
Age UK Welcomes the Public Account’s Committee’s decision to take a closer look at how Integrated Care Systems are developing, and whether these new structures are on track to meet their objectives.
Age UK routinely gathers insight and data on the experiences of older people, most of whom have regular contact with NHS services, local authorities and our network partners. Many have care and support needs that are either met by formally commissioned services or informally by family, friends or neighbours. We have drawn on some of that insight in responding to this call for evidence. We have also reflected the experiences and challenges that our network partners – local Age UKs – have shared with us. We know that that they have had varying degrees of success in understanding and working with these multi-layered and diverse new structures.
Our population is ageing and over the next 25 years it is predicted that there will be 2.6 million older people living in England. The prevalence of both multiple conditions rising with age and ADL limitations rises significantly with age. Two-thirds of people aged 65-84 have one or more long term condition, and a further 13% struggle with at least one activity of daily living (ADL). By the age of 85 more than two fifths of people report ADL limitations and around 9 in 10 live with one or more long term condition.
People living with long term conditions account for 50% of all GP appointments, 70% of bed days and 70% of the total health care spend in England. Poor management, and difficulties accessing appropriate social care support in the home also increases demands on urgent and acute care with people living with 4 or more conditions 14 times as likely to have unplanned, preventable admissions.
Supporting people living with long term conditions and/or frailty to the end of their life already represents the most significant responsibility of the NHS and social care system, and the new integrated care systems will need to plan services carefully to meet this growing need in the context of workforce and funding pressures. This will only succeed in our view if they do so in genuine partnership with providers and VCSE.
The principle of integration
We are broadly supportive of the principle of ‘bringing together the NHS and local government to jointly deliver for local communities’. Systems and services often struggle to manage the needs of people living with frailty, multiple long-term conditions and/or complex needs; and older people and their families frequently tell us about the challenge posed by disjointed, fragmented care and the harm it can cause to their health and independence.
Our research over the last two years has revealed the extent to which older people struggled during the pandemic. We have tracked the deterioration in their physical and mental health and the decline in cognitive function of those with diagnosed and undiagnosed dementia, and the impact of these problems accessing support on their carers. We have also analysed the challenges they have experienced in accessing the treatment, care and support they have needed.
We’ve have seen how the many of those struggles continue, exacerbated by unprecedented workforce shortages across health and social care, difficulties accessing primary care, and a lack of funding for local government and NHS commissioners. We now face an energy and cost of living crisis, and the prospect of further public spending cuts. These difficulties are threatening provider stability, while rapid changes in Government policy are calling into question the future of the package of social care reforms announced only last year.
However, while these conditions don’t make reform of the way we deliver health and care an easy task, they also mean that making the very best use of the limited resource that we have could not be more urgent. Meaningful partnership work to shape and align strategies across ICB, ICP, Place and Neighbourhood is needed now more than ever.
Ageing well and older people
Improving care for older people, and supporting people to age well, is, in our view, an obvious priority area for all ICSs. Without a strong focus on healthy ageing, keeping people independent for longer and reducing the number of years people spend in ill health, the needs of a growing older population could overwhelm systems.
Integration also presents an opportunity to change how we do things, both in respect of social care, and how this is commissioned and delivered, and in how we support people to stay independent for longer through community-based care and support.
It is widely recognised that the clinical acuity of older people accessing social care has risen substantially. Our services and systems have not however evolved to meet the needs of older people who draw on health and care services in 2022. All too often, older people with hugely complex medical conditions are being cared for primarily through social care services and in settings with limited, if any, clinical oversight, or support, and as they become frailer and their health deteriorates, they have frequent distressing (and costly) interactions with the acute sector.
Some foundation trusts are grasping the nettle however and announcing plans to establish themselves as care providers, others are taking much more collaborative approaches together with local authorities by investing in community services, and developing new pathways to help tackle issues with hospital flow – such approaches are likely to be essential as we head into what is widely expected to be a very challenging winter, and are already making a difference in some areas, other systems are not being so bold. ICSs are in their infancy, but the opportunity to think radically about how we might want to deliver better care and support for our older populations has not yet been seized by many systems – we have the structures now, we need to focus less on governance and more on solutions. ICSs must also ensure that money flows readily from ICBs to Places to deliver community-based, preventative and rehabilitative services to meet the needs of local populations.
