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In February the HSCIT hosted a webinar for adult social care services about what we can all do to keep antibiotics working. The webinar aimed to raise awareness of antimicrobial resistance and antimicrobial stewardship across adult social care and to explore what they mean in practice. The webinar featured presentations from two antimicrobial stewardship nurses and a principal educator from NHS Education for Scotland, as well as a question and answer session.

Adult social care is in desperate need of reform. Done well, social care has the power to positively transform people’s lives. Yet too many people aren’t getting the care they need, care workers are undervalued and far too much pressure is placed on unpaid carers. The cost of this vital public service continues to increase, with £32 billion spent on adult social care in 2023/24, and an unsustainable pressure is falling on local authorities. Without reform we will all keep paying a high price for a failing system. This Health and Social Care Committee report does not aim to document fully the current state of this failing system though the evidence does expose aspects of this, nor does it suggest how to fix it. Instead, it aims to shift the dial when it comes to reform by reframing the narrative around the cost of action to one that interrogates the cost of the status-quo or ‘inaction’. Some of the unaccounted-for costs of inaction include: 2 million people aged 65+ and 1.5 million people of working-age are not getting the care they need, leading to lives led at the bare minimum rather than to their fullest. Individuals face unknowable, and potentially life-changing, charges for care, including 1 in 7 older people with care costs over £100,000. The care individuals do receive can be inadequate, or neither the right care nor in the right place, leaving people unable to work or take part in other meaningful activities and risking the worsening of existing conditions. 1.5 million unpaid carers are providing over 50 hours of care per week to loved ones, and many of these withdraw partially or wholly from employment as a result, and who themselves suffer adverse outcomes as a consequence of putting the needs of their loved ones before their own. Due to the current funding model, local authorities’ budgets are buckling under the pressure of adult social care, with more councils seeking emergency funding and increasing proportions of budgets being spent on adult social care to the detriment of other services, leading to the perception of a democratic deficit in local government with people paying more and more for fewer and fewer services. The care provider market is in distress, struggling to cover existing costs via fees and facing underfunded increases in the National Living Wage and National Insurance. Care workers continue to be underpaid, driving high turnover and vacancy rates, and are twice as likely to be claiming benefits; The NHS struggles to divert admissions from the community and to discharge medically fit patients, causing knock-on costs of at least £1.89 billion, putting at risk the mission to build an NHS fit for the future. The economy is missing out on the sector’s potential to drive growth and regional rebalancing, as well as on tax receipts from unpaid carers and people in receipt of care, who are unable to work as much as they would like.

Despite the well documented consequences of obesity during childhood and adolescence and future risks of excess body mass on non-communicable diseases in adulthood, coordinated global action on excess body mass in early life is still insufficient. Inconsistent measurement and reporting are a barrier to specific targets, resource allocation, and interventions. This article reports current estimates of overweight and obesity across childhood and adolescence, progress over time, and forecasts to inform specific actions. The authors found both overweight and obesity increased substantially in every world region between 1990 and 2021, suggesting that current approaches to curbing increases in overweight and obesity have failed a generation of children and adolescents. Beyond 2021, overweight during childhood and adolescence is forecast to stabilise due to further increases in the population who have obesity. Increases in obesity are expected to continue for all populations in all world regions. Because substantial change is forecasted to occur between 2022 and 2030, immediate actions are needed to address this public health crisis.

Relatively little is known about mental healthcare-related harm, with patient safety incidents (PSIs) in community-based services particularly poorly understood. This study aimed to characterise PSIs, contributory factors, and reporter-identified solutions within community-based mental health services for working-age adults. Data was obtained on PSIs reported within English services from the National Reporting and Learning System. Of retrieved reports, the authors sampled all incidents reportedly involving ‘Death’, ‘Severe harm’, or ‘Moderate harm’, and random samples of a proportion of ‘Low harm’ or ‘No harm’ incidents. Of 1825 sampled reports, 1443 were eligible and classified into nine categories. Harmful outcomes, wherein service influence was unclear, were widely observed, with self-harm the modal concern amongst ‘No harm’ (15.0%), ‘Low harm’ (62.8%), and ‘Moderate harm’ (37.6%) categories. Attempted suicides (51.7%) and suicides (52.1%) were the most frequently reported events under ‘Severe harm’ or ‘Death’ outcomes, respectively. Incidents common to most healthcare settings were identified (e.g. medication errors), alongside specialty-specific incidents (e.g. Mental Health Act administration errors). Contributory factors were wide-ranging, with situational failures (e.g. team function failures) and local working conditions (e.g. unmanageable workload) widely reported. Solution categories included service user-directed actions and policy introduction or reinforcement.

