Written evidence from the British Red Cross

About the British Red Cross

1.1         The British Red Cross is a volunteer-led humanitarian organisation that helps people in crisis, whoever and wherever they are, in the UK and around the world.

1.2         We have a humanitarian vision that everyone should get the support they need to live independently at home.

1.3         We provide short-term practical and emotional support to help people get through a crisis. Often that crisis is an admission to hospital. We support people to regain and to build their confidence and skills; increasing their resilience to future crises.

1.4         We operate around 100 ‘home from hospital services’ in the UK. Some of these services are based in Accident and Emergency departments, ensuring people return home safely; with working utilities, access to medication and food in the fridge. We support tens-of-thousands of people each year – the majority of whom are aged 65 and over – who have no clinical reason to be admitted to a ward.

1.5         Our other ‘home from hospital’ services work with clinicians to support safe and timely discharge from the wards. We support tens-of-thousands of people each year – the majority of whom are aged 65 and over – to return safely home. Once back at home, we provide support in the following weeks to help people identify and work toward their longer-term goals.

1.6         We also provide short-term wheelchair loans across the UK, often at the point of hospital discharge. There is no statutory duty to provide wheelchair loans. If you need use of a wheelchair for six-months or less, then in the majority of English areas the NHS will not provide you with one. We loaned close to 100,000 wheelchairs in 2015 and are the largest provider of short-term wheelchair loans.

1.7         Beyond our work in A&E, our fleet of 150 Red Cross ambulances supported over 100,000 people in 2015 to make other essential journeys such as getting to hospital appointments or physiotherapy.

1.8         The Red Cross has operated within the space between hospital and home for over a century. We worked collaboratively with Government during the development and implementation of the NHS. Our vast experience informs and shapes our thinking on health and social care. Working with politicians, policy-makers and the public we can improve the humanitarian situation of vulnerable people.

Submission

Context

2.1         The number of hospital beds has been declining for many years in England; over the past 26 years the number of available hospital beds has more than halved.[1] Further reductions are planned.[2]

2.2         The national policy agenda, including the NHS Five Year Forward View, is committed to “enabling a shift in investment from acute to primary and community services”.[3]

2.3         However, in recent years there has been an increase in the intensity with which beds are being used (measured by occupancy rates). Occupancy rates for acute beds have increased from 87.7 per cent in 2010/11 to 89.5 per cent in 2014/15.[4]

2.4         The National Audit Office has suggested hospitals with average bed occupancy levels above 85 per cent can expect to have regular bed shortages, periodic bed crises and increased numbers of health care-acquired infections.[5]

2.5         The latest delayed transfer of care figures show that in February 2016 32.2 per cent of delayed discharges were attributable to social care, with the main reason for the delays due to people waiting for care packages.[6]

2.6         A recent investigation by the Parliamentary and Health Service Ombudsman found patients are being discharged with no home-care plan in place or being kept in hospital due to poor coordination across services. This “can not only affect people’s health but also undermine their dignity and human rights”.[7] The Ombudsman findings resonate strongly with Red Cross operational experience.

2.7         Since 2010, the ADASS Budget Survey has tracked a total of £4.6 billion budget reductions for Adult Social Care. This is equivalent to 31 per cent of the 2010/11 net Adult Social Care budget. Adult Social Care savings for 2015/16 make up 30 per cent of the total council savings for 2015/16.[8]

2.8         Directors of Adult Social Services Departments report an increasing reliance upon prevention in making savings going forward[9], and prevention is their top area for savings for 2016/17 and beyond[10]. This includes supported discharge and reablement services. However, current council expenditure on prevention represents only 6.6 per cent of the budget and has fallen by 6 per cent in cash terms since 2014/15.[11]

2.9         The funding gap in social care is now estimated to reach between £2.8 billion and £3.5 billion by the end of this parliament.[12] This figure takes into account the Social Care Precept and the additional £1.5 billion allocated to the enhanced Better Care Fund by 2019/20. The latter will not be available until 2017 and is weighted toward the end of the parliamentary term.[13]

Services that support timely and safe discharge from acute wards achieve positive outcomes for older people[14]

3.1         British Red Cross research with 90 people who used our services and 58 stakeholders across five locations (in London, Yorkshire, Northern Ireland, Wales and Scotland). The main aim was to gain a better understanding of the difference made by the service for the people who use it.

