HSJ/Serco Commission: Further evidence supporting commissioners' key findings

Key point 1: out of hospital care

There are similar findings from the Nuffield Trust’s Evaluating Integrated and Community-Based Care (Bardsley et al 2013) which examined a variety of community services including telecare and telehealth, case management, hospital at home and virtual wards. It found no compelling evidence that any of these could impact at pace on urgent hospital admissions or save money across health and social care systems.

This is not to say it is wrong to explore these community models nor focus more on integration and care coordination. However, we should not assume that they are a magic bullet which will reduce the need for urgent care in our ageing population and offer a quick fix to the need for emergency hospital based care.

‘Even when care out hospital is effective, it is not necessarily cheaper than being in a hospital bed’

A Cochrane Review, the NHS Confederation’s Dealing With The Downturn and the NHS Confederation/Royal College of General Practitioners paper Integrated Community Services for Older People all emphasise that even when care out hospital is effective, it is not necessarily cheaper than being in a hospital bed. It is unlikely to save any money unless further capacity is taken out of the hospital and remains closed. Hospitals running close to full then cease to be efficient, with knock-on effects for the rest of the system.

Key point 2: prevention

Focusing more on prevention, wellbeing and active ageing can sometimes postpone the onset of illness or dependency – known as ‘primary prevention’. A similar conclusion is mentioned in The Billion Dollar Question (Allen and Glasby 2010); Health Care Quality for an Active Later Life (Melzer et al 2012) and NICE’s Clinical Guideline 181.

Improving primary and community care may enable people to live better with frailty or long term conditions and reduce urgent crises or complication: ‘secondary prevention’.

Provision of rapidly responsive services outside hospital delivered in conjunction with ambulance, primary and social care services can support some older people in crisis and postpone the need for hospital care but it will make frail older people neither invincible nor immortal. Mostly, they will simply need the care later (British Geriatric Society’s Silver Book and Royal College of Physician’s Acute Medical Care for Frail Older People).

Despite plans by clinical commissioning groups including use of the better care fund in conjunction with local partners to reduce urgent activity, the King’s Fund Making Best Use of The Better Care Fund (Bennett and Humphries 2014), and the Department of Health allocating additional monies to emergency departments to help with four-hour performance and winter pressures, ambulance conveyances and urgent activity have continued to rise across England and many acute providers have been on ‘red’ or ‘black’ alert even in summer months in 2014.

Key finding 3: funding

Serious commentators, including the King’s Fund’s 2014 Barker Commission on future health and care funding and the Nuffield Trust’s Future Health and Care Funding report (Crawford and Emmerson 2012), think that the gap over the next decade required just to keep services at current levels is around £30bn.

The same bodies suggest that a transition fund is required to allow investment in the kind of services outside hospital that might help relieve the pressure on acute beds. The evidence that two thirds of the funding gap can be met by further gains in productivity and prevention is lacking.

John Appleby, chief economist of the King’s Fund and one of our commissioners has discussed the need for around £4bn per year additional investment. No major political party’s current health policy commitment comes near meeting this funding gap nor even to the less ambitious £8bn in the Five Year Forward View.

‘The source of funding for these provider reforms is unclear- if they do not succeed, negative implications for the quality of care would follow’

Most of the public seem to lack awareness of this funding challenge and its potential impact on them and their families. The source of funding for these provider reforms is unclear if they do not succeed, negative implications for the quality of care would follow.

Meanwhile, major cuts in direct support grants to local government have reduced older people’s access to social care support - even older people with needs classified as “substantial”. This is supported by the Health Foundation and Nuffield Trust report Cause of Concern. This in turn will make it harder to keep them away from urgent care services or get them out of hospital once in a hospital bed.

Key finding 4: care models

Work by the Oak Group in several acute providers (Edwards 2013) along with Tough Times, Tough Choices, a report by the NHS Confederation on community healthcare, have shown that between one in four and one in three patients over 65 still in hospital could hypothetically receive treatment or care and support in the community if the capacity were available.

