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Hospitals: Voluntary Sector and Emergency Readmissions

Volume 757: debated on Monday 1 December 2014

Question for Short Debate

Asked by

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.

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.

My Lords, I am very grateful to my noble friend for raising this important question. I am just very sad that we do not have a great raft of speakers because this is such an important subject, particularly the matter of the ageing society. That is going to happen more and more. Partners will be left on their own, and they do not always plan for it; they get to old age and find that they need a major operation and there is no one left in their families to care for them afterwards. If they are not given the right care after a stay in hospital, the next thing that happens is that they will be readmitted. I was struck very much by the case of my brother-in-law, who is 88 and on his own. He needed a major operation and had to have a stoma. This is quite a complicated thing for somebody of that age to cope with. Luckily, when he came out of hospital, he could board in a care home for a week and then he went to his daughter, who was nearby. So he has had very good care and very good neighbours. I am thinking of someone who is not in that position.

My noble friend and I were both at the event recently held by the RVS in the River Room here, at which it launched its report to which my noble friend referred, Going Home Alone. It was an absolutely brilliant campaign. For anyone who wonders what the RVS is, it is the WRVS without the W, because men are now admitted. It is worth saying that because I have tested it on people and they do not know what the RVS stands for.

It is worth reiterating what the RVS says are the six essentials, because, if it aims to reduce readmissions by half, it is worth the Government and local authorities taking them on board, along with others in the care business. The RVS says that, first, the older person must be told the plan for their return home from hospital. They must be accompanied before 10 pm to a “warm, well-lit house”, and they must be able to collect their prescriptions and get their follow-up appointments. After all, that is going to be one of the most important things. They may have forgotten what they were told in hospital, with all the trauma. Then someone must be there to help them shop so that they will not be hungry. They will be used to people doing things for them. They will be used to having meals provided and if meals are not provided someone will have to help them get ready meals. Finally, the RVS says that they need a friendly face to turn to for help. That is very important. Obviously, where there are family members and good neighbours, that is fine, but an awful lot of people in our towns and cities do not have such people. I suggested to the RVS that it might want to try a pilot in some areas where they are short of volunteers by putting a leaflet through everyone’s house. I have found that many people, particularly in my road in London, are only too happy to help if they know that help is needed. This could help in many areas where there is a great deal of untapped potential.

The Government should not leave it all to the voluntary sector; the voluntary sector should look to the Government for help, too. This could be a good partnership. I am pleased that it was raised by the RVS and that it has been raised today by my noble friend Lady Scott.

My Lords, I congratulate the noble Baroness on initiating this debate. Although she said that it was put down some time ago, it could not be more timely with the discussions around the health service being so relevant at the present time, and particularly today. So, although there are few us here, as she pointed out, it is a part of a wider debate and conversation about the development of services within the National Health Service.

I have fond memories of the WRVS as a former MP. We were regularly asked to do, and willingly undertook, voluntary work with it in our local hospitals. Often it was one of the most pleasurable days of the year, going round the wards with tea trolleys and seeing day after day the commitment to and enthusiasm for supporting the professionals within that setting and ensuring a high-quality service to patients within those hospitals.

To add briefly to the context of today’s debate, I looked at the King’s Fund report of 2013, Volunteering in Health and Care. Securing a Sustainable Future, which states:

“The health and social care system is under extreme pressure to improve the quality and efficiency of services. To meet the challenges ahead, service providers will need to think differently about how they work and who they work with … One important group in these debates is the millions of people who volunteer in health and social care, in both the voluntary sector and within public services—an estimated 3 million people across England. These people”—

as the noble Baroness said—

“add significant value to the work of paid professionals, and are a critical but often under-appreciated part of the health and social care workforce”.

The King’s Fund research indicates that,

“volunteers play an important role in improving people’s experience of care, building stronger relationships between services and communities, supporting integrated care, improving public health and reducing health inequalities. The support that volunteers provide can be of particular value to those who rely most heavily on services, such as people with multiple long-term conditions or mental health problems”.

It suggests that, to achieve the best scenario, the critical role of volunteers in building a sustainable approach to health and social care must be acknowledged, and the research recognises five key areas, which I hope we can debate at a future time.

I just want to add topically that, as the noble Baroness pointed out, today the Government are responding to NHS England’s five-year forward plan. In the paragraph on encouraging community volunteering, they acknowledge the importance of volunteers, as I have just described, and they put forward examples of how those volunteers might be utilised most effectively. I hope that the Minister will comment on that. I do not want to stray into the response or the Statement that is to follow but I hope that there will be some recognition of the vital role of volunteers in this country.

