In Warwickshire, we have had some success in delivering better and more sustainable care for older people across hospital and community settings. We have reduced mortality rates, acute hospital bed use, readmissions and the need for long-term institutional care.
Good care must include a compelling drive to understand the person’s individual needs and priorities, with a humble acceptance of the impossibility of ever being able to fully do so. But here are some golden rules, some guiding principles, which we can use to deliver the right care, in the right place, at the right time, every time.
Rule 1 – get in early. Most threats to health, independence and wellbeing can be reduced through early identification and a response based on the priorities of the older person.
I think there are 49 key threats. We have included them in an assessment tool for use in primary care, and in the last four years, have tested it and found it to be valid in 36 poor, middle income and rich countries around the world.
It will be widely used in China from May this year, it works as a community development tool in Tanzania, and has been found to be effective for early detection of dementia in the Netherlands. And in Warwickshire, Age UK volunteers are using iPads to undertake assisted assessments with older people identified as being at risk by their GPs, with information stored and shared with others subsequently involved in the person’s health and care. More information is available on www.easycare.org.uk.
Rule 2 – chose to admit. Many older people admitted to acute hospital care have medical needs which could be dealt with in the community, but because the older person has fallen, gone off their legs, or become confused, it is difficult to manage them initially at home, so they default to hospital admission.
In Warwickshire, we have established an emergency community response team which can deliver care and support to the older person with these presentations within two hours, following which acute hospital admission is arranged where evidence emerges of an underlying medical condition which needs to be sorted in the acute hospital. Only one in five patients with these presentations need admission, avoiding about eight admissions per day.
Rule 3 – specialist acute care. If you are frail and in an acute hospital bed, you need to be under the care of an old age specialist team as soon as possible. You will be more likely to survive, have fewer ward moves, a shorter length of stay, less risk of healthcare acquired infections, better recovery of ability to mange independently and a better death if you are dying.
You will also cost the health service less money.
Most hospitals need to increase their investment in old age specialists by about 50 per cent, and will recoup their investment within a year.
We have done this and have been fortunate to be able to recruit excellent clinicians. However there are too few to go around and we need to train more.
Rule 4 – discharge to assess. We put so many barriers in the way of discharge from acute hospital care, I sometimes wonder how anyone identified as frail, confused, needing rehabilitation or social care can ever escape. We need to turn this system on its head – discharge to assess, rather than assess for discharge.
Our emergency community response team provides this service, then hands over after two or three days to social care reablement and community health services. Sceptics said this would not be safe, but we have seen high patient and family satisfaction, a reduction in mortality rates and 0.1 per cent readmission rate, compared to the national average for older people of 5-6 per cent.
Rule 5 – recovery before placement. Too many older people are shunted into long-term institutional care prematurely, often following an acute illness or surgery, when it is common for older people to develop confusional states which take up to six weeks to resolve. Inactive convalescence leads to further deterioration, but a reablement programme which encourages recovery of independence will reduce the need for long-term care by up to third.
The biggest reductions in need for long-term support are sometimes achieved in patients with dementia or complex needs. No-one should be excluded from a chance of recovery and all will benefit from increased independence, even if long-term support is needed.
These are my five rules for disruptive innovation in the care of older people. Give them a go.
Ian Philp CBE is the medical director at South Warwickshire NHS Foundation Trust.
Download the NHS Confederation’s Transforming local care: community healthcare rises to the challenge to find out more about the trust’s innovative work.