Will named clinicians for older people work?

In his speech he went on to say: “Most people leave hospital with long term conditions which need to be supported at home… so we need to know that there is a clinician accountable for vulnerable older people in the community, just as there is in hospital… they should be named so that patients and carers all know where the buck stops.” The speech is linked to three questions for consultation on the Department of Health website, but beyond that there are few specifics.

I can see why ministers are so interested in the issue of older people’s transition from hospital to home and their post-discharge support.

Older people and their families have repeatedly expressed concerns about discharge from hospital being rushed, poorly planned or with insufficient involvement, notice or information. Lack of post-discharge support, care coordination or rehabilitation can lead to further deterioration in health, confidence and independence, and further stress for carers.

It also risks emergency readmission to hospital − an experience that older people often find distressing, and that exposes them further to the risks of hospitalisation. Readmission rates are rising, especially for the over 75s.

Fashionable policy

The “named accountable clinician” is also attractive to politicians and the public because of evidence that older people, especially those with complex comorbidities, frailty, dementia or terminal illness, as well as their carers, can feel bewildered dealing with multiple disciplines and services. Professionals underestimate the related stress and uncertainty.

‘Who will we define as sufficiently “vulnerable” to merit the “named clinician”?’

The recent National Institute for Health Research’s care transitions project, with older people as co-researchers, made this very clear, with one participant saying: “I felt like a stranger in a strange land.” If we are serious about integrating around the patient, then its tangible manifestation must be what National Voices term “person centred coordinated care”.

Primary care professor Martin Roland has said “patients with chronic diseases value interpersonal continuity and coordination of care… associated with improvements in outcomes and satisfaction”. He advocates new approaches towards care in general practice − fostering more person-centred continuity for patients.

Mr Hunt’s pronouncement also chimes with the joint report to the NHS Future Forum by the King’s Fund and Nuffield Trust, which called for named clinicians, though perhaps without the now fashionable emphasis on personal accountability. You might well say what’s not to like? But I do have some caveats.

Lack of detail

First, as so often, it’s woefully short on crucial detail. Who will we define as sufficiently “vulnerable” to merit the “named clinician”? How long after discharge will the arrangement continue? What are the consequences of “accountability” for the “named” doctor or nurse?

‘I wonder whether the arm’s length body that is NHS England is really being allowed to call the shots over decisions affecting the service’

Second, we already have patients registered with named GPs, who have a contractual obligation to provide care for everyone on their list (including those in nursing homes or those who cannot get to the surgery). Are they not the de facto accountable clinician? If not, how does it impact on their role as the most lengthily trained and highly paid clinicians working outside hospital?

Third, we also have virtual wards, home-from-hospital or supported discharge teams, case manager nurses, clinical nurse specialists and palliative care teams. Do they count too? And whose “accountability” takes precedence?

Fourth, health and social care is a team venture. However supportive and conscientious individual clinicians are, they depend on a much wider system to deliver the support that older people need − a system over which they often have little direct control. To have the buck stopping with a practitioner for failings in other services or teams seems harsh.

Finally, I wonder whether the arm’s length body that is NHS England, packed with experienced, competent clinical leaders and NHS managers, is really being allowed to call the shots over decisions affecting the service, as was the original intent in the Liberating the NHS white paper. Or whether ministers will be able to stick to the coalition script of “liberating professionals and providers from top-down control”. If it is arm’s length, then the arm is currently a short one.

David Oliver is a visiting fellow at the King’s Fund. A version of this article also appeared on the King’s Fund blog.