As the noble Baroness pointed out, an excellent report on the Hospital 2 Home scheme was produced by the RVS a short while ago. It gave some interesting statistics about the scale of the issue, particularly regarding the over-75s. It is estimated that there are now 5.1 million over-75s in this country, up from 4.4 million in 2010, with there being an estimated 7 million by 2035. Forty-six per cent of those over-75s live alone, and 38% of 75 year-olds now return home from hospital—up from 10% in 2004. The RVS’s report was very timely in showing that a much greater number of over-75s go home from hospital and that they need support to ensure that they are not readmitted, as this debate is about. Before they are discharged, they often feel anxious and not ready to go home. That is often because they know that they are going home alone and that they will not get the support that they require to give them confidence, or may not get the immediate services that are required to ensure that they return home in a satisfactory way and are not looking for early readmission. Early readmission can be a consequence of that anxiety. I am not suggesting that no people in this age group will have to return to hospital, but let us see whether there is a mechanism to ensure that the services that are required to wrap around them at the point of discharge are most satisfactory.

From my experience of working in the voluntary sector with people with mental health problems—particularly those who come into contact with the criminal justice system—I have found that there is very poor evaluation of the cost benefits of the work of the voluntary sector. In the RVS report, it is estimated that savings on readmission are around £40 million a year but there is no solid evidence to support that figure. It is a very good estimation of what those savings can be but the Government should look rigorously at better models for considering outcomes and for assessing the real value to society of volunteers. As I said, from my work with the mental health and criminal justice system, I know that there is a paucity of information about the support that mentoring can give, for example, to people with mental health problems who may come back into the community from the criminal justice system. That value of that to society is completely underestimated. I am not comparing it directly with readmission to hospital but there is a great value to society to be had when we are talking about readmission to the criminal justice system as a result of not having that support. I urge the Government to look very carefully at how we can assess more effectively the savings that can be made through effective mentoring and the use of volunteers.

However, we should never presume that volunteers are in some way a cheap option within the development of public services. They have to be valued as part of the team, and we have to ensure that, when services are commissioned using the voluntary sector, the sector has sufficient support and infrastructure to ensure that it can be an effective part of service delivery. I am always concerned that, as we move into the new contracting arrangements within the commissioning of services, the value of volunteers or the voluntary sector is not adequately taken into account as those contracts are developed to ensure that the high quality and local nature of those services are properly recognised and become integrated into the way in which the 3 million volunteers so willingly give their time and expertise.

I again congratulate the noble Baroness on this debate, and the debate will go forward very effectively now because, as we struggle to ensure that we support people whatever their illnesses or age group, the voluntary sector will become an even more important part of our civic life.

My Lords, I begin by thanking my noble friend Lady Scott for tabling this important topic for debate and for introducing it so ably. The Government appreciate, as all speakers have acknowledged, that voluntary and community sector organisations make a substantial contribution to the delivery of high-quality local health and social care services. They have a strong track record of designing, providing and supporting services, based on their insight into people’s needs, and they are often well placed to respond in a flexible way to those needs. Their unique understanding of local communities also means that they are ideally placed to reach those vulnerable and sometimes hard-to-reach groups that statutory organisations might struggle to reach.

Moreover, social action and volunteering contribute to every sphere of health and social care and are fundamental to building strong and resilient communities. For example, the Royal Voluntary Service—mentioned by my noble friend Lady Thomas and the noble Lord, Lord Bradley—is a charity that supports older people to live well at home, in the community and in hospitals. With a network of more than 40,000 volunteers nationally, the Royal Voluntary Service uses its strong community links as a platform to deliver a range of services that improve the hospital experience for older people and their relatives, reduce hospital readmissions by linking hospital and home-based services, contribute financially to patient and community services, and provide people with practical and accessible information about local services. These types of schemes can help to avoid unnecessary emergency readmissions.

The report mentioned by a number of noble Lords makes very interesting reading. The conclusion of the report is that, in the RVS’s estimation, this support could save tens of millions of pounds in public money. That needs testing, as the noble Lord, Lord Bradley, indicated, as there are a number of important assumptions underlying the figure that it quotes. Nevertheless, it points the way to the usefulness and value of the voluntary sector in all the areas that I have mentioned. There are many other voluntary sector organisations that do similar work—for example, Age UK.

I shall now set out the range of actions that the Government are taking to improve integration of care to ensure that people can receive the care that they need and avoid emergency admissions and readmissions, including through use of the voluntary sector. The better care fund is a £3.8 billion pooled budget between health and social care, with areas choosing to pool £1.5 billion extra to bring the fund to £5.3 billion. The vast majority of this is being spent on social care and out-of-hospital community health services, which aim to keep people out of hospital and support them to leave safely as soon as they are well enough to do so.

