Prof David Oliver is a Consultant Geriatrician in Berkshire and a visiting Professor in Medicine of Older People at City University, London. He is President Elect of the British Geriatrics Society.
At the recent King’s Fund Integrated Care Summit, I shared a speaking platform with David Prior – the new Chair of the Care Quality Commission and a man of experience and sincere commitment to improving patient care. In the course of his talk, he stated that “far too many patients are arriving at hospitals as emergencies, with accident and emergency departments out of control and unsustainable in many parts of the country.” He added that “the healthcare system is on the brink of collapse” and “if we don’t start closing acute beds and investing instead in community care, the system will fall over”. He stated that with “almost half of hospitals providing care which is either poor or not terribly good, the pressure means that regulators cannot guarantee there will never be another care disaster such as Mid Staffs”.
In the week beforehand, the Health Service Journal had published national figures showing rising breaches of the national 4 hour Emergency Department waits and a rise in much longer waits. In the same week the Royal College of Nursing had raised the issue of increasing pressures on staff at the front door of hospitals at their annual conference. Shortly after I heard David Prior speak, the Foundation Trust Network and College of Emergency Medicine stated that current emergency pressures were unsustainable.
Amidst the growing sense of crisis generated by these statements, even the Secretary of State for Health, Jeremy Hunt, admitted that in the first three years of this government, there had been an additional 1million extra ED attenders each year. Care minister, Norman Lamb, suggested that the care of older people is key to saving the whole system and re-iterated the general view that too many older people were coming to hospital inappropriately and staying for too long. He also said that “hospitals are incentivised to admit people but not to prevent admission or discharge them” (a dubious statement in view of the non-payment for readmissions policy and marginal tariff for excess emergency activity).
So, was David Prior right in asserting that the way to solve system problems was to close even more acute beds? It seems counterintuitive given current pressures. A recent BMJ paper showed that the UK has lost more beds, more quickly than other OECD countries. We have among the lowest ratio of acute beds per head of the population of any of them. Yet (as the RCP also acknowledged in “Hospitals on the Edge”) these bed closures have been accompanied by inexorable rises in emergency admissions and readmissions, with the acuity and dependency and age of patients getting higher along the way.
What are the factors behind the rise in demand (besides what are hopefully “teething troubles” with the new 111 number)? They include: inadequate focus on prevention of morbidity and self-care; rapid population ageing and the rise in prevalence of the oldest old, the frail, those with dementia and multiple co-morbidities; a model of primary care that finds it hard to deliver sufficient proactive, anticipatory care for this group of patients given multiple demands on it; the fact that for half the hours in the year we rely on out-of-hours services but spend around 0.4% of the entire NHS budget on these (even though most GPs I meet are the first to admit that whilst they have a fighting chance of keeping their own patients at home and accepting risk, a doctor out of hours who doesn’t know them and doesn’t have their records is likely to admit); the impact of major cuts in support grants to local government on social care provision, with the NHS picking up the pieces and dealing with delayed transfers; the very variable provision of adequate step-up or step-down home-based or bed-based intermediate care services; a lack of healthcare inputs into long-term care; and insufficient focus on advance care planning and end-of-life care closer to home.
Two factors are crucial in the response to this. The first (acknowledged by ministers and NHS England) is that if people with complex needs and multiple problems are now “core business” we need to focus far more on person-centred co-ordinated (for this read “integrated”) care with far better information sharing and real attention to gaps and hand offs. The second is the help-seeking behaviour of the public. Most emergency admissions are not referred by GPs but are rather a consequence of patients presenting themselves directly to hospital. Patients and their carers, when there is a crisis, will vote with their feet and present to hospital because they have confidence that something will happen and happen quickly if they do so – even though we all know the risks of hospitalisation. We need to change public expectations that hospital is not the default option but the last resort and that you can’t stay there till you are completely back to baseline. We haven’t faced up this public dialogue.
Which brings me back to David Prior’s comments. Yes, we might be able to close beds IF we have adequate capacity and access in community alternatives. The trouble is, that if you take capacity out overnight with nothing credible in its place, mayhem will ensue, with trolleys on “any flat surface” and more black alerts, major bed incidents and 12 hour waits. We might have to accept some “double running” for a spell, with beds maintained in hospital whilst alternatives are properly established and staffed. A good example of this approach from South Warwickshire has just been published. The NHS might also have to give some money to very constrained social services to help with delays and capacity in social care.
Of course, to save money across the health economy, closures of whole hospital wards are required, given the running costs of keeping one open. But options closer to home do need to be cheaper than being in an acute bed on a marginal or readmission reduced tariff. It is not currently clear that they are.
It is completely wrongheaded to characterise hospital doctors as somehow engineering admissions to keep tariff income and then keeping people in hospital to generate even more. As if?! – it is not in our thoughts and we are desperate to keep people out, given the massive bed pressures. It is difficult to assert the tariff is the problem given a 3.5 fold variation in admission rates and bed days for over 65s and a national tariff. The other nations in the UK (no tariff, not purchaser-provider split) face the same challenges, suggesting the fault does not lie with this particular aspect of the machinery of the English NHS.
In the midst of this, whatever we do, we need to stop accepting that “hospitals are bad places for older people to be”. However well we do at care closer to home, older people will come to hospital (often quite appropriately) and when they do we need to heed Marion McMurdo’s radical suggestion, “Make them good places for older people to be”.