The RCP Future Hospitals Commission: That was the week that was.

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. jumper

Twenty-first century health and care services face a number of existential challenges. I do say “challenges” rather than use apocalyptic language of crisis and catastrophe but face them head on, we need to respond with constructive solutions. These challenges are universal in developed and developing nations – even those spending more per capita on healthcare and have been widely acknowledged.

The challenges are in large part a result of modern medicine’s success in prevention, public health, disease management and life-prolonging intervention.

  • Population ageing, with the fastest rise in the oldest old
  • The “flat funding” settlement for health services (accompanied in England  by reduced social are funding)
  • The rising proportion of people with multiple long-term conditions, including dementia, functional impairment and frailty syndrome: Often relying on multiple services and on multiple medications.
  • The consequent need to design systems and services – including hospitals – around people rather than single disease entities
  • The need for much more person-centred, continuous, co-ordinated care (or “integration”)
  • The tension between growing specialisation (fostered by an exponential growth in the evidence-base for treatments and the fact that patients with single diseases do better under expert care) and generalism (because “core business” in hospitals is now patients with complex co-morbidity. They generally want a single named clinician to co-ordinate their care).
  • The growing importance of unpaid caregivers in supporting people as they age
  • The need to combat ageism and age discrimination
  • The need to have a workforce with the right skills, training and attitudes and employed in the right places to deal with these new realities. Designed around what the population needs rather than what they as providers might be drawn to.
  • The growing pressure on acute hospitals from rising admissions and attendances despite the rapid loss of acute beds.
  • The need for a radical “right-left” shift from reactive high cost interventions and treatment of ill health towards wellness, prevention and proactive care

Clearly specialists in the care of older people, with geriatricians leading the way, have a key stake in all of this. But we can’t look after every older person and despite the growing number of community and interface geriatricians, we are still mostly hospital-based.

At a time when there are growing calls for clinical leaders to step up to the plate, we must commend the Royal College of Physicians for seizing the day and being prepared to challenge all specialisms in acute medicine and all hospitals to change the way they work. A theme throughout the “hospitals on the edge” and “hospital workforce: fit for the future” reports, the “acute are toolkit” and the Future Hospitals Commission report is the need to ensure that hospitals are made fit for our ageing population. This theme was echoed in the Francis Report – where many of the issues raised concerned older people. These assorted documents recognise the need for better skills in the care of older people and a renewed commitment to generalism in training and in hospital care. All physicians need to take ownership for all the aspects of patient care including discharge planning, care co-ordination and communication and not merely the diagnostic and therapeutic aspects.

The Future Hospitals Commission is a long and rewarding read, but here are the headline recommendations. I can’t imagine any of us disagreeing with them.

  •  Fundamental standards of care must always be met
  •  Patient experience should be valued as much as clinical effectiveness
  •  Responsibility for each patient’s care should be clear, co-ordinated and communicated
  •  Patients should have effective, timely access to care
  •  Patients should not move wards without over-riding clinical justification
  •  Robust arrangements should be in place for transfers of care
  •  Good communication with and about patients should be the norm
  •  Care should be designed to facilitate self-care and health promotion
  •  Services tailored to meet the needs of vulnerable patients with complex needs
  •  All patients should have personalised care plan reflecting individual needs, choice, control
  •   Staff should be supported to deliver safe, compassionate care and quality

Because of the report’s importance to the care of older people, we have published a series of blogs this week covering various aspects from Paul Knight, Adam Gordon, Zoe Wyrko and Amit Arora. We hope they will kick start a healthy discussion and be widely shared.

Given our general support for FHC, the involvement of geriatricians on the working group and the BGS’s opportunity to influence earlier drafts, it might seem churlish to express any caveats, but nothing is perfect so here are mine.