Underlying the new approach are improvements in seven-day working across health and social care to help quicker, more appropriate discharge from hospital. One of the metrics for the fund is the number of people supported to remain at home at least three months after discharge from hospital. Plans project that, over two years, 11,860 older people will be supported to remain at home at least three months after discharge from hospital. This equates to a 33.7% increase over two years. Schemes in plans typically focus on things such as increasing capacity in reablement or intermediate care services, or multidisciplinary emergency response teams, which focus on avoiding unnecessary admissions to hospital.

We know that the voluntary sector can also play an important role in providing advocacy to people who need it. One of the drivers for the better care fund is to stop people having to undergo multiple assessments and telling their story repeatedly. Having someone to represent them and to help them navigate their way through often confusing health and care services can be invaluable. For example, in Greenwich the hospital ward support scheme trains volunteers to engage with people in hospital to support them to do practical things such as maintaining hygiene or engaging in conversation. The scheme prepares people for discharge, with volunteers on hand to support those identified as socially isolated who will be leaving hospital. Doncaster’s better care fund plan sets out a comprehensive falls prevention programme, through which Age UK Doncaster is being commissioned to help increase physical activity levels in older adults to increase strength, stamina and flexibility. That reduces the risk of falls and fractures, which are a major reason for hospital admissions and readmissions.

As well as providing services directly, we know that the third sector is represented at the strategic decision-making level in better care fund planning, with Nottingham and Southwark being just two examples of the many areas with voluntary sector representatives as members of their integrated care programme boards, as well as the health and well-being board itself.

The £2 million social action fund has delivered improved engagement with the independent, voluntary and community sectors. Eight schemes are being funded, aimed at supporting frail and elderly people. The aim is to scale up and robustly test interventions that use social action to reduce demand on hospital services, with funded projects making their impact over the course of winter 2014-15. We hope to be able to mainstream the most successful interventions down the line, and all evaluations and learning will be shared widely with the sector. The projects will help develop the potential of services that use social action to help older people stay well, manage their conditions or recover from illness or injury, thereby reducing growing pressure on hospitals. Currently, such services are small in scale and piecemeal, and often are not robustly evaluated. By March 2015, the aim for each project will be to contribute to a significant impact in the local area over the winter of 2014-15, develop a robust evidence base on its effectiveness through evaluation by the Nuffield Trust, and lay the foundations for the service to continue and grow on a long-term basis.

I am conscious that I have mentioned only a very few of the many voluntary sector organisations that are relevant to this issue, focusing primarily on the generic services provided. There is also a wide range of different, more condition-specific services provided by the voluntary sector—for example, some of the support provided by charity helplines that enable people to manage their conditions at home. There are also the very important services provided by voluntary sector hospices that support people at the end of their life within their homes, thereby avoiding unnecessary hospital admissions.

I shall highlight one particular example of where I have observed fantastic contributions made by the voluntary sector. Last month, I visited a medical practice in Hertfordshire to see how the role of developing well-being services within local NHS communities works. The Wellbeing Service was developed in order to support patients’ physical, psychological and social needs through improved health and well-being. The practice has engaged with a number of voluntary organisations to help prevent readmissions. I was particularly struck by the help that the volunteers give patients in navigating their health journeys, and I commend their tremendous work on this.

The noble Lord, Lord Bradley, asked whether there would be any spend on the voluntary sector from the additional £700 million of winter funding. Planned spend by system resilience groups identified for voluntary sector organisations is approximately £3.9 million. Approximately 110 independent and voluntary sector schemes are planned across the country, covering the expansion of capacity to provide care at home, hospital-to-home aftercare, out-of-hours cover and beds in care homes, the community and hospices. These plans include voluntary sector providers referenced in plans, such as Age UK, the British Red Cross and various hospices and smaller providers. Many schemes are focused around helping with improved hospital discharges, support for patients on return to their homes, community care provisions, and longer-term work to reduce readmissions and prevent admissions in the first place. I think we can be encouraged by that picture.

I conclude by saying that I recognise that the voluntary and community sectors make a substantial contribution to the health and care system. This has been an excellent short debate. Like my noble friend, I regret that there have not been more speakers, but the issues raised by those who have spoken have brought to light what value is available from the voluntary sector in a range of fields in health and social care. I thank my noble friend for having given us this opportunity to look at those areas. I encourage commissioners to engage with voluntary sector organisations to understand the kind of support that they can deliver to prevent emergency admissions, looking at some of the excellent examples that we have heard about this afternoon.

Committee adjourned at 5.02 pm.