Guidance: Integrated care ‘critically important’ for older people with social care needs

Health and social care services should work more closely together to ensure older people with social care needs and multiple long-term conditions receive effective care, says NICE.

In latest social care guidance, NICE calls for care to be integrated so that better, more person-centre care can be provided for the growing number of older people with social care needs and multiple long-term conditions.

Many long-term conditions such as dementia, diabetes, heart disease, and cancer are linked with age.  Since the population is ageing, the number of people with long-term conditions is set to rise by about 1 million in the next 3 to 5 years.

The best outcomes for older people with social care needs and multiple long-term conditions are improved quality of life, and increased independence, choice, dignity and control. These can be achieved through coordinated care that is person-centred.

However recent reports suggest that care is often fragmented and hard to access, and that some people are being treated as a collection of conditions or symptoms rather than as a whole person.

To help tackle these issues NICE has published a new guideline on older people with social care needs and multiple chronic conditions. The guideline provides services with a framework for acting more effectively so that they can offer appropriate care to those who most need it.

Coordinated care, planned collaboratively

Aimed at social care and health practitioners, managers and commissioners, the guideline recommends ensuring that older people with social care needs and multiple long-term conditions have a single, named care coordinator who acts as their first point of contact.

The care coordinator should lead in the assessment process, liaise and work with all health and social care services, including those provided by the voluntary and community sector, and ensure referrals are made and are actioned appropriately.

Care plans should be updated regularly and at least annually to recognise the changing needs associated with multiple long-term conditions.

In addition, health and social care services should ensure they are tailored to each person, giving them choice of control and recognising the inter-related nature of multiple long-term conditions.

Integrate health and social care planning

The guideline also recommends ensuring community-based multidisciplinary support for older people with social care needs and multiple long-term conditions. This support should recognise the progressive nature of many conditions.

Members of such teams might include a community pharmacist, physiotherapist or occupational therapist, a mental health social worker or psychiatrist, and a community-based services liaison worker.

Elsewhere the guideline calls for health and social care providers to ensure that care is person-centred and that the person is supported in a way that is respectful and promotes dignity and trust.

A number of recommendations are also directed towards care home providers, to ensure the specific needs of people in care homes are catered for.

Integrated health and social care is “critically important”

Bernard Walker, Independent Consultant in social care, health and management, and Chair of the guideline development group, said: “When social care and health practitioners work together well, it helps both people using services and their carers to have choice and control over their care. It also avoids unnecessary duplication of services.

“As a committee, which brought together a knowledgeable group of experts including practitioners, carers and people who use services, we recognised how critically important this issue is. Better integration of health and social care services is best practice to which everyone involved in the care of older people with complex care needs and multiple long-term conditions should aspire.” 

Professor Gillian Leng, Deputy Chief Executive for NICE, added: “An estimated 6 million people in England aged 60 and over are living with more than one long-term health condition.

“As the number of older people in society increases, this figure is expected to rise too. A recent report by Age UK warned that a further one million older people in England could be living with multiple long-term conditions by 2020. This will inevitably put pressure on health and social care services and our new guideline highlights ways to best address the growing needs of this group.”