  • Amidst all the talk of reviving generalism, there is little acknowledgement that a large proportion of GiM is led by geriatricians – increasingly so in places where organ specialists are leaving the rota to focus on speciality provision. Geriatrics also has the highest number of trainees of any RCP speciality. Most adult patients remaining in hospital beyond a few days are older people with complex needs. The frailty syndrome and the oldest old account for a large proportion of the medical take. Although CGA and the BGS are mentioned there is little acknowledgement that we are key in achieving the desired changes nor that more geriatricians would solve many of the problems.
  • As the UK already has the longest postgraduate GiM training in the world and many of our specialist colleagues have dual accreditation, it is not clear how merely having even more people train in GiM will make them interested in doing it as “core business”. The evidence suggest that those trained or training in GiM are taking flight from it as we speak.
  • We can all support the idea of care without boundaries and much more seamless transitions between community and hospital settings. And there are some fantastic examples of “vertically integrated” organisations with one provider of acute, primary care and community services. But the FHC report looks very much through the hospital lens. We must remember that around 90% of care episodes happen in primary care, even though it receives less than 10% of the NHS budget. Nearly half of registerd doctors in the UK are GPs. Despite the power, funding and “iconic building” status of hospitals, it will increasingly be Primary Care organisations who are taking a lead in pathway redesign, calling the shots and attempting to shift care closer to home. So the RCP setting out its vision unilaterally for acute hospitals having greater reach into the community might sit badly with our primary care colleagues
  • Finally, whilst all the high level objectives in the report are laudable, there is currently less detail about implementation. And when it comes to enacting a vision like the FHC – the devil is in the detail.

The BGS and its members need to use the momentum generated by the FHC and ensure they engage with implementation plans to help effect lasting change in the care of older patients.

4 thoughts on “The RCP Future Hospitals Commission: That was the week that was.

  1. ,Paul, Zoe, Adam, David and Amit I agree with almost everything you have written – I was also a little perturbed about the push for G(I)M without an acknowledgement that Geriatric Med has been doing this stuff for years – however of course there are many non older and non frail people admitted to hospital who don’t seem to be claimed by any specialty and who therefore don’t have anyone rooting for them- the geriatricians don’t have time and more G(I)M consultants doing this would be ideal.Should we be revisiting the length of training issue to address the current unattractiveness?

    I was also initially pretty cynical about the whole hospital ‘centricity’ of the proposed changes;
    I am a community geriatrician based in a community trust with no acute in-patient responsibility( a model of care which suits our situation and not one necessarily appropriate for most other areas). I firmly believe the whole management system for older peoples’ health and social care needs to be rooted in the community and primary care with forays into hospital (for reasons of diagnostic need or treatment necessity) being as short a possible. No long term care planning should be done whilst someone is in an acute bed, and older people should have to stay in an acute bed only as long as they have an acute need. This means community services need to take responsibility for Comprehensive Geriatric Assessment and the consequent formulation of care and support plans both before and after crisis management. We need to see staff of all disciplines who are trained in or specialise in Medicine for Older People working wherever the older person is, not where the beds happen to be.
    I have therefore rationalised the ‘Division of Medicine’ led by a chief of medicine, as being a virtual Division which encompasses services for patients across a whole pathway of care be it inside or outside hospitals.The chief of geriatric medicine(in the case of older people) is responsible for clinical quality in all its forms along the pathway. Staff work where needed regardless of whom is their employer and the organisational boundaries are simply the means to organise pay and other HR imperatives.

    I do realise this is asking a lot – but it is not impossible; we know that there are moves afoot to challenge the current acute ‘tariff’ system in England with its perverse incentives(for example the Year of Care project) and we also know the CCT’s want to commission pathways of care(and indeed have already started to do so in East Anglia I understand) rather than individual pockets of health care based on historical provision.

    I am not sure that the FHC’s authors had envisaged the Division of Geriatric medicine working in this way or that the ‘chief of medicine’ might be a primary or community care employee – but their encouragement of all specialists to work outside of hospitals certainly helps us move along this path.
    Bring it on as they say!!

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