Introduction

This quality standard covers the planning and delivery of coordinated, person-centred social care and support for older people with multiple long-term conditions. The quality standard is focused on people aged over 65 as this is the largest group of people affected by multiple long-term conditions. It includes older people living in their own homes, in specialist settings or in care homes, and those who receive support with funding for their social care and those who do not. For more information see the social care for older people with multiple long-term conditions topic overview.

NICE quality standards focus on aspects of health and social care that are commissioned locally. Areas of national policy, such as funding for social care, are therefore not covered by this quality standard.

Why this quality standard is needed

Older people with multiple long-term conditions are likely to have a wide range of care needs as a result of their conditions. Those with social care needs may need support with personal care and other practical assistance.

The prevalence of long-term conditions is strongly linked to ageing; in England a quarter of people over 60 have multiple (more than 1) long-term conditions. The number of people with multiple long-term conditions in England is rising, and is projected to be 2.9 million by 2018, an increase from 1.9 million in 2008 (Long term conditions compendium of information third edition Department of Health).

A 2012 King's Fund report on Long term conditions and mental health suggests that depression is 7 times higher in people with 2 or more long-term conditions. In addition, the National Development Team for inclusion report A long time coming part 1 indicates that symptoms of depression can often go untreated and affect the abilities of older people to manage their own conditions.

People with long-term conditions account for around 50% of all GP appointments, 64% of all outpatient appointments and 70% of all inpatient bed days. Older people with long-term conditions are at a higher risk of needing admission to hospital, sometimes for health problems that could be managed at home. Overall, a significant proportion (70%) of government health and social care spending is attributed to the care of older people with long-term conditions, and the costs per individual increase with the number of conditions the person has (Long term conditions compendium of information third edition Department of Health).

In 2014/15, 603,000 people aged over 65 used long-term social care support funded by local authorities (Community care statistics, social services activity, England – 2014–15 NHS Digital) with total local authority spending on social services for older people of £6.8 billion (Personal social services: expenditure and unit costs, England – 2014–15, final release NHS Digital). Although the number of older people in the population is rising, the number receiving publicly funded social care is falling.

Older people may not know what social care support they are entitled to or what their funding options are. This may lead to their needs being left unmet because they are not claiming support. Options for people who pay for their own care and individual budget holders can be complicated and people may not know how to fund residential care if their conditions worsen.

Despite recent policy focusing on integrated health and social care services, some people are still treated as a collection of conditions or symptoms, rather than as a whole person, and there can be poor coordination of care. There is significant variability in the commissioning and provision of health and social care for older people in England. Although good practice on integrating health and social care is beginning to emerge from local areas that have developed new approaches to transforming services, considerable variability remains.

This quality standard has been developed in the context of important legal changes affecting people with social care needs. The Care Act 2014 establishes new provisions as well as updating existing ones, bringing together relevant policy and guidance that may have a significant impact on this group.

The quality standard is expected to contribute to improvements in the following outcomes:

  • social care-related quality of life

  • health-related quality of life

  • involvement in decision-making

  • safety of people using services

  • hospital admissions

  • residential care admissions

  • older people being supported to live where they wish

  • service user and carer satisfaction.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – safety, experience and effectiveness of care – for a particular area of health or care. They are derived from high-quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 3 outcomes frameworks published by the Department of Health:

Tables 1–3 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 Adult social care outcomes framework 2015–16

Domain

Overarching and outcome measures

1 Enhancing quality of life for people with care and support needs

Overarching measure

1A Social care‑related quality of life**

Outcome measures

People manage their own support as much as they wish, so they are in control of what, how and when support is delivered to match their needs

1B Proportion of people who use services who have control over their daily life

Carers can balance their caring roles and maintain their desired quality of life

1D Carer‑reported quality of life**

People are able to find employment when they want, maintain a family and social life and contribute to community life, and avoid loneliness or isolation

1I Proportion of people who use services and their carers, who reported that they had as much social contact as they would like

2 Delaying and reducing the need for care and support

Overarching measure

2A Permanent admissions to residential and nursing care homes, per 100,000 population

Outcome measures

Everybody has the opportunity to have the best health and wellbeing throughout their life, and can access support and information to help them manage their care needs

When people develop care needs, the support they receive takes place in the most appropriate setting and enables them to regain their independence

