This post is from The King's Fund Blog
There is a great deal of focus in the health and care system on measuring the quality of care being provided. But what about care that isn’t provided at all?
We have published several reports this year highlighting pressures in community-based services, including social care and district nursing. These pieces of research raised concerns about changes to the availability and quality of services as a result of rising demand and insufficient funding and staff numbers. The reports also raised concerns that these pressures might be leading to rising levels of unmet need.
Unmet need is difficult to define, and harder still to measure. This would be true in any setting, but particularly for services like district nursing that are delivered in people’s own homes. People who are not receiving district nursing care but would benefit from it, or those who are receiving some care but require more than they are currently getting, are often out of sight. There are no overcrowded waiting rooms or queues to bring this unmet need to light.
Local authorities are required to seek to identify unmet need for social care. But currently, monitoring arrangements are only in place in just over a third. Recent research from Age UK estimates that 1.2 million older people are not receiving the social care they need, a number they report has increased by almost half since 2010. This means that more people who have difficulties with activities of daily living – such as washing, eating or going to the toilet – do not have the support they need.
These findings are hardly surprising when you consider the context: our research found that the number of older people receiving publicly funded social care fell by a quarter (more than 400,000 people) over the past five years, despite growing numbers of older people living with high and complex care needs.
This not only affects the individuals struggling to cope without the support they need; it also puts additional strain on their carers and family members. Knock-on consequences for the health service are also inevitable. Many of those struggling to cope may eventually reach the door of A&E, and subsequently find themselves among the growing number of patients delayed in hospital while they await the care they need to be safely discharged.
And what about unmet need for NHS services? While the social care system rations services to those with the highest needs and is heavily means tested, the health system prides itself on being ‘free at the point of use’ and meets a wide range of needs. But we are hearing growing concerns through our research that unmet need for health services may also be growing. However, as in the case of social care, this is innately difficult to define, detect and measure. In addition, unmet need may not only result from straightforward denial of access. NHS services may be rationed through a number of mechanisms, including longer waiting times, higher referral thresholds, difficult access acting as a deterrent, deflection of care to other providers or payers, or dilution of the level or quality of care provided.
Early next year we will be publishing a report examining the impact of NHS financial pressures on patient care. This research looks in detail at whether the availability and quality of patient care has changed as a result of resource pressures in four service areas. During our research we, once again, heard concerns from interviewees that unmet need is growing, particularly for district nursing care and sexual health outreach services, which have been affected by significant cuts to public health budgets.
When considering the performance of the health and care system – particularly during this period of huge financial and operational pressure – it is important to focus not only on what the service is doing and how it is doing it, but also on the things it is not doing and what that means.