‘Older people should only remain in an acute bed so long as it adds value to their care’

Studies such as Avoidable Acute Hospital Admission in Older People (Mytton et al 2012) and the Foundation Trust Network’s Driving Improvements in A&E Services on preventable admission and readmission in older people have shown that lack of access to responsive community alternatives or more proactive and coordinated primary care are behind many potentially avoidable admissions.

The development of ‘in-reach’, ‘pull’ or ‘discharge to assess’ models (see Flow Cost Quality and The Health Foundation’s Improving Patient Flow), in which community services actively take people out of hospital as soon as they are medically fit for discharge, is in its infancy. The use of rapid chair based assessment clinics with specialist phone advice as an alternative to hospital admission remains very patchy.

A whole variety of factors explain variation in urgent activity and bed occupancy in older people and point the way to potential solutions. Although, in our complex, adaptive health and social care system, nothing is certain and simply dropping a new service model into a system which cannot support it or only providing some of that model for some of the population is unlikely to deliver big gains. This was also found in FTN study Older People and Emergency Bed Use (Imison et al 2012).

These factors include the help-seeking behaviour of the public, the availability of responsive community alternatives, the age of the local population (acute hospitals dealing with large numbers of older people are more likely to get care right); the number of commissioners, community providers and local authorities the acute hospital is dealing with and the quality of relationships between agencies.

In addition, some “vertically integrated” models have had success in creating additional capacity outside hospital and more seamless transitions, as evidenced in Does A Process Flow Make A Difference to Mortality and Cost? (Silvester et al 2014); the Health Foundation’s Unblocking A Hospital in Gridlock and the King’s Fund Specialists in Out-Of-Hospital Settings.

We can do all of these things as well as possible but older people will still continue to present to hospital. And hospital is often the best place for their care needs to be met. The issue is that they should only remain in an acute bed so long as it adds value to their care.

Key finding 5: community focus

Ipsos Mori and the NHS Sustianable Development Unit’s Sustainability Survey show that the public still have great faith when polled in local hospitals – even ones who have suffered reputational damage. There can still be an attitude that it’s wrong to send older people home quickly; that they need to be wrapped in cotton wool protected from risks, and that when problems occur at home- hospital is the solution.

However, this is not a zero sum game. It can be safer and more person-centred to provide care, assessment and support in the homes of older people. Being in hospital can entail repeated ward moves, a rapid loss of mobility and confidence, institutionalisation and risks of harms such as delirium (acute confusion), avoidable bed rest, falls, poor nutrition or infection as well as poorly coordinated care and poorly planned discharge from hospital. Reports such as Making Our Care and Health Systems Fit for An Ageing Population (Oliver et al 2014); Continuity of Care for Older People (Cornwell et al 2012) and Clinical Risk’s Managing Risk in Older Inpatient Hospitals (Oliver 2012) support these findings.

We have a responsibility to minimise those harms and to ensure that frail older people are in hospital for the shortest time needed for their acute condition. Many of the solutions lie entirely in the control of the acute hospital in terms of leadership, skills, training and safety culture as well as a clear focus on discharge planning and post acute rehabilitation seven days a week. But some rely on much greater partnership working and integration with community and social care services and primary care.

No patient should need to be admitted to hospital due to a lack of home help and adaptations along with other straightforward and obvious requirements. Ensuring adequate community provision is in place is a commissioner’s responsibility which will become more important as a consequence of demographic change.

Increasing community and social care resources may enhance the care that older people receive at home and bridge gaps in current services. It is well known that the quality of those services is little measured and little understood. It is unclear whether increasing investments on out of hospital health and social care will wholly or partly just satisfy demand for services in the community that are presently un-met.

‘Older people with frailty, dementia and complex comorbidities are now the “core business” of the acute general hospital’

Older people with frailty, dementia and complex comorbidities are now the “core business” of the acute general hospital. So we have to get their care right rather than wishing them away. The HSJ/Serco Commission aims to give practical and ongoing support and information to help improve hospital care for older patients with frailty who do need acute care (fractured hips, acute stroke and other such conditions). Providing care for older patients with frailty and multiple health problems is often more complex due to their comorbidities and age related issues. Hospitals need to gear up to provide the very best care for such older patients who are now their most frequent customers.

