As The King's Fund argued in Transforming the delivery of health and social care: the case for fundamental change, any discussion about developing new models of care must focus on shifting care closer to home. However, there is a danger of 'shifting care closer to home' becoming just a slogan and consequently not being examined sufficiently. It is not a step forward to relocate an activity that should really be stopped or redesigned, or to move care closer to home when this is less convenient for the patient or leads to a reduction in the quality of care.
There are some key questions to consider: can changing the location of care act as a catalyst for developing completely new models of delivery, and will redesigning services lead to more convenient and cost-effective settings? Although moving care closer to home has been a policy ambition for some time, non-elective admissions have continued to rise over the past two decades, and there are worrying signs that primary care is buckling under the current pressures of demand. This month's Time to Think Differently blog posts – and the responses to them – suggest that opinions on this policy continue to differ and that some of the evidence is still patchy.
Paul Corrigan's post concentrated on hospital strategy, claiming that radical new visions within the hospital sector will shift the location of care. However, as is often the case when you scratch beneath the surface, there is a frustrating lack of detail about these ideas and one wonders how truly radical they are. This may be because we need to move beyond thinking about the future of the hospital and how to move services into the community and begin to think of approaches that might fundamentally change the health and social care system. In many health communities these conversations start by looking at issues such as urgent care or individual long-term conditions and then quickly migrate to the development of new and imaginative approaches to dealing with frailty and the more effective management of population health. For example, the development of multi-disciplinary teams (including social care, mental health and other services) wrapped around groups of practices using a shared record and care plan and getting significant input from specialists that would previously have been confined to hospital. Many of these approaches are experimental, leading to evolutionary change that will be significant over time and could eventually be radically different.
The first step should be rethinking the operation of primary care, not having more conversations about hospital configuration. Hugh Reeve articulates some of the key issues that need to be dealt with. Hospital is the default option for many patients because we have failed to rethink how primary, community and social care currently operate. Primary care often operates on too small a scale, has inadequate access to specialist support and diagnostics, and has workflows and processes that are inappropriate for the types of patients it deals with (for example, the length of appointments are not sufficient for dealing with multiple morbidity and it is hard to provide continuity of care). Creating a strong primary care platform, as Hugh suggests, would allow the major change needed. Wrapping community services, mental health services and social care around groups of practices; giving those practices access to specialists and diagnostics; creating more systematic approaches to working collaboratively would provide continuity or rapid access to treatment depending on their patients’ needs. GP information systems are quietly helping to create the information infrastructure required for this. New technology offers hope as well, although more evidence and lower cost solutions are needed to make this viable.
But do we need to be even more creative in our solutions? Listening today to a GP describing the difficulty of providing care in the homes of some of their patients made me realise that we need to think even more broadly about the care system. Jeremy Porteus makes the case for bringing housing design into the system not only at a strategic level but in thinking about discharge and care planning. Helping people to remain at home is very dependent on them having a home that is fit for purpose and Jeremy is right to draw attention to this and the need to make better links to health and other services. The same is true of private domiciliary care, residential care and nursing homes that have more beds and care staff than the NHS and can make a huge contribution.
With investment, these changes could lead to big shifts in the location of care. Moving outpatients, surgery, endoscopy and other diagnostics into the community might reduce some patient travel time, but this is just tinkering with the system and we will need critical examination to see if it is truly cost effective. The big gains need a much more strategic approach to the re-imagining of the whole system. Despite Paul Corrigan’s confidence that hospitals have new visions that might support this redesign, it will also need transitional arrangements and major changes in business models and payment systems. Is this why making the transition is so much harder than the policy commentators tend to think?