The 'State of Care' is the Care Quality Commission (CQC) annual assessment of health care and social care in England. The report looks at the trends, shares examples of good and outstanding care, and highlights where care needs to improve. Areas of specific concern The 2023/24 report highlights some areas of specific concern. The concerns involve issues around safety, quality, workforce, and inequalities, including: Too many women are still not receiving the high-quality maternity care they deserve. Of the 131 locations we inspected in our national maternity inspection programme, almost half were rated as either requires improvement (36%) or inadequate (12%). We have concerns that children and young people are not always able to access services in a timely way – both planned and in an emergency. Anecdotal evidence suggests that parents and carers are well placed to recognise when their child is very unwell, but many feel they are not being listened to. The number of health visitors, who give individual support for young children and their parents, has declined by 45% over the last 9 years. Only around a quarter of people with a learning disability were recorded on the learning disability register, which means that many people are missing out on the proactive care and treatment they are entitled to. Despite fewer new referrals for autism diagnoses over 2023/24, the average waiting time to start an assessment reached a peak of nearly a year (328 days) in April 2024, rather than the recommended 3 months. People in Black or Black British ethnic groups are over 3 and a half times more likely to be detained under the Mental Health Act than people in white ethnic groups. Work on our cross-sector dementia strategy is highlighting the compassionate care and initiatives that are improving people’s lives, but staff do not always understand the specific needs of people with dementia.

This National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report highlights the care provided to adults presenting to hospital with a diagnosis of community-acquired pneumonia and gives recommendations. Community-acquired pneumonia (CAP) is one of the most common infectious diseases seen in clinical practice. It results in many hospital admissions and has a high mortality, primarily as the patient group is often frail and older with multimorbidity. The diagnosis of CAP is not always apparent at the time of first clinical assessment, and in many hospitals, there is no specialist team that takes overall responsibility for the care of patients with CAP. Clinical teams need to be more accurate in making the diagnosis of CAP, assessing its severity and ensuring appropriate antibiotic therapy. Local leadership is key in developing an infrastructure to ensure the care of patients with pneumonia is organised appropriately and a programme of ongoing monitoring and improvement is introduced. In this study, the quality of care provided to patients aged 18 years and over, who had a diagnosis of CAP during the sampling period of 1st October 2021 to 31st December 2021, was assessed by analysing data from 767 clinician questionnaires, 149 organisational questionnaires and the output from the peer review of 401 sets of case notes.

This study in Intensive and Critical Care Nursing examined the association between safety attitudes, quality of care, missed care, nurse staffing levels and the rate of healthcare-associated infection (HAI) in adult intensive care units (ICUs). The authors concluded that positive safety culture and better nurse staffing levels can lower the rates of HAIs in ICUs. Improvements to nurse staffing will reduce nursing workloads, which may reduce missed care, increase job satisfaction, and, ultimately, reduce HAIs. Key findings ICUs with strong job satisfaction had lower incidence and nurse-reported frequency of CLABSI, CAUTI, and VAP. Missed care was common, with 73.11% of nurses reporting missing at least one required care activity on their last shift. The mean patient-to-nurse ratio was 1.95. Increased missed care and higher workload were associated with higher HAIs. Nurses’ perceptions of CLABSI and VAP frequency were positively associated with the actual occurrence of CLABSI and VAP in participating units.