CCGs and local authorities have already been working together with a pooled budget to deliver localised initiatives through the Better Care Fund. It is hoped that where evidence shows positive progress for populations and individuals, this work will continue and where appropriate be scaled up, with ICBs delivering the requisite financial support. There is a concern that where relationships have not yet been built – and our local partners tell us that in some areas they have not - opportunities will be missed.
Finding time and space to build relationships and align objectives, while also grappling with budgetary constraints and resource pressures is a difficult ask. Local government can also be particularly risk averse. Equally, ICBs, ICPs and Place-Based Boards are not yet in lockstep. Differing political priorities between local authority leaders within ICS footprints will inevitably create more complexity, and board members who are chiefly remunerated for their role at Place (for example local authority CEOs, or NHS trust leaders) may at times find themselves conflicted.
CQC quality assurance processes will need to be effective at monitoring the quality of leadership, whilst not creating unnecessary burdens – a difficult balancing act - and must ensure that systems are working with providers and VCSE as strategic partners.
The need for greater focus on prevention and community care
Current pressures in A&E and the electives backlog will not be addressed without upstream prevention, but the need for central Government to make more money available to systems, local authorities, and providers to both carry out prevention work and tackle recruitment and retention issues in the workforce is inescapable. We support the recent recommendations of the Health and Social Care Select Committee on workforce. Public health funding constraints are also a problem at both systems and Place.
Maintaining health protection capacity, (and restoring it where it has been lost) is important too, if we are to safeguard against unmanageable pressures in primary, acute and social care due to new outbreaks of Covid, flu or, indeed, future pandemics. Older people living with multiple long-term condition have lower resilience to disease and, as we have seen over the last two years, are more likely to require hospitalisation if they do become sick.
The elective care backlog is just the tip of the iceberg, and long waiting times at A&E are a symptom of a system that has reached breaking point. There are now high levels of unmet need manifesting across primary and community care, in social care and mental health.
Recent Age UK data analysis paints a grim picture of unmet need for care and support in the 50+ population in England. It found that:
With insufficient social care capacity to support older people in the community post-discharge, they remain patients in hospital for longer than clinically necessary. This challenges not only the health and care system, with beds not available for new patients, but also damages the older person’s health and recovery.
At the same time, it is clear that many older people have experience a deterioration in their overall mental and physical health, and are finding it harder to manage their health conditions. Recent Age UK research, amongst those aged over 60 has found that:
Overwhelmingly older people have told us that they wanted improved access to GP and community-based services – including mental health services – to help manage their conditions, as well as better holistic support in the community and much more help for informal carers to manage their responsibilities.
Allowing flexibility for ICSs, Places and Neighbourhoods to develop an offering that is best able to respond to those differing levels of need is important. However some trends, and therefore service requirements, are universal. Collectively reducing the risk of unplanned, urgent or chaotic care by spotting and responding quickly to changes in an individual’s condition or circumstances, and putting plans in place to manage, for example, a flare up of their condition or if their carer should become unwell, should be priorities for all integrated care systems.
Every ICS will see an increase in the numbers of people ageing with more complex health and care needs over the next decade. Individuals and communities in areas of greater disadvantage may age more quickly, but they age nonetheless. As a result managing frailty, multiple conditions and cognitive decline will need to be priorities for all integrated care systems, and we were pleased to see the belated addition of palliative care services to the statutory guidance for ICBs.
Population-wide interventions to promote wellbeing or prevent disease or ill-health can be particularly effective for older people, wherever they live. For example, promotion and provision of interventions that support and encourage appropriate and inclusive physically activity can improve health and resilience at a population level, as well as preventing falls amongst older people. NHS health checks and screening act as effective detection of health conditions, as well as opportunities to have conversations with patients about developing and maintaining a healthy lifestyle for healthy ageing.
