How to keep older people out of hospital

Dr Mark Newbold, chair of the NHS Confederation’s Commission on Improving Urgent Care for Older People, highlights the key ways to cut avoidable hospital admissions

As an acute trust chief executive I was part of the daily struggle to maintain safety standards and meet performance targets amid staff shortages and worsening finances. But the people it is toughest for of all are the older people in our care.

There is too little capacity in the wider health and care system to allow older people quick access to the appropriate care outside hospital, whether home-based or residential care. It means people are unnecessarily admitted to hospital or subject to delays in leaving once they are well enough to return ‘home’. This puts them at greater risk of losing independence or suffering from complications, such as chest infections, the longer they stay in hospital.

It is significant that NHS England chief executive Simon Stevens has joined the growing consensus across the system that there is a critical need to prioritise social care for more funding over the NHS. Speaking at the NHS Confederation conference in Manchester, Simon Stevens noted that social care funding remains “unfinished business”.

But as chair of the NHS Confederation’s Commission on Improving Urgent Care for Older People, it is clear to me that there is a lot health and social services can do now, within existing resources, to improve care and reduce pressure on services.

We need to support older people to stay well for as long as possible, both because it is best for them and because it can relieve pressure on hospitals. By focusing on proactive, preventive support and care we deliver what older people and the system need.

The commission’s report, Growing Old Together, focuses on practical solutions that are locally-based and tailored to the needs of individuals.

The commission found many inspiring initiatives across the country where NHS organisations, either alone or in strong partnerships, are transforming care.

It found frontline clinical leadership producing fantastic initiatives in acute hospitals, such as Sheffield Teaching Hospitals NHS Foundation Trust and Royal Berkshire Hospital NHS Foundation Trust, though to innovative community based initiatives such as the Age UK Pathfinder Project, which demonstrates the impact care co-ordinators can have by acting as advocates for individuals and ‘integrators’ of the services they receive.

The Sheffield example is a great one for other hospitals to consider. Teams caring for older people realised that the traditional method of occupational therapists assessing medically fit patients for discharge to home could be improved, so they trialled assessing individuals in the more familiar surroundings of their own home.

Instead of being assessed in mock kitchens and bathrooms on the ward, individuals were assessed in their own homes to see how they managed within their own kitchens, bathrooms and beds. With the support of senior clinicians and managers, the team started with a single patient being assessed in their own home. The assessment gave the team a stronger sense of the individual’s ability to remain living independently at home and a better understanding of their support networks locally. So the process of discharge to assess (D2A) was developed.

Once they carried out a number of such assessments in people’s homes, the team found that the majority of those assessed needed lower levels of care package than assumed under the previous ward-based assessments.

This new way of working in Sheffield was gradually rolled out and more than 7,000 people had been assessed on discharge using the new active recovery service over the last year. Patient satisfaction has been high and results show people have been discharged home when medically fit in an average of 1.1 days, compared with 5.5 days three years ago – a saving of more than 30,000 bed days and higher quality of patient experience.

Community nurses from North East London Foundation Trust and paramedics from London Ambulance Service are together providing a home-based emergency assessment and care packages for people who fall, avoiding them needing to go to A&E. The initiative has shown that only 5 per cent of those seen and kept at home were admitted to hospital within 48 hours.

Patient and public engagement at Oxford Terrace and Rawling Road surgery in Gateshead has mobilised the local community to provide a range of options to support ‘social prescribing’ for people whose support needs are often social rather than medical.

The Age UK work showed that care co-ordination does not have to be led by the NHS and that support can be provided in the community, with Age UK staff or volunteers taking on the care co-ordination role. They identified those most at risk of hospital admissions in the area and then produced a tailored care plan to help keep them out of hospital. By intervening early there has been a significant improvement in the health and well-being of the local community and a 31 per cent reduction in hospital admissions.

Age UK showed care co-ordination does not have to be led by the NHS

To help spread success like that experienced in Cornwall we need local leaders across the country to introduce a care co-ordination function and to ensure they are empowered to cross the organisational boundaries of the health and care sector for the benefit of local people.

A common feature of successful change seen by the commission is the presence of a single, dedicated individual who fights tirelessly to overcome the blocks to progress. Unsurprisingly, progress is greater when these individuals are helped by system leaders to overcome these barriers. Supporting the frontline and those driving constructive change must become the norm for senior leaders.

National bodies, in turn, must move away from a regulatory approach that focuses on individual organisations and better encourage local transformation. Data that measures whole system performance, based on outcomes important to older people, should be one solution.

Together, national and local leaders can help ensure the workforce is trained and supported to deliver the eight key principles outlined in the Commission’s report. These espouse cooperative values and techniques, while putting the needs of the individual at the centre of large and small care decisions. The individual will have more options. For example, changes to someone’s home may do more to lessen their back pain than surgery.

We know what works, and we know how it can be done. The challenge the commission lays down to leaders in health and local government, and across the voluntary sector, is to support each other and to look outside of their organisations, redesigning services based on what is important to those who use them.