Hospitals: Voluntary Sector and Emergency Readmissions

Baroness Scott of Needham Market Excerpts

Monday 1st December 2014 Grand Committee

Asked by

[Baroness Scott of Needham Market]

To ask Her Majesty’s Government what assessment they have made of the role of the voluntary sector in reducing emergency re-admissions to hospital.

[Baroness Scott of Needham Market (LD)]

My Lords, it is about a year since I first tabled this Question for Short Debate. I was inspired to do so by reports from the Royal Voluntary Service which described the impact of its Home from Hospital schemes. I regret that, having waited all this time, the Motion was in the end tabled at very short notice, which prevented many Members who would have liked to participate doing so. Given that it appeared on the Order Paper only on Wednesday and that the speakers list was closed on Friday, that comes as no surprise. I am particularly grateful to both Front Benchers and my noble friend Lady Thomas, who will speak in the gap. For the record, I give an assurance that the modest speakers list does not reflect the level of interest in this matter.

I am not one of the usual contributors to debate on health matters, so I thought long and hard before venturing into this area, but I do know about the voluntary sector, and here I declare an interest as chair of the National Volunteering Forum, and it occurred to me that I should table the Motion precisely because I do not come at this from a health expert’s perspective. We have all agreed that the time for silos is over.

It seems a long time ago now, but in 2010, the Secretary of State for Health took measures to manage emergency readmissions, which had risen, in part at least, because hospitals were reducing the length of stay. Despite this, about 19% of emergency readmissions—about 190,000—occurred in 2012-13. The evidence shows that people from lower socio-economic and vulnerable persons groups are at a higher risk of avoidable emergency readmission.

The Government and the NHS have made a good start on getting to grips with this problem by creating individualised discharge plans and ensuring that hospital-led discharge teams provide continuity of care. Of course, the better the integration of primary, secondary and social care, the better the contribution by prevention, early diagnosis and self-treatment. However, as Simon Stevens noted in the NHS Five Year Forward View,

“voluntary organisations often have an impact well beyond what statutory services alone can achieve”.

Last week’s report on patient-centred care from the Royal College of General Practitioners makes specific reference to the role played by community groups and the voluntary sector in achieving self-management of health conditions. Also last week, the NHS published Stephen Bubbs’s report into the commissioning framework for people with learning disabilities and autism, in which he, too, notes the role played by the voluntary sector in the sort of community-based support which reduces both initial admissions and readmissions. It is an area that I am beginning to know well as a fairly new patron of ACE Anglia, which provides just that kind of advocacy and support to people with learning disabilities and autism living in my area. Of course, they are all right. Voluntary organisations can help with early intervention by spotting problems early on and by helping to join up fragmented services. They often bring specialised and local knowledge and, precisely because they are not from the statutory sector, they tend to be trusted.

Provision of hospital-to-home services in a range of contexts can often give patients the time and space they need to make a recovery and avoid readmission to hospital, with all the trauma that that entails. The British Red Cross gave an example of Mrs Jones, a widow in her mid-80s suffering from dementia. Discharged from hospital but needing treatment for a urinary tract infection, staff referred her to the BRC, which arranged for a volunteer to meet her in hospital and then visit her at home to make sure that she completed her course of medication. It ensured that the social services team was aware of her needs, and that she felt supported. She not only recovered well at home but, because of the ongoing support and encouragement she received, her quality of life actually improved on a long-term basis.

AGE UK Cornwall carried out a pilot scheme where volunteers worked closely with patients to identify their needs and offer support. It acted as a key link with the NHS and social services. Under that scheme, emergency readmissions were reduced by 25%. The Midhurst Macmillan Service is a specialist palliative care service covering a 400 square mile area of rural England across three counties. By offering a host of roles from shopping and gardening to emotional support for the patient and their family and liaison with the NHS, the scheme is aimed at reducing the number of hospital admissions. Although they are not strictly emergency readmissions, nevertheless, its work is very successful: 73% of its patients died at home or in a hospice rather than having to be admitted to hospital.

In its recent report, Going Home Alone, the Royal Voluntary Service highlighted its own scheme in Leicestershire which showed that a package of support reduced emergency readmissions by half, from 15% being readmitted in 60 days to 7.5%. It was not rocket science. Contact was made with patients before they left hospital, and someone went home with them and made sure that the house was warm and lit, and that some food was available. They offered support to collect prescriptions, make follow-on medical appointments and liaise with the statutory services. Many of these actions are so simple, but make so much difference. However, like many simple things, they are not always easy.

Like most other services, voluntary organisations have had to deal with funding cuts. In many cases, when they wish to bid to provide services, they are disadvantaged against the private sector because they want to provide decent terms and conditions for their staff and are not going to go down the zero-hours contract route. In some cases, these organisations simply lack the capacity to engage in complex and expensive tendering processes.

The reorganisation of health and social care at a local level has meant that new relationships between the sector and the commissioners have had to be developed. Some health and social care providers are simply not aware of the range and extent of the work of the voluntary sector in their area and so patients miss out on the support they can offer. Then there is the vexed question of substitution. Volunteers do not want simply to replace public services which have been cut, but want to add value.

What we are now calling austerity looks likely to be the new norm. It is hard to take that on board, but we should be planning for it. Government spending should be much less reactive and give some priority to preventive spending, which involves a genuine forward look at the likely impacts of spending decisions made now on outcomes in a decade hence. Policy and funding changes which push costs off into the future are no different from borrowing, and the sooner we understand that, the better.

I am looking forward to hearing from other Members about how we can better harness the collective strengths of the statutory services and the voluntary sector. The old dividing lines have become blurred and the picture has become more complex as a result, but the need has never been greater.