What does good look like?
Good strategic partnership working between ICSs and the VCSE will help to ensure that systems benefit from the insight and expertise of the sector. Where this is working well there is a clear route to enable organisations to advocate on behalf of their populations and communities, and to engage in delivery challenges. Mature systems have invested time and resources into VCSE forums and platforms that enable the sector to come together and take on a strategic leadership role. ‘Third Sector Together’ in Northwest London is one such example.
There are other examples of good practice engaging the VCSE in the design, development, and delivery of key services. Age UK Bradford is working with their ICS to develop personal support navigator roles, focusing co-producing plans that matter to the individual who would be drawing on those services. In Bristol, a ‘One City’ approach has brought together three ICPs.
In Rotherham, Age UK’s CEO, Lesley Dabell has taken a Non-Executive Director’s position on the ICB where it is hoped she will be able to use her expertise to contribute to the development of improvements to health and care services in her area.
And not all interventions are costly - small projects can have a big impact. Age UK Bedfordshire’s Hotbox scheme worked well last year to keep older people warm in the colder winter months. The commissioning of frailty specialist practice nurses through the BCF in Gateshead has resulted in a service linked with community geriatricians, occupational therapists and physio. Scaling up such schemes across ICS footprints make sense. We hope that this type of good practice and innovation will transfer to the new, larger structures without the sort of operational or contractual disruption or delay that too often sees services lost.
What needs to improve?
We know that there is a lot of variation in ICS development and that partnerships with VCSE organisations are progressing at different paces and in different places within each system. We sought feedback from local Age UKs within our network on their level of engagement with their local ICSs.
The interventions offered by local Age UKs can help reconnect older people to their communities and help them manage some of the challenges of ageing - such as loneliness, isolation, restricted income as well as variations in physical and mental health – before they reach crisis point.
Several local Age UKs told us about increasing willingness of people working within ICSs to engage with VCSE organisations, but that short-term approaches to funding services were incredibly difficult to manage. In year, non-recurrent funding for services, such as those supporting hospital discharge, makes it very difficult for organisations to plan services, recruit, develop and retain staff. One Age UK felt that older people were not seen as a priority by their local ICB, with issues affecting older people spread out over several workstreams, rather than being seen as a whole.
Some Age UKs felt that there was a lack of clarity over leadership and accountability, others didn’t know where to start in creating partnerships. The perceived lack of understanding within ICSs about what VCSE organisations can deliver was a common frustration. Some felt that there is a misconception about the level of volunteer resource within the sector as a whole; using volunteers seems like a cheap and easy answer to providing more support to older people. Others felt frustrated by an overall failure to comprehend challenges facing the VCSE particularly in recruiting, training, supporting and retaining volunteers or the precarious financial position of many in the sector as cost pressures increase.
Strategy development is well underway in most systems, with ICPs set to publish their strategy by the end of the year. Yet many of our local Age UKs tell us that they still don’t know who to speak to in their area, and many services that could be delivered across an ICS footprint continue to be commissioned at Place, with no clear plan for scaling up. In some areas it could be said that ICPs are failing to involve people and organisations in the strategy, and there is a risk that the opportunity to iron out inconsistencies in the service offer for older people within ICS footprints, share good practice, and improve health and wellbeing outcomes will be lost. In other areas a strategic commitment to partnership at system level is there, but this is failing to translate to work on the ground.
While Place, and even Neighbourhood, should be able to drive priorities for their populations, all systems will recognise the challenge of meeting the needs of older people; all ICSs will see their budgets impacted by the need to support and care for people living with frailty and multiple long-term conditions. And as we head into what is widely anticipated to be one of the most difficult winters on record, the need to focus on keeping older people well in their own homes has never been greater.
NHS and local authority leaders have key roles in Integrated Care Systems, but they must be clearer about their structures and should not be developing strategies without partner involvement. Reforming out of hospital care is an obvious area of development, and one where local Age UKs are ideally placed to deliver. However, there is currently insufficient evidence of close partnership working across all systems.
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