Response from the Coalition for Quality in Care to the ‘Shaping the Future of Care Together’ consultation

Organisation Members Age Care Age Concern and Help the Aged Alzheimers Society Anchor Trust Association of Charity Officers Beth Johnson Foundation Brendoncare Foundation British Geriatrics Society Change Agents Counsel and Care Elizabeth Finn Homes Ltd Heart of England Housing Group Ltd HICA Group IndependentAge Jewish Care Leaders of Worship & Preachers Homes (LWP Homes) Lester Aldridge Solicitors National Care Forum National Housing Federation NHFA Care Fees Advice Open University, School of Health and Social Welfare Relatives & Residents Association Ridouts Royal British Legion Salvation Army Social Services Sheffield Institute for Studies on Ageing (SISA) Vegetarian for Life Westminster Homecare Limited Independent Members Ms Rosemary Hurtley - Independent Member Kina, Lady Avebury - Independent Member Ms Judy Downey - Independent Member Mr Neil Selby - Independent Member

Introduction to the Coalition for Quality in Care

The Coalition for Quality in Care (the Coalition) consists of 32 organisations and individuals who share a common concern in promoting the well being of older people receiving long term care in a wide range of settings and differing circumstances.

The aim of the Coalition is to maintain and increase professional, political and public awareness of the needs, rights and aspirations of all older people, including those most vulnerable through mental or physical infirmity. It seeks to do this through the promotion of good practice and vigilance in the face of pressures from many quarters to compromise on important basic ingredients which guarantee good quality care, such as realistic funding, an effective regulatory framework, and investment in training, practice development and quality improvement so that older people’s human rights can become a reality not just an aspiration.

The unique characteristic of the Coalition is that it provides a voice and a forum for people from all sectors, the independent, voluntary and statutory providers as well as academics, health and policy analysts and relevant Royal Colleges and other professional institutions, and most importantly older people for themselves.

This is a consensual response rather than one of total agreement.

The Coalition’s response

The Coalition welcomes the debate regarding the future of care and supports the need for change. We agree that any new system needs to demonstrate fairness and affordability. Therefore the proposal for universal entitlements is the one which we endorse and with which we agree.

Apart from this key endorsement, the Coalition has decided to focus its response to this consultation around the older person and quality. It is the Coalition’s opinion that the proposals do not adequately address quality in relation to service provision or the experience of the person using the service. Improving quality would be an effective investment and effective use of taxpayers’ money. Quality must be evidenced in the way older people are treated in society and by the services and staff they come into contact with as their needs change. Staff working in health and social care are essential to the delivery of quality services for older people. They must have the necessary knowledge, training and skills, as well as the right attitude to deliver services that respond to each individual’s assessed need.

The proposals as presented in the consultation appear to have diminished the notion of choice and control in relation to the personalisation agenda.

The concept of integrated working between health and social care and other agencies is once more to be welcomed. However the reality of making this work from an older person’s perspective appears to be a long way off, especially since the single assessment process has now been in place for some significant time and yet older people still report having to repeat information to a number of different professionals who do not in their opinion appear to talk to each other. The examples cited in the consultation document are to be commended. However, making these mainstream appears to be a long way off and this is not adequately recognised in the proposals.

Whilst quality is mentioned in the consultation, the references made saying 'high quality' and 'good quality' appear to lack reality without any reference to cost. It is the Coalition’s belief that quality and cost are intrinsically linked. The Green Paper appears to be somewhat casual in relation to financial estimates and modelling, as well as in its presentation of evidence and costings. Quality must be linked to what the evidence shows and what older people say is important to them, what relatives want to experience in their guardian and advocacy roles, and what staff need to deliver these things as well as to service delivery, workforce and regulatory realities. The Green Paper not only fails to reflect what the general public has stated was important to them - clearly expressed during the consultation process - nor does it chime with the reality of current social care provision and the extent of the required transformation needed.

Whilst the Coalition supports the personalisation agenda, it would be naive to think that the need for residential care will diminish. The Coalition is, therefore, not impressed by the suggestion on page 19 of the document that older people as part of their accommodation costs in a care home setting may additionally be charged for food. Why has this logic been examined and rejected over the years in relation to NHS ‘board and lodging’? Does this really correlate with what older people and those who speak on their behalf are saying is important to them? The implications of this proposal show little understanding of the needs of older people using care services, what the staff need to deliver these, nor the commensurate commissioning responsibilities. Furthermore with personalisation residents need to be empowered to influence and shape services eg. ensuring the workforce is equipped for purpose and individual needs.

In recent years there has been significant media attention in relation to health and social care and the nutritional needs of older people not having been adequately met. Concern about food/nutrition and meal times have been high on the agenda in relation to dignity campaigns.

In the autumn of this year, the ‘Hungry to be Heard - nutritional action plan’ should be published by the Department of Health. The Caroline Walker Trust has also produced several practical nutritional guidelines. In the current National Minimum Standards for Older People, it is one of the 38 standards. It is also a key feature of the NHS Framework for Older People. Nutritious food is an integral component of care and is essential both in prevention and in promoting recovery. To ignore it as an intrinsic component of the care package would be a great disservice to older people. It is known that older people experience deterioration in both taste and smell. Many care home providers have made significant strides forward to improve the dining experience of the people who use services; this includes the quality of the food that is served and the frequency of its availability. Examples of spend on actual food (not including staff time or utility costs) from within the Coalition range from £21.00 - £31.00 per resident per week.

The current fees paid by local authorities vary significantly and do not in the main correlate with the real costs of providing a quality service reflected in contracts itemising the proportionate amounts of the fee that will be allocated to particular aspects of their life in the home so that audits can demonstrate with evidence to the user of services what their money is spent on e.g. direct care, practice development and staff training, quality assurance activity, advocacy services, ‘hotel services’, management, professional leadership, equipment and resources, maintenance etc. For example fees paid by the local authority in Cornwall range from £337 -£375 per week which is not nearly sufficient to fund quality care. Good providers will invest in staff development, will pay above the minimum wage, will ensure that there is effective leadership and will invest and re-invest in a wide range of services available for the benefit of people using care.

Conclusion

In conclusion, the Coalition supports the need for change but not change at any cost and based upon incomplete and seemingly inadequate information. In Chapter 4 the Green Paper states that 'an important part of improving quality is knowing which services will be most effective'. The recent and repeated trend to continually introduce new initiatives but not sustain them cannot be cost effective and has a demoralising effect on the sector. The basis of many aspects of current service provision is sound.

The Coalition has further questions which it believes need further consideration and answers:

• How do the proposals assure the public that what is paid for a service in the future, be it in a care home or at home, actually guarantees a quality service in the future?
• The green paper appears to be vague on how care, health and other services will achieve integration for the benefit of the person needing care and how financial savings achieved from more joined up working will benefit the person using the service? Will it give the person confidence and an assurance of quality?
• The proposals appear to suggest that universal entitlement equates with a ‘basic’ level of care. If this is the case, what will the person see for their additional personal contribution? As consumers they will want to know what they are getting for their money and, therefore, precisely what will be delivered and what will it look like?

The Coalition restates its support of the need for change but considers that the current proposals are less than specific in relation to quality and seem unaware of the reality of the individual experiences of those in receipt of or needing the service. Consideration must, in the opinion of the Coalition, also be given to the people using the service now and not just future service users. The paper is also unclear about transitional arrangements. The systems should support people to deliver high quality cost effective services. There is little in the proposals that suggest that this will be achieved.