Social Care

Baroness Scott of Needham Market Excerpts

Thursday 29th November 2012 Lords Chamber

[Baroness Scott of Needham Market]

My Lords, I thank the noble Baroness, Lady Pitkeathley, for securing today’s debate. Like the right reverend Prelate, I am not one of the usual suspects; I rather share his nervousness about stepping into this. However, as the chair of the England Volunteering Development Council, I want to speak today to talk a little about the role of volunteers and the voluntary sector as they relate to social care.

Of course, people are living longer across all age groups, with much more complex needs, and there is a rightful expectation that they will be cared for. The noble Baroness, Lady Campbell, was quite right to set this in a human rights context. The strain of trying to provide social care and the scale and cost of this provision have been well highlighted in the briefings from the LGA and the NHS. It still begs a response from the Government. While I accept that Dilnot is not the answer to everything, it still represents the best that I have seen in many years. Therefore, I am also looking forward to hearing what the Government might say. I was very taken by the comments of my noble friend Lord Sutherland about the worry and stress on individuals who are concerned about what may face them as they get older.

In medical terms, this is not a crisis but a chronic condition. The situation has been getting worse for many years, as my noble friend Lady Gardner points out; it did not start in May 2010, nor will it end at the end of this Parliament. We therefore have to look at more long-term sustainable solutions, of which I would argue the voluntary sector is a part. That is particularly the case with the growing concern about the quality of care and the isolation and vulnerability of people, either in private care settings, as we heard in the Southern Cross case, in their own homes or even in hospitals, as we saw in the recent reports from the Patients Association and the CQC.

Set against this, there is an important role for volunteers to play in the care of vulnerable people as befrienders and advocates, and in complementing much of the work of the statutory services. I was pleased that my noble friend Lord Shipley made the point that older people are also of huge benefit to society. We must not always couch the “aging population” debate in negative terms.

The genuine integration of social care cannot happen unless there is a real community dimension to it, and that means using volunteers. For example, we need to have a proper look at how care homes can be opened up to the community, with more volunteers going in to offer personalised support, friendship and advocacy, and helping to generate a better quality-of-life experience. No regulator can be on hand all the time, nor can they see everything. Indeed, in my experience, regulators operating within statutory frameworks, subject to legal challenge and so on, often focus on systems and fail to be centred on individuals. As a complement to the work of regulators, volunteers can be around to see that individuals’ interests are foremost.

Volunteers can add enough support to enable someone to stay at home instead of in hospital. It is a much more humane as well as cost-effective approach, a point made well by my noble friend Lady Barker. Indeed, having someone around a little more of the time who can spot problems in earlier stages can reduce the need for later acute visits and hospitalisation. There are some very good case studies in the briefing from the WRVS.

I noted with interest last week the PM’s announcement on dementia, which came the week after an announcement that prisoners on release would be provided with one-to-one support. Both of these initiatives will rely on volunteers to deliver them. I make two points to the Government on this. First, the enthusiasm for volunteering that we saw during the Olympics had a lot to do with involvement in an iconic, one-off event. It is a different proposition to go from that one-off commitment to a weekly commitment to one individual who can have very difficult needs. Secondly, volunteering is not free. The Government have to put money in to recruit volunteers, to sort out the ones who are suitable and to train and organise them. The great lesson that we should learn from the Olympic volunteering programme is that it worked because the money went it to make sure that it worked.

Moving from individual volunteers to voluntary organisations, a piece of work needs to be done, on which I am sure that Volunteering England would be happy to work with the Government, on the placement of volunteers in care homes. I recognise that placing volunteers in a commercial operation is a controversial proposition. We probably need to do some work to develop protocols for that, as I know that Volunteering England already has with the rather tricky question of job substitution.

It is just over 20 years since I went into local government. At the start we always just talked about inputs; it was about how much we were spending. Then we started thinking about the outputs, and then finally we started talking about outcomes. Voluntary organisations by their nature are focused on outcomes; it is what they do. The conundrum now is that, with tight budgets, the focus on outcomes runs the risk of becoming lost. For example, a local charity or social enterprise that uses ex-offenders to deliver a lunch club to older people has multiple benefits, but they are quite hard to monetise. Outcome-based procurement requires commissioners to be much less prescriptive about how something is delivered and just to empower providers to deliver it. Commissioners often look down their noses at these soft outcomes—“Give us hard facts”, they say—but there is nothing soft or woolly about measuring the internal changes that service users experience.

There is a problem with commissioning. Public authorities are not good at seeing the added value that comes, for example, from giving contracts to organisations that use small local suppliers or those that employ long-term unemployed or people with mental health problems. Among local authorities and health authorities, procurement is the sort of area where cutbacks have resulted in fewer staff. They tend to take the rather easy route of offering single, larger contracts that are much less likely to deliver added value. Small to medium voluntary sector organisations and social enterprises do not always have the capacity to join in a lengthy bidding process. Even larger ones like CABs and volunteer centres are having their core funding cut. If you do not have core funding, you do not have an organisation to make robust bids. The social value Bill has been designed to get at some of this, but help is still needed to learn how to value certain things and to assist smaller organisations in the procurement jungle.

We should not still be having this debate; we have been talking about it for years. Therefore, will the Minister say something about how the new commissioning arrangements will work in this regard, and how he sees the voluntary sector interfacing with the health and well-being boards? I genuinely believe that the voluntary, community and social enterprise sectors have a fundamental role to play in securing and facilitating this community involvement and genuine integration of health and social care. However, it needs the Government to think carefully about their policies in a whole range of areas.