Placeholder 2F Dementia – a measure of the effectiveness of post-diagnosis care in sustaining independence and improving quality of life**

3 Ensuring that people have a positive experience of care and support

Overarching measure

People who use social care and their carers are satisfied with their experience of care and support services

3A Overall satisfaction of people who use services with their care and support

3B Overall satisfaction of carers with social services

Placeholder 3E The effectiveness of integrated care

Outcome measures

Carers feel that they are respected as equal partners throughout the care process

3C The proportion of carers who report that they have been included or consulted in discussions about the person they care for

People know what choices are available to them locally, what they are entitled to, and who to contact when they need help

3D The proportion of people who use services and carers who find it easy to find information about support

People, including those involved in making decisions on social care, respect the dignity of the individual and ensure support is sensitive to the circumstances of each individual

This information can be taken from the Adult Social Care Survey and used for analysis at the local level.

4 Safeguarding adults whose circumstances make them vulnerable and protecting from avoidable harm

Overarching measure

4A The proportion of people who use services who feel safe**

Outcome measures

Everyone enjoys physical safety and feels secure

People are protected as far as possible from avoidable harm, disease and injuries

People are supported to plan ahead and have the freedom to manage risks the way that they wish

4B The proportion of people who use services who say that those services have made them feel safe and secure

Alignment with NHS Outcomes Framework and/or Public Health Outcomes Framework

* Indicator is shared

** Indicator is complementary

Indicators in italics in development

Table 2 NHS outcomes framework 2016–17

Domain

Overarching indicators and improvement areas

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions**

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition

Reducing time spent in hospital by people with long‑term conditions

2.3 i Unplanned hospitalisation for chronic ambulatory care sensitive conditions

Enhancing quality of life for carers

2.4 Health-related quality of life for carers**

Enhancing quality of life for people with dementia

2.6 ii A measure of the effectiveness of post-diagnosis care in sustaining independence and improving quality of life* **

Improving quality of life for people with multiple long-term conditions

2.7 Health-related quality of life for people with three or more long-term conditions**

4 Ensuring that people have a positive experience of care

Improvement areas

Improving the experience of care for people at the end of their lives

4.6 Bereaved carers' views on the quality of care in the last 3 months of life

Improving people's experience of integrated care

4.9 People's experience of integrated care**

Alignment with Adult Social Care Outcomes Framework and/or Public Health Outcomes Framework

* Indicator is shared

** Indicator is complementary

Indicators in italics in development

Table 3 Public health outcomes framework for England, 2016–19

Domain

Objectives and indicators

1 Improving the wider determinants of health

Objective

Improvements against wider factors that affect health and wellbeing and health inequalities

1.18 Social isolation

2 Health improvement

Objective

People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities

Indicators

2.23 Self-reported well-being

2.24 Injuries due to falls in people aged 65 and over

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, whilst reducing the gap between communities

Indicators

4.03 Mortality rate from causes considered preventable**

4.13 Health-related quality of life for older people

4.14 Hip fractures in people aged 65 and over

4.15 Excess winter deaths

4.16 Estimated diagnosis rate for people with dementia*

Alignment with Adult Social Care Outcomes Framework and/or NHS Outcomes Framework

* Indicator is shared

** Indicator is complementary

Safety and people's experiences of care

Ensuring that care is safe and that people have a positive experience of care is vital in a high-quality service. It is important to consider these factors when planning and delivering social care and support services relevant to older people with multiple long-term conditions.

Coordinated services

Social care and support services for older people with multiple long-term conditions should be commissioned from and coordinated across all relevant agencies encompassing all of the person's needs and their whole care pathway. A person-centred, integrated approach to providing services across the statutory, private and voluntary sectors is fundamental to delivering high-quality care to older people with multiple long-term conditions.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high-quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high-quality service for older people with multiple long-term conditions are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All health and social care practitioners in statutory, private and voluntary sector organisations who are involved in assessing, caring for and supporting older people with multiple long-term conditions should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development source on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers (such as family members, friends and neighbours) have in supporting older people with multiple long-term conditions. If appropriate, health and social care practitioners should ensure that family members and carers are involved in the decision-making process about all aspects of the older person's care. The support needs of carers should also be recognised, and carers should be offered referral for a carer's assessment in line with the Care Act 2014.