3.2         Our findings showed that four people outcomes were significantly improved or increased following receipt of the service:

1. Improved wellbeing: We support people to feel in good spirits; we provide reassurance and alleviate worries.
2. Increased ability to manage daily activities: We support people to rebuild/regain their confidence and to get back on their feet again after a stay in hospital.
3. Increase in leisure activities: We support people to build their social confidence, as well as the physical confidence to go out and they have more things they enjoy doing with their time.
4. Improved coping skills: We support people to keep on top of things and make decisions on a range of issues they are dealing with and help to reduce the struggles people face.

3.3         Other positive changes were also reported related to the wider benefits of the service beyond the people outcomes:

5. Enabling safe discharge: We provide reassurance (to both people using the service and referrers) that they will be checked up on, and that there will be someone to turn to when they get home from hospital.
6. Supporting carers: We alleviate some of the stress, providing reassurance and giving valuable information on local sources of support.
7. Enabling individual advocacy: We support service users to get help and ensure their needs are met.

3.4         It is worth noting the proportion of research participants living alone ranged between 7 in 10 to 9 in 10, compared with 49 per cent in the UK population as a whole.[15] We also asked participants how much contact they have with family, friends and neighbours. Thirteen per cent had no contact at all with family (highest in London at 19 per cent), 21 per cent had no contact with friends (again highest in London at 29 per cent), and 22 per cent had no contact with neighbours.

Services that support timely and safe discharge from acute wards are cost-effective[16]

4.1         Building on the above findings, the LSE explored cost savings for two of the people outcomes – improved wellbeing and increased ability to carry out daily activities. Cost savings were identified related to a reduced need for formal/informal care and general help around the home, a reduced risk of falls and malnutrition associated with unmet care needs, and, to a lesser degree, a reduced need for treatment of depressive symptoms.

4.2         The total savings identified amounted to more than five times the cost of the service. The average cost of the intervention was £169 per person and the identified savings came to £880 per person (based on the services and sample data in the evaluation).[17]

4.3         It is worth noting that many of the benefits of ‘home from hospital’ services, and similar interventions, are likely to be quality of life benefits which could not be quantified for the purposes of this economic modelling.

Short-term wheelchair loans can support timely discharge, and have a preventative value. There are cost savings associated with this.[18]

5.1         Short-term wheelchair loans are an enabler of recovery, choice, control, independence and wellbeing.

5.2         Short-term wheelchair loans are valued by the people who use them, their carers, and healthcare professionals alike.

5.3         Our economic evaluation revealed overall health and social care savings ranging from £469 to £4,607 across the case studies, with an average saving of £1,676. As such, the findings clearly quantify the preventative value of short-term wheelchair loans with cost savings evidenced across both health and social care.

5.4         We loaned almost 100,000 wheelchairs in the UK last year, but we are confident there remains an unmet humanitarian need for short-term wheelchair loans – not least in London, where we do not currently operate a loan service.

Local authorities have made progress implementing the Care Act 2014 prevention duties, but the ambition of the legislation is yet to be realised[19]

6.1         More than 80 per cent of local authorities have developed or are in the process of developing a local approach to prevention. However, there is still a severe lack of understanding, innovation and development in this area.

6.2         A majority of local authorities have sought to review and revise structures, processes and guidance, but these changes are not necessarily translating into enhanced provision of services or improved outcomes – either for people or for statutory agencies.

6.3         Local authorities identify funding as a key barrier to ensuring preventative services, including supported discharge and reablement services, are made available in their area. Our findings resonate with those of ADASS, identified in paragraph 2.7 above.

Conclusion and Recommendations

7.1         The “division between different aspects of health care…can not only affect people’s health but undermine their dignity and human rights”.[20]

7.2         There is a humanitarian imperative to ensure older people are discharged from acute wards in a safe, supported and timely way.

7.3         Supported discharge services (which the Red Cross terms ‘home from hospital’ services) are an essential response to the division between different aspects of health and social care. They are cost-effective and achieve positive outcomes for older people and their carers. The Red Cross is by no means the only provider of these services – we believe the voluntary sector is both well-placed and proven[21] to bridge the divide.

7.4         Ultimately, there needs to be an expedited shift toward a community-based and preventative system. A feasible mechanism is available to support this:

We recommend frontloading the enhanced Better Care Fund to 2016 (rather than weighting it toward the end of the parliamentary term, as is currently planned) and focusing these funds on responding to the “division between the different aspects of healthcare” identified by the Ombudsman. This would enable local health and social care economies to invest in cost-effective services that ensure older people are discharged from hospital in a timely, safe and supported way – preserving dignity and rights.

23 May 2016