This report explores community health and social care in Lewisham. The report has two views on the issues. One is the patient and service user experience captured through an extensive community engagement programme by Healthwatch Lewisham. The other is the Save Lewisham Hospital Campaign’s complementary analysis of the provision of community care services and the impact of financial constraints and reductions on services, service users and staff.
Community care is an often almost invisible but vital web of support for the most vulnerable in our society receiving care outside hospital and often in our own homes. Service users may find it hard to comment on their quality of care and it can therefore be difficult to monitor the impact of any reduction or change to provision. It is easy to see a hospital and get angry when it is threatened. It is harder to see threats to a jigsaw of services to an often vulnerable and sometimes silent population. Community care is a prerequisite for safe and effective care pathways between hospital and home. With pressures to reduce hospital provision, it is even more essential to examine current community provision.
This report follows the Appreciative Inquiry that demonstrated the excellent quality of care in Lewisham. This Inquiry gives voice to service users of community care in Lewisham who may find it more difficult to comment on these services rather than those of a hospital. The Inquiry showed that, from the points of view of users, clinicians and NHS managers, the following dimensions of care were key to a good service:
- Time
- Accessibility
- Smooth Proactive Pathways
- Empowerment of the Patient
- Professionalism, Skill, Sensitivity, Listening
- Sees the Person and the Social Situation not just the Condition
It was also clear that privatisation of NHS services was a concern for Lewisham residents
This report explores the daily reality of community health and social care in Lewisham. We look at both the quality and the provision of services.
We have tried to extend work across the protected equality characteristics and focus on communities that are poorly heard.
The report draws on many sources of evidence: Healthwatch has gathered over 100 stories from service users and carers. The Campaign has spoken to NHS staff to provide a different perspective. The report also draws on previous Healthwatch reports and desktop research. Data was gathered using quantitative and qualitative methods, speaking with individuals and groups. Some evidence has been difficult to gather, some is incomplete, and some will change. We acknowledge that more engagement is needed with service users, particularly those receiving services at home. We invite our partners to support us to do this.
The Campaign emphasises that current community care provision in Lewisham needs to be seen against central government’s financial and organisational pressure on health, social care and voluntary agencies. The TSA process disrupted some effectively growing services and networks, as has the re-organisation of the Health and Social Care Act.
- Although NHS funding is technically static, it is effectively falling by 5% annually nationally (4% is the figure usually quoted. There is an annual 1% tariff ‘deflation’ which, added together, makes a 5% average ‘cost pressure’ annually for most trusts). Inflation of products and services for the NHS outstrips the national inflation rate.
- Government money to fund local authority services in Lewisham is projected to fall by 33% by 2017–18 from the level it was in 2013–14. That is from £208.1 million to £138.3 million.
- Adult social care spending nationally has suffered cuts of 26%: £3.53 billion over the last four years. The service is now under extreme pressure and facing financial crisis. If the trajectory of cuts experienced to date continues over the period to 2019/20 spending must fall by 21% in cash terms or 33% in real terms.
- There is a 5% decrease nationally in the number of people receiving social care services. As the National Audit Office concludes: “Need for care is rising while public spending is falling, and there is unmet need.”
- To set a balanced budget for this year Lewisham Council has had to agree measures to save £39m. This comes on top of £93m savings already made since 2010.
289 more staff could be threatened with redundancy out of 1,133 staff employed.
There is a commitment to improvement in community care by the SE London Strategy Programme, the Local Authority and the Clinical Commissioning Group. Both the NHS and the local authority agree that sometimes savings, when combined with imaginative redesign, do not inevitably result in a deterioration of service. Ensuring that the public are fully engaged in the development of current and future redesigns of community care while using existing patient experience evidence such as this report is imperative to winning the best possible community care for Lewisham.
