Your top ideas: structural changes and funding

Incentivise older people’s care

“Incentives could be built into the tariff system to reward hospitals for better treatment of frail older people, based on outcomes, readmission rates and friends and family scores.”

Radical change 

“Close these ‘warehouses’ and build the new infrastructure for care at home, I would allow a phase of transition and an eventual existence of small local clinical units with short stay overnight facilities.”

“Ramp up care at home; remove the artificial barriers of false and excessive focus on miniscule risk avoidance policies rife in current care (health and social). Build a new paradigm based on a kindness culture. Cum scientia caritas.”

• How to improve care for older people: HSJ readers’ ideas

Health and social care planning

“Allow health commissioners and social services to work together to plan services relevant for a particular area using the public health expertise now in local authorities. Involve NHS providers in the planning process becaue they know what is going on more than the commissioners. Stop contractual gaming in this process. Devon is successful because there are so few commissioners and providers.”

Improving pathways and referrals into community services

“Unfortunately in many areas there is a fundamental confusion on accessing district nurse services and primary care and on what services are provided. There are a number of contributing factors to this:

• the restructure of community services;
• both community and acute services are becoming more stretched and are under increased pressure; and
• Pathways are often not redesigned across the whole pathway (including community services post discharge)

“This often leads to patients needs not being identified prior to discharge and avoidable readmission to hospital. Improved referrals and multidisciplinary teams working between services is vital to break this cycle. It cannot be resolved by the community or acute service alone. Pathways must be designed to include movement across community acute services and funding distributed to account for this. There are some really good examples but until this becomes the norm in commissioning and delivering services, older patients will continue to be stuck in the middle of a disjointed NHS which fails to support them fully.”

“Reduce the number of inpatient beds in large acute hospitals and transfer resources to community provision which is a combination of intermediate care and virtual wards where services wrap around the individual and their family to support them at home.”

Implement the King’s Fund recommendations on polypharmacy and medicines optimisation

“Polypharmacy in the elderly is shockingly common and linked to unnecessary admissions. This results in a  ‘revolving door’ situation for many, adversely effecting quality of life and wasting resources.

“Very few people with multiple long term conditions have all their medicines reviewed together. Very often a medicine started in secondary care is prescribed in primary care way longer than it’s needed. Full clinical reviews of a patient’s medicine, including adherence, are not as common as they should be. This will only change if medicines optimisation services across the patients pathway are specifically commissioned.

“A useful recommendation is, rather than attending several disease-specific clinics, patients could have all their long term conditions reviewed in one visit by a clinical team responsible for coordinating their care. Patients with multi-morbidity admitted to hospital under one specialty may require access to a generalist clinician to coordinate their overall care.”