The recommendations of the commission in its final report in March 2015 will provide a template for doing this well. The commission has also showcased numerous examples of good practice going on right now in services around the UK. It has also linked its recommendations with the work of the British Geriatrics Society; with the RCP London 2014 Future Hospitals Commission which has made the care of acutely ill frail older people a priority in its pioneer hospitals; with the King’s Fund report Making Our Care and Health Systems Fit for an Ageing Population (Oliver et al 2014), and with the newly established Acute Frailty Clinical Network.

Hospitals can fix this issue but the right leadership is too often lacking. Too many leaders are not copying others’ good work ethics. Failing this, they are not creating a local environment conducive to front line clinicians focussing beyond national key performance indicators on improving quality and safety in their own services. Besides they are not providing an organisational culture from board to ward that makes high quality care for frail older people a key priority and poor quality care a rare exception to the norm.

It is welcoming that the Care Quality Commission has now prioritised the care of frail older people and those living with dementia in acute hospitals for every inspection. And that it has advertised for a specialist senior inspector with specific expertise in the care of older people. However, even from the CQC, solutions are less forthcoming than critiques. Leaders still feel that they are distracted by regulatory interference in measuring the wrong things and by tariff distorting priorities for incentivising inappropriate things.

We need to ensure that older patients with frailty are not punished for the system’s inability to provide what they need. To quote the Canadian geriatrician Ken Rockwood in 2005: “When we design services for people with one thing wrong at once, but people with many things wrong turn up, the fault lies not with the user but with the system. Yet all too often these patients are deemed inappropriate and labelled as a problem.”

Former national clinical director for older people Ian Philp said in 2006 that we need to make services “age proof and fit for purpose”. In 2007 the all parliamentary committee in the Human Rights of Older People in Healthcare concluded that “an entire culture change is needed” as in effect did The Second Francis Inquiry and Recommendations for The CCG.

Yet despite the banning in the 2010 Equality Act of age-based discrimination in health and care services and the revised NHS Constitution [DH 2013] stating clearly that access to services should be equitable for all ages and reflect the preferences, priorities and dignity of service users, we still have a long way to go.

Building on existing good work

The government’s structured response to the Francis report has generally been a force for good. (DH 2013 and 2014) There has been a focus on transparency and public-facing information and on willingness to learn more from feedback and complaints. The report has led to many hospitals increasing nursing establishment on wards where older people are cared for even at the risk of worsening financial positions (McLellan 2014). The training of healthcare assistants has been in the spotlight (Health Education England 2013).

The new CQC inspections for hospitals now focus on many of the issues identified by the Francis report, not least privacy, dignity, nutrition, hydration and the care of older people and those living with dementia. The NHS England ‘safety thermometer’ has focussed minds on common harms of hospitalisation for older people.

The Age UK/NHS Confederation 2012 Delivering Dignity commission and then two major King’s Fund reports in 2012 and 2014 set out a range of good practice. There has been a national movement to improve the physical environment and care for older inpatients with dementia (Prime Minister’s Challenge on Dementia). NHS England has set out a vision for better practice in the care of older people in Compassion in Practice.

Many services are getting on and delivering – realising as they do that we cannot save health and care services for the future without improving the care of older people. And if we can get care right for the most frail or vulnerable hospital patients, we should be able to get it right for everyone.

However, there are still too many care gaps, too much variation and too much inadequate care that falls well short of what we could be proud to deliver for our ageing patient population, and would want for ourselves, or our relatives, in old age.

Quality, variation and care gaps

When we think about “quality” in the care of frail older people in hospital, of course those aspects of dignified, person centred essential care highlighted by the Francis report and in the Age UK/NHS Confederation “Delivering Dignity” Commission, in the Patients’ Association CARE Campaign or in past and recent reports by the NHS Ombudsman are important and make big headlines. However, beyond this key element of patient experience, there are other equally important aspects of quality:

• Outcomes and the application of evidence based interventions known to deliver them;
• Safety and preventing avoidable harms;
• Fairness and equity- free of discrimination based on age or other factors such as dementia or poor mental health;
• Continuity and care coordination (integrated care);
• Responsiveness and person-centredness efficiency.

Across all these domains of quality there is still much work to do.