The Campaign highlights privatisation as an additional threat. Lewisham CCG has not been known for extensive privatisation, but, nationally, independent sector providers could provide 50% of NHS community services by 2020. The Campaign points out that there is no evidence that the market improves patient outcomes, while there is ample evidence that profits go out of the NHS, staff and skills are often reduced and fragmentation increased. Companies exit because profits are inadequate – and instability results.
A consistent picture emerges from the research and the stories.
Staff are increasingly stretched and are working harder and longer hours. Despite these challenges, in the majority of cases users in both social and health community care still receive a quality service delivered by caring and attentive staff who listen and involve them in decisions about their care.
Services overall, however, seem to be reducing in most sectors. Lack of access, resulting from a reduction in community care provision, poor co-ordination of services and continuity of care, confusion about where to access services and access information are themes arising in the second stage of this inquiry.
These can cause some clinicians to focus on the immediate problem rather than the bigger picture of the patient and the wider determinants of their health.
On occasion, as in findings on hospital discharge, services can be unsafe.
Time
Service users continue to tell us that time is vital to the quality of care they receive. Once patients access a particular service the majority feel that they are given enough time. However, this appears not to be the case in some areas of social care, and for patients with complex needs in general practice.
Accessibility
Access has been the number one issue raised during this inquiry, particularly access to GPs, chiropodists, practice nurses (in some areas) and diabetes support nurses, CAMHS and mental health services. It is a direct result of fewer, stretched staff. In services provided by the NHS, this is often because of recruitment problems.
Poor user access to information was a related issue.
Smooth Proactive Pathways.
The report finds that many patients have experienced difficulties in the coordination of different services, often when moving between services or being discharged from one service to another. It is hard to link services if they have different management structures and reduced administrative support with too few professionals to meet the demand.
The inquiry found that Continuity of Care, a related theme issue, is also compromised by lack of access to services.
Empowerment of the Patient
Most users told us that they feel supported in sharing decisions, as much as they want to, with professionals. However, there is always room for improvement, particularly when looking at carer involvement and working with patients with learning difficulties.
Professionalism, Skill, Sensitivity, Listening.
Once users get to see a professional for a service, almost all said that they are treated well, with respect, care and commitment. This, again, is a tribute to the professionals working under pressure and still delivering high quality care.
Sees the Person and the Social Situation not just the Condition
Users reported that this aspect of good practice is not always addressed. It is central to some disciplines, such as CAMHS, where understanding the wider determinants of mental health is core. However, in other disciplines, such as district nursing, it seems that pressure encourages an almost exclusive focus on the immediate. On occasion, it appears that this can become a critical problem.
The reason for the squeeze on staff and services is clear – it is austerity.
This report supports the visions created through the Appreciative Inquiry. Service users, community leaders, health and social care staff have told us community care needs:
- Adequate investments in community care services to ensure that service users receive the highest quality of care
- Well trained and well paid staff, well supported, who have the time to offer patient-centred services with a focus on continuity of care
- A holistic approach, taking into account many aspects of the patient’s life and health
- Connectedness and cooperation between services, the voluntary sector and the community
- Patients to be supported to make as many decisions about their care as they want
- Patients to have all the necessary information made available to them to support them and their wellbeing, as well as enabling them to make positive choices about their health
- Patients to be able to access services in a timely manner with choice made available wherever possible
- Healthcare as a whole – we reject suggestions that boosting community healthcare opens the door to reductions in hospital care
- Smooth integrated pathways: this cannot be provided through privatisation and fragmentation
- New media to be used where appropriate.
The Save Lewisham Hospital Campaign challenges two assumptions behind current NHS thinking. It is highly unlikely that improving community care services will enable cash-releasing cuts in hospital services. There is virtually no evidence for this. Indeed, the number of hospital beds probably needs to increase rather than contract: current bed occupancy is well over the safe threshold of 85-90%. England has fewer beds than all but one OECD country per head of population.
The Campaign calls for:
- Increased government funding for community health and care services
- An end to austerity for public services
- A dissemination of this report to community groups and Lewisham residents
- Public support for rapid and permanent support for existing staff, increasing numbers and engagement