Archive for Matron Mary’s Blog

Has the Better Care Fund worked ?

Monday, December 15th, 2014

Has the Better Care Fund worked ?

Well intentioned but needs equality in social care funding as well as a ‘bureaucratic enema”

Yes :

  • A catalyst for a national and local conversation around integrated services from health and social care.
  • The requirement that plans are signed off by health and wellbeing boards has created a shared understanding of the challenges of delivering integrated services
  • The size of the fund was meaningful: it represented just 3 per cent of the NHS budget but around 20 per cent of the social care budget.
  • The opportunity to share best practice and learning has helped some areas move forward. There was a start to local problems being jointly owned.
  • It led to a picture of how commissioning intentions impacted on the whole system and included providers in the conversation.

No :

  • The heavy bureaucracy and mixed messages from the Department for Communities and Local Government, the Department of Health and NHS England belied the goal of more integrated working between health and social care.
  • The judgment of the better care fund is by some about finance, when those and other benefits will not have been realisable at this point,
  • The national process to date has arguably been frequently perceived to be about creating a plan and filling in the forms correctly, not necessarily delivery.
  • There are many in local government who see themselves as victims of a process, when they were intended to be beneficiaries.
  • The requirements of the process were too generic to be sufficiently flexible to the nuances in different localities.
  • The fundamental flaw in the analysis is the belief that a single policy around funding can fix the problem, or that it is synonymous with integrated care.

The better care fund will never succeed fully unless it is part of another group of parallel changes that promote more integrated care.

What is required is:

  • a multidirectional approach from provider development, education and training;
  • removing biases in the system;
  • information sharing;
  • maximising the involvement of – and sharing care with – individuals.

Financial flow and tariff changes are important as well. But start with better care for the citizen, then align the rest to make that happen.

Ref: The better care fund needs to be stripped of bureaucracy : HSJ – 9 December 2014




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Better Care Fund – spending to save

Tuesday, October 7th, 2014

bcfEvidenced-based approaches on how to effectively spend BCF


In preparation for the full Better Care Fund, which will come into effect in 2015/16, £200 million will be transferred from the NHS to social care in 2014/15, in addition to the £900 million transfer already planned. This pooled budget must be used to support adult social care services that have a health benefit, based on agreement between local authorities and CCGs, which are signed off by both parties and the local health and wellbeing boards.

Approach for ‘Spending to Save’

1. A sound understanding of the key local challenges and the underlying issues that need to be addressed

2. Evidence-based approaches interpreted and used accordingly (see list below)

3. Balancing evidence-based decision-making with a willingness to innovate and try out different approaches.

  • ? Primary prevention
  • ? Self-care
  • ? Managing ambulatory care-sensitive conditions
  • ? Risk stratification or predictive modelling
  • ? Falls prevention
  • ? Care co-ordination
  • ? Case management
  • ? Intermediate care, re-ablement and rehabilitation
  • ? Managing emergency activity, discharge planning and post-discharge support
  • ? Medicines management
  • ? Mental and physical health needs
  • ? Improving management o f end-of-life care
  • ? Delivering integrated care eg House of Care model


BCF Plans

Plans for spending from the Better Care Fund must detail how they will provide:

•   protection for social care services

•   seven-day services in health and social care to support patients being discharged and prevent unnecessary admissions at weekends

•   better data sharing between health and social care, based on the NHS number

•   a joint approach to assessments and care planning and, where funding is used for integrated packages of care, an accountable professional

•   agreement on the consequential impact of changes in the acute sector, with an analysis, provider- by-provider, of what the impact will be in their local area alongside public and patient and service user engagement in this planning, and plans for political buy-in.


The national metrics for how well the Better Care Fund is being used to develop integrated care will be admissions to residential and care homes

  • effectiveness of re-ablement
  • delayed transfers of care
  • avoidable emergency admissions
  • patient / service user experience.

