How to transform long-term care services

Transforming hospital services - we have been here before. Since returning to the NHS as a non-executive director of a foundation trust last April, I have been struck by one thing above anything else: a consensus seems to have emerged about the need to address the health and social care system’s over-reliance on hospitals when it comes to treating patients – and the older population in particular – with long-term conditions.

Given that severe depression is, in many cases, just as much a long term condition as diabetes, trusts and clinical commissioning groups looking for a new template should start with the experience derived from the transformation of mental health services

The reasons, both clinical and financial, have been very well presented by the King’s Fund programme Time to Think Differently and chief executive Chris Ham has been consistent over the last decade in promoting the example of the transformation achieved by the US Veterans Health Administration in the 1990s.

This exemplified approach is welcome; however, if this specific model has not proved compelling by now, it may not be one the NHS believes it can emulate.

In contrast, many pieces I have read are much better at analysing the problem and providing a generalised vision of a better future, than they are at articulating models that might underpin significant service change. It is almost as if the NHS had not already undertaken a major transformation of services for patients with long term conditions from hospital to community settings.

Learning from history

A recent study published in the British Medical Journal estimated that the number of beds in England for patients with mental illness reduced by more than 60 per cent between 1988 and 2008. As director of the Centre for Mental Health Services Development (a Department of Health sponsored consultancy focused on creating community mental health services) from 1994 to 2002, I was one of the leading figures in delivering this re-alignment of provision. What lessons might we draw for the present-day reformation of treatment for a much broader range of long term conditions?

‘Local transformation involved major changes in professional practices and relationships, and was not uncontroversial’

The first, and a necessary if not sufficient, condition was widespread agreement among a critical mass of stakeholders – patients, politicians, commentators, many clinicians – that something had to change. This was based, in part, on reports of neglect in asylums that had recurred within psychiatric hospitals in the 1960s and 1970s.

However, while bed numbers also reduced over that period, the focus of care remained steadfastly on the hospital ward. Despite many examples of local innovation, which were frequently researched and reported, health and local authorities lacked a blueprint for comprehensive communitybased services and the tangible steps to deliver them.

Where we’re at

It seems to me that is precisely where we are at present in the debate about alternatives to acute hospital care for older patients with a range of chronic diseases.

In psychiatry, sectorisation of services – one group of consultants looking after all the patients with specific conditions in a defined geographical population – was a rather mundane yet essential starting point. This enabled the creation of community mental health teams, with doctors, nurses, psychologists, occupational therapists and, crucially, social workers coming together to undertake assessments, design care plans and monitor progress.

Given the complexity and longevity of serious cases, these teams entirely took over the psychiatric care of these patients from primary care teams. Some community mental health centres became points of self-referral where patients could directly access secondary services whether or not they were known previously to those services. Others provided day care facilities.

Furthermore, they drew on innovations in the US and Australia to develop crisis intervention, dealing with emergencies in patients’ own homes to avoid admission wherever possible, in addition to assertive outreach – routinely going to patients who were vulnerable when they did not access the service of their own accord.

Effecting change

Previous research and emerging experience suggested rigorous implementation of these approaches could underpin hospital bed closures and therefore also recycle resources into community provision following a relatively short, and predictable, period of double running costs. At the same time, specialist teams oversaw long-term asylum residents’ discharge into small local homes and continued to provide them with psychiatric care. More recently, the same applied to patients admitted with dementia.

Overall, it became the predominant blueprint in the UK, and most of the local transformation programmes in which I was involved took five to seven years to complete. It sounds simple, indeed that was part of its recipe for success; however, it involved major changes in professional practices and relationships and, as a consequence, was not uncontroversial.

‘Trusts and CCGs looking for a new template should start with the experience derived from the transformation of mental health services’

In particular, some psychiatrists and GPs argued against the shifts in clinical responsibility that it entailed. This was especially so with regard to the move away from the traditional distinction between primary and secondary care that was based on the location of the provision of care, towards one rooted in the nature of the problem being treated.

It is also worth bearing in mind that not all psychiatric conditions were seen as being the same; there were, from the outset, distinct teams for children and adolescents, for patients over 65 and/or those with dementia, and for so-called adults of working age.   

In the absence of other proven approaches, and given that severe depression is in many cases just as much a long-term condition as diabetes, trusts and clinical commissioning groups looking for a new template should start with the experience derived from the transformation of mental health services.

This means introducing a model that includes locality teams of specialist clinicians and social workers who: take responsibility for the care of patients with serious long term conditions in their own front rooms and residential and nursing homes as much as on hospital wards; address medical and social issues in one integrated care plan; and are proactive in dealing with both acute episodes and ensuring engagement with treatment regimes. We know it can be done.

Professor Edward Peck is pro-vice chancellor, social sciences, at the University of Birmingham and a non-executive director at Heart of England Foundation Trust