Will 'care in the community' leave the elderly wandering in the streets?

Wishful thinking on 'care into the community' is damned by another expert report - but why are most politicians so quiet about hospital bed closures?

Jenny Shepherd
2 December 2014
elderly people sign_0.jpg

‘Care closer to home’ and ‘integrated care’ have been blasted as a ‘”Messiah concept” in a new expert Report on Hospital Care for Frail Older People. The report suggests it is a “myth” and “magical thinking” that that providing “more integrated” care “closer to home” for frail older people will solve the problem of poor care.

The Report, published in Health Services Journal, points to a history of failed NHS Messiah concepts - such as lean/Toyota management, community matrons and case management pyramids.

The Report echoes the findings of earlier reports - though in more colourful language. The evidence cited by the Commission is already well known.

The Nuffield Trust observes: “Current policy is aimed at cutting cutting the number of emergency admissions by providing more, better services outside hospital that can either prevent the need for hospital admission or offer the same care but in different settings”.

But it adds “This is a common theme in initiatives…including the government’s Better Care Fund. But there is little evidence that this can be achieved.”

In a damning report last month, the National Audit Office found:

“limited evidence that integrated care is effective in reducing emergency admissions sustainably, improving outcomes for patients and saving money”.

The Better Care Fund, in particular, has been slammed by Margaret Hodge MP as a “shambles”.

The HSJ Report identified that there is some international evidence of benefits from integrated care - but these don’t include a sustained, long term reduction in hospital admissions. They take years to achieve. And “the commonly made assertion that better community and social care will lead to less need for acute hospital beds is probably wrong”.

Clinical staff know this. Hackney GP Jonathan Tomlinson commented on Twitter: “Seriously chaps, if policy-makers-hack-wonks listened to clinical staff, we would have told you this ages ago”. 

HSJ journalist Shaun Lintern replied to Dr Tomlinson “We’ve known it too… Will probably be ignored by politicians of both parties.”

So why is NHS England is so signed up to this “myth”?

And why is there not more of a fight-back from local politicians?

Across the country, NHS commissioners are busily implementing this Messiah concept,  which goes under the name of Right Care Right Place Right Time - a commissioning model heavily promoted by NHS England.

This centres on cutting costly hospital care for frail older people and the chronically ill, and replacing it with supposedly cheaper care in the community.

The steady closure of NHS beds (particularly non-acute beds including in smaller district and cottage hospitals) means there a patient in an acute bed often has nowhere go for intermediate care, except home - or a private care home.

But massive cuts to Council’s social care budgets mean that frail patients who need care to be discharged home, can’t access the support they need, and this is why they remain in hospital.

Two rounds of the National Intermediate Care Audit have shown we only have about half the intermediate beds needed to make sure that no older person is in hospital if their needs could be met elsewhere.

England has few hospital beds per 1000 population compared to similar countries. Our hospitals run “hot” with around 95% occupancy. This compares to optimal occupancy for good patient flow of 85-90%.

Added to the hospital beds shortage (and the lack of intermediate beds), acute hospitals are being squeezed on all sides as a result of growing demand and reduced tariffs.

Hence the panic about “bed blockers”.

Showing just how desperate some acute hospitals have become, Bournemouth Hospital recently threatened to take legal action to evict frail older patients who “no longer need to be there”.

As the HSJ report says,

“We need to ensure that older patients with frailty are not punished for the system’s inability to provide what they need.”

It quotes Professor Marion McMurdo:

“The acute care of older people has progressed from being an inconvenience to being an anathema.”

It endorses her “radical suggestion” that we should “make hospitals good places for old people”, learning from best practice - instead of making the ageist inference that hospitals’ “core business” of caring for old people is too tricky to manage and the problem can best be solved by ceasing to attempt to deal with it.

Without this, Dr Jonathan Tomlinson half-joked on Twitter that

“Before long the frail, elderly with nowhere to go will be wandering the streets like a zombie apocalypse.

Need for appropriate real terms increases in NHS funding

The Report criticises the focus on “slash and burn” efficiency cuts.

It says that, far from being able to cut spending on acute hospital services, over time spending in the acute sector will not reduce; and demand for acute services will continue to rise in line with our aging population, with “at best… a temporary dip”.

This pragmatic approach challenges the whole direction of travel for the “transformational” NHS shake ups that are taking place across the country, which focuses on cutting acute hospital services.

The Report is clear that unless funding increases deal with these problems, the result will be damage to the quality of care for frail elderly people in hospital.

But no major political party’s NHS funding plans will fill the projected £30bn funding shortfall that is projected by 2020.  So what kind and amount of NHS care is possible with this funding shortage?

NHS England’s 5 Year Forward View imagines that this funding shortfall could be reduced to £8bn, on the assumption that rapid structural change would save £22bn in “efficiency savings” ie cuts. But the Report says that there is no evidence that this is possible.

In the absence of adequate NHS funding, the Report says that making acute care hospitals fit for purpose for frail older patients

“will require meaningful changes in the distribution of funding through the system (and disinvestment is always hard.”

It doesn’t say where the extra funding for improving acute hospital care for frail older people will be redistributed from and what disinvestment will be needed - although the obvious source of extra funding would be for the new post-General Election Parliament to pass the 2015 NHS Reinstatement Bill. If we’re going to have radical transformation anyway - as NHS insiders and politicians all seem to agree - why not abolish NHS marketisation and privatisation and save a conservatively-estimated £4.5bn/year? That’s funding which, if  restored to front-line NHS services, will plug the £30bn NHS funding gap that’s predicted for 2020.

Too little too late?

This Report may be a bit late in the day.  The integrated care closer to home “Messiah” concept is already well advanced. 

CCGs across England have awarded £billions of contracts to private companies to operate the new system.

Hospitals are being squeezed not just by lower tariffs, cuts and fines - but also by having hospital cash diverted to the Better Care Fund to provide ‘integrated’ ‘care in the community’.

The NAO found the scheme delivered very little. It was slammed as a ‘shambles’ by Margaret Hodge MP.

But it goes into council’s depleted adult social care budgets.

Is this why Councils have not used their overview and scrutiny powers (and duties) to stop or at least slow down damaging local NHS reconfigurations and ward closures?

We can at least exercise our vote to throw out Councillors who don’t fulfill their duties and responsibilities to stop this massive scam.

And luckily, there’s also general election coming up in May.

When, hopefully, the public will only elect MPs who are committed to enacting the 2015 NHS Reinstatement Bill at the start of the new Parliament.

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