These measures will be important in allocating the £1 billion of the Fund that is related to performance against outcomes, though there is some scope to use locally developed measures.

Understanding the sources of need and demand

•   Nationally, our population is growing, ageing and becoming more diverse (The King’s Fund 2013). Over the next 20 years the number of people aged over 85 is expected to increase by 106 per cent.

•   In the next 20 years, the number of people with some diseases is expected to double

•   By 2018, the number of people with three or more long-term conditions is expected to rise to 2.9 million; in 2008 this figure stood at 1.9 million


Reference: Making Best Use of the Better Care Fund : Kings Fund January 2014

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Startling facts about elderly care

Wednesday, June 11th, 2014

The story in statistics. Some startling facts about hospital care for frail older people.

“All parts of the healthcare system must contribute to improving care for frail older people”

Elderly care

 The Commission on hospital care for frail older people suggests questions staff should consider in their care pathway for frail older people  :

1. Are frail older people receiving the right level of specialist input in the hospital ?

2. Is the whole health system working well for frail older people ?

3. Do you listen to frail older people, carers and staff, and improve services accordingly ?

4. Is the service for frail older people comparable on any day of the week ?

5. Do you have policies for frail older people and are they evident everywhere ?


ref: HSJ 30 May 14

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Nurse staffing levels – is the topic of conversation

Tuesday, May 27th, 2014

As May turns to June things are really hotting up in preparation for the first national staffing numbers return for publishing on 24th June and the NICE Guidance recently published on the same.

All hospitals that have beds have to report planned staffing versus actual staffing by the hour, by day shift and by night shift. This raw figure will report on the number of Registered Nurses, Registered Midwives and Clinical Support Workers working any given shift against what the staffing levels should have been.

This will be a great challenge and industry for ward managers where electronic rostering is not implemented, or where the exceptions to support individual working pattern preference over service need is not well managed.

For better or worse this exercise will force Ward Managers, Senior Sisters, Midwives and Matrons to have those difficult conversations and will shine a beacon of good practice on those who ‘run a tight ship’

…and what of the published data? Matron Mary’s opinion is that without a narrative and story it will be pretty meaningless, how acutely ill were the patients? How many beds on a ward? What is the expected acuity for elective admissions over the week and is this reflected in staffing numbers? There is so much more to safe staffing than pure numbers! Lazy journalists may well have a field day with this – But  YOU know that, comments please?

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Invite to Health+Social care conference 25, 26 June 14

Wednesday, April 23rd, 2014

e-invite to H+C conference

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9 Components of care

Tuesday, April 8th, 2014

Redesign of services for the 21st century

In 1948, just over half of the population lived longer than 65 years; today, more than 85 per cent of us live at least that long and by 2030 one in five of us will be over 65.

Screen Shot 2014-04-08 at 12.22.42The King’s Fund has recently produced a report Making our health and care systems fit for an ageing population. It looks at each of the main components of care for older people reviewing the quality challenges that exist and summarising the evidence for what works, alongside examples of good practice and pointers to more detailed guidance.


The nine main components of integrated care are:

  1. King's Fund - Components of careHealthy, active ageing and supporting independence
  2. Living well with simple or stable long-term conditions
  3. Living well with complex co-morbidities, dementia and frailty
  4. Rapid support close to home in times of crisis
  5. Good acute hospital care when needed
  6. Good discharge planning and post-discharge support
  7. Good rehabilitation and re-ablement after acute illness or injury
  8. High-quality nursing and residential care for those who need it
  9. Choice, control and support towards the end of life


The report highlights three themes :

i.     The importance of joint working between health, social care and wider public services to support older people to remain healthy, happy and independent.  Crucially this includes providing the right housing to help maintain independence.

ii.     Correct use of the comprehensive geriatric assessment and specialist support at the right time is another key theme.

iii.     Treating older people with compassion, respect and dignity.

