Sipping my morning coffee on Friday, I caught BBC reports that the Secretary of State was announcing yet another initiative designed to assuage concern over the care of older people. ‘Elderly patients to be assigned named clinician’, ‘Mr Hunt will announce that a named doctor or nurse will be responsible for vulnerable patients at all times.’
In his speech he went on to say ‘most people leave hospital with long-term conditions which need to be supported at home…so we need to know that there is a clinician accountable for vulnerable older people in the community, just as there is in hospital...they should be named so that patients and carers all know where the buck stops.’ The speech is linked to three questions for consultation on the Department of Health website, but beyond that, there are few specifics.
I can see why ministers are so interested in the issue of older people’s transition from hospital to home and their post-discharge support.
Older people and their families have repeatedly expressed concerns about discharge from hospital being rushed, poorly planned or with insufficient involvement, notice or information. Lack of post-discharge support, care co-ordination or rehabilitation can lead to further deterioration in health, confidence and independence, and further stress for carers. It also risks emergency re-admission to hospital − an experience that older people often find distressing, and that exposes them further to the risks of hospitalisation. Re-admission rates are rising, especially in the over 75s.
The ‘named accountable clinician’ is also attractive to politicians and the public because of evidence that older people, especially those with complex co-morbidities, frailty, dementia or terminal illness, as well as their carers, can feel bewildered dealing with multiple disciplines and services. Professionals under-estimate the related stress and uncertainty. The recent National Institute for Health Research Care Transitions Project, with older people as co-researchers, made this very clear, with one participant saying ‘I felt like a stranger in a strange land’. If we are serious about integrating around the patient, then its tangible manifestation must be what National Voices term ‘person-centred co-ordinated care’.
In a recent article in the British Medical Journal, Primary Care Professor Martin Roland commented that ‘patients with chronic diseases value interpersonal continuity and co-ordination of care…associated with improvements in outcomes and satisfaction’. He advocates new approaches towards care in general practice – fostering more person-centred continuity for patients.
Mr Hunt’s pronouncement also chimes with the joint report to the NHS Future Forum by The King’s Fund and Nuffield Trust, which called for named clinicians, though perhaps without the now-fashionable emphasis on personal accountability. You might well say ‘so what’s not to like?’. But I do have some caveats.
First, as so often, it’s woefully short on crucial detail. Who will we define as sufficiently ‘vulnerable’ to merit the ‘named clinician’? How long after discharge will the arrangement continue? What are the consequences of ‘accountability’ for the ‘named’ doctor or nurse?
Second, we already have patients registered with named GPs, who have a contractual obligation to provide care for everyone on their list (including those in nursing homes or those who cannot get to the surgery). Are they not the de facto accountable clinician? And if not, how does it impact on their role as the most lengthily trained and highly paid clinicians working outside hospital?
Third, we also have virtual wards, home-from-hospital or supported discharge teams, case-manager nurses, clinical nurse specialists and palliative care teams. Do they count too? And whose ‘accountability’ takes precedence?
Fourth, health and social care is a team venture. However supportive and conscientious individual clinicians are, they depend on a much wider system to deliver the support that older people need – a system over which they often have little direct control. To have the buck stopping with a practitioner for failings in other services or teams seems harsh.
Finally, I wonder whether the ‘arms length’ body that is NHS England, packed with experienced, competent clinical leaders and NHS managers, is really being allowed to call the shots over decisions affecting the service, as was the original intent in the Liberating the NHS white paper. Or whether ministers will be able stick to the coalition script of ‘liberating professionals and providers from top-down control’. If it’s ‘arms’ length’, then the arm is currently a short one.