There are an estimated 363,000 adults experiencing multiple disadvantage in England—they may be experiencing a combination of homelessness, substance misuse, mental health issues, domestic abuse and contact with the criminal justice system. The Changing Futures programme works in partnership in local areas and across government to test innovative approaches and drive lasting change across the whole system, in order to provide better outcomes for adults experiencing multiple disadvantage.  This prospectus provides information for partnerships interested in submitting an expressions of interest to be part of the Changing Futures programme.

Health and care services in England are not always able to provide individualised, equitable and coordinated palliative and end of life care (PEoLC) to meet the holistic needs of people and their families. To understand the impact of inconsistent palliative care, the Healthcare Safety Investigation Branch (HSIB) looked at the case of Dermot, a 77-year-old cancer patient. Dermot's case shows the gap between what is needed and what is available. HSIB make three safety recommendations to NHS England aimed at improving the delivery of palliative and end of life care. The reference event Dermot was 77 years old and lived at home with his wife. He had been diagnosed with a myxofibrosarcoma (cancer of the soft tissues) in his armpit. Following surgery and radiotherapy, which were hoped would cure the cancer, the cancer returned and was found to have spread to other parts of his body. It was no longer possible to cure Dermot’s cancer and so he was referred to specialist palliative care services. Dermot initially received specialist palliative care at home from a team of specialist nurses. An assessment of his needs identified his main issues as nausea, anxiety, insomnia, and constipation. The assessment also resulted in a referral to a support organisation for Dermot’s wife, but the referral did not progress and so support was not provided. During the 9 days following his assessment, Dermot’s health deteriorated, and it was not possible to control his symptoms at home. He was admitted for inpatient specialist palliative care at his local community hospital. The aim of the admission was to manage Dermot’s symptoms and then discharge him home. However, his health rapidly deteriorated and he remained at the community hospital until the end of his life. Two days before Dermot died, his consciousness level decreased, and he became more settled and free of pain. Findings Health and care services in England are not always able to provide individualised, equitable and co-ordinated PEoLC to meet the holistic needs of people and their families. They are unable to consistently provide what people have been led to expect from PEoLC. Holistic assessments for PEoLC may focus on physical care needs, with more limited attention to identifying, understanding and addressing other care needs, particularly psychological needs. The availability of PEoLC across England is variable and inequitable. This is influenced by the location of third-sector organisations, available charitable donations and NHS commissioning, and workforce shortages. There is no stated minimum standard for PEoLC that all people must be able to access. There is limited information to help the public and health and care staff to identify, access, and understand the roles of different aspects of PEoLC, with variation in words and definitions. PEoLC services are not always able to proactively plan care for people whose condition will deteriorate because of limited inpatient PEoLC and the unpredictability of some diagnoses. There is limited, specific guidance to support integrated care boards to identify the PEoLC needs of their populations in line with the expectations of the Health and Care Act 2022, and what could/should be done to address those needs. There is limited support available for health and care professionals to have honest conversations with people around death and what to expect, and to plan for the end of life. HSIB recommendations HSIB recommends that NHS England specifies a palliative and end of life care data set to help integrated care boards to understand their populations’ demographics and needs, in order to support commissioning and improvement of services. HSIB recommends that NHS England develops and promotes a minimum expected service specification for specialist palliative care in England to clarify the minimum services a person can expect to be available to them no matter where they live. HSIB recommends that NHS England commissions palliative and end of life care career pathways, ensuring that they include staff from the allied health professions, in order to build specialist workforce capacity. Safety actions HSIB suggests the following actions for integrated care boards: Identify and describe the palliative and end of life care services in their areas through engagement with integrated care partnerships and third-sector organisations. This is to provide the public and health and care professionals with accessible and accurate information about available services. Support collaboration between health and care organisations to define clear routes of support for people in and out of normal working hours to ensure they know how to access help for palliative care and end of life needs. Work with integrated care partnerships to account for capacity and resource in social care when planning palliative and end of life care services. Support collaboration between health and care organisations, including those in the voluntary and charitable sectors, to encourage more open discussions about death and dying in their local communities, accounting for their population demographics. Include palliative and end of life care in strategic workforce plans to ensure staffing of services is appropriately capable and can provide the capacity needed to meet demand. Further reading on the hub; Sarcoma UK: Family insights from Dermot’s experience (reflections on the HSIB report)

This framework sets out what good digital working looks like for care providers and local authorities with responsibility for adult social care in England.