The golden thread that runs through all nine components of good care is integration, in which care is coordinated around the needs of the individual so that they receive the right mixture of services in the right place at the right time.

Whole-system changes are needed to deliver the right care at the right time, and in the right place, to meet older people’s care preferences and goals.


Ref: Catherine Foot and Richard Humphries at the King’s Fund

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PRISMA key features for integrated care

Sunday, February 2nd, 2014

Integrated care has come to the fore in the health policy landscape with the announcement of 14 integrated care pioneers and the better care fund.

Across the world, countries have taken different approaches to developing models for integrated care.  Canada and the UK face similar problems integrating care for people with complex needs including fragmented finances and poor collaboration between acute and community or primary care providers.

Some small, evaluated pilot programmes across Canada have demonstrated promising results. In Quebec, the PRISMA approach was developed in 1994 to improve continuity of care for older people.

The PRISMA model uses an integrated service delivery network of health and social care providers alongside case management delivered by multidisciplinary teams.

The key clinical features are:

  • coordination between services;
  • a single point of entry;
  • case management;
  • an assessment tool;
  • a personalised care plan; and
  • an information tool.

A four year evaluation comparing patient outcomes of the project in three pilot areas against three control areas found that the model significantly reduced both patient functional decline and visits to the emergency department.

Levels of patient satisfaction and empowerment also increased and yet the PRISMA model did not appear to reduce costs or significantly effect hospital admissions. In Quebec, the PRISMA approach did not demonstrate a positive impact until the third year of the evaluation. It should be remembered that new approaches need time as well as support to demonstrate real improvements in care for patients.


Ref: HSJ 24 January 2014

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Barts Health Trust offers top tips for mobilising change to improve its outpatients pathway.

It has streamlined its outpatients’ services with a focus on user standards and improving patient experience. It undertook a program of transformation for outpatient services over the past three years to ensure consistency of service and to develop innovative pathways with strong links to its local community

Here are their top tips for mobilising change :

  1. Support from the board
  2. Engagement events across the organisation
  3. Setting up a transformation board to oversee change and share good practice
  4. New measures for outpatient services reported across the organisation
  5. A tried and tested programme of pathway change for all clinical teams
  6. Operation meetings on each site
  7. A training and development programme to embed pathways through lean principles
  8. Weekly meetings to lead change with general managers


Ref: HSJ 17 Jan 14

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Top tips for successful collaborative working from the Olympics

Here is a great case study demonstrating whole system collaboration from how the Olympics transport was planned and delivered. Here are their top tips for successful collaborative working, so applicable to integrated healthcare.

The transport challenges around last year’s Olympics were the most demanding the nation’s network has faced, covering 34 venues, 26 sports, 10 500 athletes, 8.8m spectators and 22 000 media. More than 40 organisations were responsible for delivering aspects of the games’ transport.

In a review of lessons learnt by the Olympic Delivery Authority and Transport for London the main points were :

  1. The creation of one transport team for years before the games
  2. Strong programme, risk, budget and change management governance
  3. Working with, and de-conflicting, other big infrastructure projects that may be using the same resources or operating in the same area
  4. Engaging trade unions
  5. Collaborative working across other organisations and aligned domains, for example security.
  6. ‘One source of truth’ in terms of demand forecasting and modelling providing all parties with a clear understanding for the dimensions and scale of the challenge facing the whole network



“Effective collaboration across a system means having the necessary levels of trust to let your partners get on with the job”


Ref: HSJ 1 Nov 13


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FAQs for care homes on new CQC inspections

Thursday, November 7th, 2013

FAQs for care homes on new CQC inspections

I listened to a recent HSJ interactive webinar about CQC inspections in care homes, titled “Are you ready for the CQC?” on 31 Oct 13.

