Posted on: 24/08/2016
In March 2015 the NHS confederation, a membership organisation that speaks for the whole health care system, commissioned a study looking at the challenges of providing urgent care for our ageing population. It brings together experts from across the care system, who have a shared purpose of making care better for older people. The aim of the Commission was to produce guidance for people involved in designing care for older people.
Patients over 65 account for half of all hospital bed days and over-85s are twice as likely to have an emergency admission to hospital as the general population. The challenges of managing urgent care demand in the face of increasingly overcrowded hospitals have dominated the thoughts of NHS leaders and clinicians for years, and there is an understanding that solutions lie in the creation of more effective and accessible home and community care that focuses strongly on the maintenance of health and wellbeing.
Concerns about care include:
• Older people being directed towards A&E inappropriately, because of a lack of alternative out-of-hospital services that might better suit their needs.
• Problems with how people move through hospitals and out again to their own home or other place of care. People need to have swift access to expert opinion, diagnostic services and then treatment before being given what help they need to return home when clinically appropriate.
• Variation in what services are available in different parts of the country.
• Difficulties in putting social care packages in place for older people who need support at home after a hospital admission meaning people are stuck in hospital long after they are medically fit to leave. Longer hospitals stays are associated with a loss of physical condition, especially muscle mass, and independence.
• A lack of focus on the preventative measures and early intervention that could stop deterioration in quality of life for some older people, and reduce pressure on the health system.
• A system that concentrates on the medical model and does not fully acknowledge the wider aspects of an individual’s life that contribute towards health and wellbeing. For example, social isolation, which has been linked with a higher risk of death. (see our previous article on this subject: http://www.expertisehomecare.co.uk/blog-post/2016/04/25/social-interaction-as-part-of-a-healthy-lifestyle/ )
• The growing number of people living with dementia. Within ten years, more than 1 million people in the UK will have dementia. This group may find hospital admissions disorientating, while staff and others who come into contact with them may not realise how dementia is affecting them in that environment.
• Older people living in housing that does not meet their needs as they age and as their mobility decreases. If their housing requires adaptations to enable them to return home after a hospital stay, this can lead to delays in discharging them.
By examining examples of care across the country, the commission produced a vision for what excellent urgent care should look like.
• It should respect the wishes and goals of the individual and their carer(s).
• It should support medical and non-medical care in the most appropriate setting.
• It should use the right resources – clinical or social – to support the delivery of care.
• It should prevent escalation to any inappropriate services.
• It should seek to use the right alternatives to resolve a crisis as early as possible, to avoid major disruption to a person’s daily life.
• It should provide a clear plan to the individual of what the immediate and longer-term next steps are when acute care is required.
Commission members drew up eight key principles to be used as a guide in any redesign of services, to ensure older people’s needs and wishes were being met.
1. We must always start with care driven by the person’s needs and personal goals. The term ‘integrated care’ is frequently used to describe the structure of service providers, but to be meaningful it should instead be used to describe the provision of care that is coordinated around the needs of the individual.
2. A greater focus on proactive care. The current system often focuses on providing care reactively. The Commission believes the mindset of the care system needs to change from reacting in a crisis, to proactively planning to avoid one and to react appropriately if someone deteriorates.
3. We should acknowledge current strains on the system and allow time to think. Local leaders need the space to build relationships and sustainable solutions to the challenges they face. The current regulatory approach tends to assume that overwhelming urgent care pressures result from poor management and lack of effective planning, and reacts by requiring inappropriate actions that do not address the underlying causes. It is collaborative working that has the potential to bring about longer-term and transformative solutions.
4. A need for care coordination and navigation – recognising the importance of having a single connection within a complex system. The Commission views a care coordination function as a crucial part of providing people with truly integrated urgent care
5. Encouraging greater use of multidisciplinary and multiagency teams. These teams could operate in both the hospital and the community, bringing together staff from different backgrounds. Where appropriate, they should encourage and support self-management by working with people and carers.
6. Ensuring workforce, training and core skills reflect modern day requirements. A system that is focused on treating people in the right place for their needs is likely to require a different workforce than that in place today.
7. Leadership should encourage us to do things differently. Leaders who support staff to innovate and make a difference are needed to drive through change
8. Metrics must truly reflect the care experience for older people. Much of the data captured by the NHS at the moment is not attuned to the experience of the person or what matters most to them.
The words used to describe healthcare provision for older people are often very negative. There is a definite need to stop describing older people as a problem for the system by using unhelpful labels like ‘social admission’ or ‘bed blocker. People often end up stuck in A&E because other parts of the care system has not adequately anticipated or delivered their care needs.
The challenge is to provide urgent care when it is needed but to concentrate on measures that keep people well and out of hospital. The focus must be on the individual as no two people’s care needs will be the same.
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