A study from Jackson et al. looked at how the prevalence of psychological distress in the adult population of England has changed since 2020. The study found that the proportion reporting any psychological distress was similar in December 2022 to that in April 2020 (an extremely difficult and uncertain moment of the COVID-19 pandemic), but the proportion reporting severe distress was 46% higher. These findings provide evidence of a growing mental health crisis in England and underscore an urgent need to address its cause and to adequately fund mental health services.

Health Education England (HEE) commissioned the Royal College of Physicians (RCP) to undertake the development of a training programme to meet the medical needs of adults with a learning disability. The training programme consists of two modules and applicants are expected to complete both modules which will result in a post graduate certificate. The second module is under development but will be available in the autumn of 2023. Funded places for both modules are available. The training programme is designed for doctors, nurses and allied health professionals working at a senior level and caring for people with a learning disability within their role. It will enhance their skillset and to address a number of cross cutting themes. This is key to enable practitioners to provide high quality and person-centred care for adults with a learning disability. The training programme has been developed and will be delivered with the input of experts by experience. The first module has been developed by RCP and Edge Hill University. The Learning Disabilities Mortality Review Programme (LeDeR) reported on the preventable inequalities in health experienced by people with a learning disability who die on average 15-20 years sooner than people without a learning disability. The medical module will enable practitioners to critically appraise and synthesise information that will support the implementation of evidence based best practice to treat and support individuals and promote quality of care. This will support and address a number of recommendations. The LeDeR programme highlighted the need to: develop the concept of learning disability physicians reduce specific risks from aspiration pneumonia and therefore understanding of dysphagia, specifically diagnosis, assessment and treatment improve multi-disciplinary care coordination adapt early warning system (EWS) for people with learning disability including soft signs and response to known baseline assessments improve safety of people with epilepsy improve the diagnosis and management of chronic constipation - including managing its underlying causes.

Hospitalised adults whose condition deteriorates while they are on hospital wards have considerable morbidity and mortality. Early identification of patients at risk of clinical deterioration has traditionally relied on manually calculated scores, and outcomes after an automated detection of clinical deterioration have not been widely reported. The authors of this article published in The New England Journal of Medicine developed an intervention program involving remote monitoring by nurses who reviewed records of patients who had been identified as being at high risk. Results of this monitoring were then communicated to rapid-response teams at hospitals. They compared outcomes among hospitalised patients whose condition reached the alert threshold at hospitals where the system was operational, with outcomes among patients at hospitals where the system had not yet been implemented. The authors found that using an automated predictive model to identify high-risk patients, for whom interventions could then be implemented by rapid-response teams, was associated with decreased mortality. 

An estimated 90,000 people are living with dementia in Scotland, with that number expected to increase to 164,000 by 2036. These national clinical guidelines from Health Improvement Scotland, the first to be published in nearly 20 years, provide recommendations on the assessment, treatment and support of adults living with dementia. It calls for greater awareness of pre-death grief for people with dementia, their carers and their loved ones, as they fear the loss of the person they know. To accompany the guidelines, a podcast has been produced by Health Improvement Scotland speaking to professionals, including Dr Adam Daly, Chair of Healthcare Improvement Scotland’s Guideline Development Group and a Consultant in old age psychiatry, and Jacqueline Thompson, a nurse consultant and the lead on pre-grief death for the guideline. We also hear from Marion Ritchie, a carer who experienced pre-death grief while caring for her husband.