The speakers were:

  • Matt Tee, chief operating officer, NHS Confederation
  • Alex Baylis, head of better regulation, CQC
  • Jan Filochowski, chief executive, Great Ormond Street Hospital for Children Foundation Trust
  • Paul Ridout and Neil Grant, partners, Ridouts
  • Chaired by Nick Golding, HSJ news editor

8 hospitals have been visited so far. Here is a summary of how their discussion about the change in CQC approach applied to care home inspections ….. 

What is different about this CQC ?

  • Data-led, confidence in leadership to tackle their issues judged and affects ratings
  • The CQC owns the report and has the final say on its content
  • Essential Standards are going, new guidelines in December.
  • The inspection is about demonstrating improvement not just compliance.
  • CQC has greater enforcement powers.
  • A hospital cannot be an FT until it has had an inspection.
  • Larger inspections will provide more confidence in judgements. The teams will use evidence and data better.
  • CQC is advancing holding hands with Monitor and NTDA. Monitor will be a close partner if a hospital review demonstrates failings. CQC will use Monitor’s discretionary powers.

 Is the CQC learning from history ?

  • There is a learning workshop due before Xmas for 8 inspected trusts to reflect and review
  • The CQC expects a steady state from April 2014
  • The CQC is being more transparent in how inspectors are trained and how they are being told to write reports.
  • There is a stronger emphasis on standardisation across inspection teams – there will be an increase in the inspection team’s training to ensure quality and standardisation.
  • CQC is working with Kings Fund, Monitor and NTDA to give leaders guidelines on inspections. These include guidelines around measurement and judgements.
  • The CQC wants to be better at using data to inform judgements

But Care homes are different to the hospitals being visited in the pilot phase ?

  • CQC recognises that care homes are different environments to acute hospitals. It has a signposting document for care homes to engage them in applying the new standards. Guidance will be ready in October 2014 for care homes.
  • Outside hospitals data is poorer therefore it is important to engage care homes leaders in developing standards

Will our care home have time to prepare ?

  • Preparation is very important 
  • Staff need to be proud of their achievements from good preparation. Many improvements come about through preparation. A Care Home should feel comfortable in having an honest conversation with CQC about their strengths and weaknesses.
  • The CQCV does not want preparation to be bureaucratic
  • NHS Litigation Authority is a good model.

How much does this cost ?

What does regulation cost, is it value for money ? To be seen but it needs to demonstrate to the public that it is value for money.

How can our care home challenge the CQC

  • Care homes need to be engaged in compiling the report as it will stand as fact when signed off.
  • Care homes can now challenge judgements as well as evidence
  • There will be an appeal process. Applying learning from CSCI and Ofsted.
  • Large teams will add to credibility of judgements, rather than relying on a few individuals to form an opinion. Large teams can challenge each other before forming a view.

 How will other regulators be involved ?

Looking to improve co-ordinating with Healthwatch and Overview and Scrutiny Committees.

 Will the metrics be published

  • First set now published. Different to quality and risk profiles that were used in acute hospitals and which was not public information. CQC will make data public which means it needs to be communicated alongside judgements to give a balanced view. CQC hopes this is not viewed as a league table but improvement work in progress.
  • We are in an era of transparency, the public tends to find data less interesting when it is published eg surgeons performance data. Secrecy brings anxiety to the public

 Will patients and carers be able to give their opinions ?

  • The voice of the public is very important
  • However the CQC intends to tap into people who have had both good and bad care to get a balanced view. Testing a variety of methods to get a rounded input from patients and carers.
  • Wants to give a credible depth of analysis, for example evidence from a couple of disgruntled patients is not credible evidence of the public voice.

 What happens after an inspection ?

A Quality Summit will be held to apply next steps with stakeholders from around the community. First one for an acute trusts is due shortly in Croydon

 Final thoughts from panel

“NHS is unprepared for this regulation”.


“Need to demonstrate value for money”

“Feel positive in the hope for standardisation”

“Key is credibility in judgements”


Ref:  HSJ interactive webinar “Are you ready for the CQC?” on 31 Oct 13.

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