We know from major national clinical audits – inpatient falls pilot audit; dementia care in general hospitals; national audit of continence care and Age UK’s nutrition audit – along with reports of National Confidential Enquiry into Patient Outcomes and Deaths, for example An Age Old Problem (Wilkinson et al 2010) and Adding Insult to Injury (Stewart et al 2009) that we are still failing to deliver basic assessments and treatments around nutrition, falls and bone fragility, continence, perioperative care or fluid balance.

We know too that the ‘big ticket’ patient safety items – falls, pressure sores, healthcare acquired infections, deep vein thrombosis, drug errors are progressively more common with age in hospital inpatients. And other harms of hospitalisation such as immobility or delirium or institutionalisation and loss of physical function are not generally classified as safety incidents but are avoidable harms nonetheless (Long S et al 2013)

From Achieving Age Equality in Health and Social Care (Carruthers and Ormonroyd 2009), we know that there is still endemic evidence of ageism and age discrimination both in attitudes, language, values and access to assessment and treatment for frailer older people and that we still don’t have a workforce with values and skills fit for our largely older inpatients.

This was summarised in the “Dignity in Practice study (Tadd et al 2011) and the accompanying “Tale of Two Wards DVD, in which nurses often expressed a “right bed, wrong patients” attitude to older people and failed to “see the person in the bed”. Language and terminology around older people are still too often ageist and patronising and create an attitude that little can be done to help older people get better (‘Acopia’ and ‘Social Admission’ Are Not Diagnoses: Why Older People Deserve Better Care; David Oliver’s blog post on the British Geriatric Society; Centre for Policy on Ageing 2009 and the Delivering Dignity commission).

We know that too often care within hospital is poorly coordinated with too many hand offs and ward moves and delays and a failure to provide seven day services. Effective Approaches in Urgent and Emergency Care’s Priorites Within Acute Hospitals has made this evident to us. And that at the transitions between community and hospital and out again, older people and their families are often bewildered and insufficiently involved in the decision making: National Institute for Health Research Service Delivery and Organisation Programme Understanding and Improving Transitions of Older People: A User and Care Centred Approach (Ellins 2012).

In particular the experience of discharge from hospital, or urgent readmission that is currently running at around 15 per cent within one month and seven per cent within one week in over 65s, is distressing (The ‘Delivering Dignity’ Commission and RVS 2013). Too often, it seems that different professionals and agencies fail to talk to each other and older people “fall through the gaps”.

Workforce and skill mix

There is a real push to revive general medicine in hospitals. Already, acute medicine physicians, emergency department doctors and geriatricians need to be all-rounders, as indicated in Clinical Medicine’s Transforming Care for Older People in Hospital: Physicians Must Embrace The Challenge (Oliver 2012). But many other general or internal medical specialities have a ten year postgraduate training and increasingly general internal medicine study includes large amounts of geriatric medicine. So all hospital doctors need to embrace it and even in surgical specialties, basic skills and awareness are required. In the nursing workforce, we know that wards for older people have traditionally been under established.

And though there is a body of evidence and knowledge around the care of frail older people akin to that required in paediatrics, coronary care, ICU nursing or specialist palliative care, we don’t have many consultant nurses or nurse specialists in the care of older people and government. This is a response to the Francis report (DH 2013) that ducked the recommendation to create a cadre of such nurses.

Due to so many older people in hospital having functional impairment, immobility, speech and swallowing problems, poor hearing, foot care or and because of comprehensive geriatric assessment and complex discharge planning and post acute rehab being multidisciplinary ventures, it is also crucial to have an adequate allied health professional workforce to deliver high quality care, and all too often this is overlooked (showcased in Tthe Nuffield Trust’s Focus On: Allied Health Profressionals).

The growth in highly specialist consultant numbers show that we must pay greater attention to postgraduate medical education and reproducing generalists by making a specialism out of generalism. The Shape Of Training Review, chaired by University of Nottingham vice chancellor David Greenway, will have an impact on this.

The Cancer Services Coming Of Age report (Age UK/DH/Macmillan 2012) report confirmed that skill mix and workforce are significant ongoing issues for providing appropriate care for older patients.