I spend my time as an NHS doctor working in acute care at the front door of the hospital and on the wards, trying to get people better and back home as soon as I can. It’s a great window into the impact of gaps in community services, especially for older patients, who end up in hospital most frequently and stay the longest.
I think about ‘what might have been’ for many of the patients I see, every day, if only alternative solutions and services were readily available. I often wonder ‘what if?’ before realising it is all a daydream and returning to the pragmatic ‘make-do-and-mend’ solutions actually in my gift.
But what if that dream came true? What if community services really were available to all those older people who need them 24/7?
The most frequent users of our services – whether acute, primary or community, mental health and social care – are older people. I am not talking about those remaining in fair health, but those living with multiple long-term conditions, frailty, dementia or age-related disability. Getting their care right is crucial, especially with an ageing population, rising demand, and pressures on workforce and funding.
These citizens often rely on unpaid care. In the UK, one in four of the six million people who care for an older person is over 65; their own health may be poor and is often affected by their caring role. And it’s often carer stress, burn-out or concern that triggers use of health services in a developing crisis. Any 24/7 community service supporting older people must support their carers too.
High-quality community services must inspire confidence that they are safe or safer than hospital services, deliver outcomes that matter and focus on individuals’ specific needs. For the sake of people, systems and services, they should ensure that time and resource aren’t wasted on duplications, delays or hand-offs and that people don’t spend time in beds they don’t need to be in.
So what would our utopia look like?
I’m focusing on people who need access to rapid assessment or additional support in a crisis, who need services that run on a stopwatch not a calendar. To achieve this, properly funded and staffed primary and social care is a must, as is a better focus on planning and support to live with long-term conditions. And planned social care would be available 24/7. It’s often night-times that are the deal breaker that make staying at home impossible.
In this wonderful new health service, when people did require urgent primary care they’d see their GP or nurse practitioner quickly – in their own home if needs be. Around 90 per cent of urgent care is urgent primary care, remember. If it’s not working well, there is additional strain on already rammed A&E departments and beyond.
Currently around four in five people over 75 admitted to hospital have not been referred by the GP. Sure, many of them are very sick and going straight to hospital by ambulance might be the right decision, but plenty could have been dealt with outside hospital.
In future-land, we’d also make more use of chairs not beds. Instead of sending people into overcrowded, noisy A&E departments, we’d get them to a centre where they could be seen by a team of clinicians, access some diagnostics and go on to hospital only if really needed.
We would have ambulance organisations working closely with community health providers and employing their own advanced practitioners. This would be available everywhere 24/7 and not only in some places, on some days as now. When done at scale this really works in keeping people – notably those who have fallen – in their own home and away from the risky conveyor belt of the acute system unless truly needed.
If people did spend time in hospital as the result of a crisis, we’d be able to get them out, 24/7, as soon as they no longer needed to be there. Maybe we could (as some units now do) ‘discharge to assess’ so that any new needs could be assessed and care provided in their own home.
If the patients got beyond the acute medical unit into the ‘deeper’ wards, they would have exactly the same 24/7 access to rapid response ‘step-down’ services as they would have if they’d still been at home or in A&E. Need wouldn’t be defined by where you happened to be in the system.
Joyously, we could virtually abolish ‘delayed transfer’ bed days in hospital. The moment someone was fit to go home with intermediate care, or palliative support to die with dignity and comfort, or social care, they would be gone with a day or two’s period of grace to prepare and plan. Often, the same team already supporting them at home could seamlessly pick up their care again.
For crises at home, we know that older people, especially those with frailty, can lose function very quickly. They go from coping to not coping, being lucid to being confused, being upright and mobile to falling and being immobile. For these patients, something needs to happen quickly and reliably and we’d make sure that ‘first response’ assessment and support teams – with the skills and professionals available to accept some risk and keep people at home – were available 24/7. We know that such models work well especially if the team can provide ‘wrap around’ care.
Our wonderful 24/7 offer would also include access to mental health support, preferably at or close to home. It would involve specialists delivering care outside hospital walls, working closely with GPs and other community staff as part of a single team. And we’d make certain it included specialist palliative care support to enable people to die at home or in a hospice or care home if that was their choice.
We’d also ensure that care home residents had the same access to these services as people living anywhere else. Too often they can be poor relations in terms of access and this can lead to many avoidable hospitalisations, especially at the end of life.
Finally, we’d make sure that what’s available in the community is consistent, repeatable and not left to chance about whether that service has capacity on that day or whether the professional assessing you knows how to access it. Neither professionals nor the public should require a reference manual or Masters degree to navigate the system. We would abolish all duplication, referrals and delays and arcane rules that put procedure and organisational protocols at the centre and not the person.
If we did all this it would be ‘win/win’ because basing care around what people need and want is generally better for the system. Right place, right time and a focus on care closer to home should produce gains for everyone in the long run.
But to do all this, we would need to ‘double run’ for a while, stop overpromising the scale and pace of benefits, and both fund and staff the workforce adequately.
The shame is that none of this is really ‘magical thinking’. Everything I have imagined already happens right now in some parts of the NHS. And it works brilliantly when it happens. We need the rest as good as the best.
‘The NHS if’ is a collection of essays published by The King’s Fund that explores hypothetical scenarios and their impact on the future of health and care.
We are asking a small number of experts – some of them members of staff at The King’s Fund and others external experts in their fields – to write short essays that consider ‘what if’ questions about health and care in England. We’ll be publishing these essays on this website throughout 2016.
Our aim is to encourage new thinking and debate about possible future scenarios that could fundamentally change health and care. The essays cover three themes: the NHS and society; medicine, data and technology; and how the NHS works.
In each essay, the author gives their informed but personal view of a possible future. We invite you to let us know what you think and join the debate by adding your comments below the essays or by tweeting using the hashtag #NHSif.
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