The aim of this investigation and report is to help improve the inpatient care of adults with a known learning disability in acute hospital settings. It focuses on people referred urgently for hospital admission from a community setting, such as a person’s home or residential home. In undertaking this investigation, the Health Services Safety Investigations Body (HSSIB) looked to explore the factors affecting: The sharing of information about people with a learning disability and their reasonable adjustment needs following admission to an acute hospital. How ward-base staff are supported to delivery person-centred care to people with a learning disability. Reference event The investigation used as a reference event a patient safety incident involving a 79-year-old man who was recorded on his GP’s learning disability register as having a mild learning disability. After being admitted to hospital due to his worsening health. Throughout the patient’s stay, up to his death following a cardiac arrest, his individual needs were not always identified and reasonable adjustments to meet his care needs were not always made. Findings The health and care system is not always designed to effectively care for people with a learning disability. People with a learning disability who are admitted to an acute hospital are often cared for by staff without specialist training, skills and experience in working with people with a learning disability. These staff often have limited support and are unable to take the time they would like to meet the person’s needs. There is no standard model or national guidance for an acute learning disability liaison service (that is, teams that are specifically trained in caring for people with a learning disability). Consequently, there is variation in how these services are funded, their availability, the size of teams and what they are expected to do. The quality of learning disability services is currently monitored via the learning disability improvement standards annual benchmarking survey which is funded until the end of 2023/24. Decisions on future years have yet to be made. Staff in acute hospitals may lack confidence and support in assessing the mental capacity of people with a learning disability, in line with the Mental Capacity Act (2005). There is no national shared system with a single point of access for storing and managing information about the needs of people with a learning disability and the reasonable adjustments required for each individual. Current mechanisms for sharing information about a person – such as ‘care passports’ (a document that gives staff helpful information about the person’s health and social needs, including their preferred method of communication, likes and dislikes) and alert flags (a way to highlight key information to staff) on the electronic patient record – can be unreliable. Instead, information is often gathered from friends and family. Evidence exists that people with a learning disability experience health inequities. Long-held societal beliefs about the abilities of people with a learning disability may influence the provision of and decisions made around their care. Safety recommendations As a result of this investigation, HSSIB recommended that NHS England should: Develops and issues learning disability liaison nursing service best practice and workforce guidance to all acute hospitals. This is to help local decision making about specialist learning disability provision and enable appropriate support for people with a learning disability and the staff who care for them. Ensure that the national learning disability improvement standards annual benchmarking survey for the care of people with a learning disability is continued for acute hospitals in order to help assure that local population needs are met. Commission the development and dissemination of guidance on the practical assessment of the mental capacity of people with a learning disability in acute hospitals. This is to ensure that appropriate decisions are made about the person’s care. With support from key stakeholders including the Professional Record Standards Body, work collaboratively to develop and publish a set of guidelines on information to be included in a health and care passport (which could be paper based, digital, or both) for people with a learning disability with consideration of the reasonable adjustments that people may need. This is to ensure the most current and accurate information about reasonable adjustments to the person’s care is accessible when and wherever it is needed. Safety observations HSSIB made four safety observations as a result of this investigation: Health and care providers can improve patient safety by ensuring that local configuration of electronic patient record systems consider the accessibility and usability of the digital record reasonable adjustments flag in patient records. Health and care curricula can improve patient safety by aligning with the national code of practice on statutory learning disability and autism training, when finalised. Health and care providers can improve patient safety by advocating for all people with a learning disability to have an up-to-date care passport.

This report provides a comprehensive analysis of the adult social care workforce in England and the characteristics of the 1.52 million people working in it. Topics covered include: recent trends in workforce supply and demand, employment overview, recruitment and retention, demographics, pay, qualification rates, and future workforce projections.

Monitoring and responding to deterioration in social care settings is critical to providing safe, effective and responsive care. Front-line staff are pivotal for highlighting change to wider teams and managing low to medium risk individuals in their place of residence. However, there is a core set of principles that most systems use which may not be used by non-clinical staff in residential settings. This case study explores an intervention to empower non-clinical staff to take observations. The Whzan blue box contains a digital tablet and equipment to take temperature, pulse, oxygen saturation levels and blood pressure measurements. Staff were trained and supported on site to use the system and set up a digital platform to share measurements with wider teams. Staff fed back that they felt empowered and able to better engage in conversation with health care professionals, highlighting the importance of having a common language. This case study was submitted to the Care Quality Commission (CQC) by North East and North Cumbria ICB.