This is the second of two blogs by BGS President David Oliver, focusing on the recent launch of the NHS England Five Year Forward View. Read part one here.
In my blog on 24th October, I described the crucial marker that this document has laid down for the mid-term future of English Health and Care services and the “big picture” implications. Here I want, in the words of the “Dragon’s Den” voice-over, to “drill down” into some of the key features and their implications for fellow BGS members.
Whilst we deal with the consequences of preventable ill health in older age, the report’s focus on prevention across the lifecourse is commendable. We know that there are major inequalities in life expectancy and healthy life expectancy at 65 and that around half of all poor health in older age is attributable to life style factors. So its good to see a clear challenge to government around diet, obesity, alcohol, cigarettes and exercise and the need to move away from “nudge” and “responsibility deals” to more proven preventative interventions. We also welcome the greater focus on local government’s role in reducing social isolation or improving housing for older people. And on the untapped contribution that volunteers can make to helping older people remain connected and active – as well as the benefits for older people who are volunteers.
Most care for older people happens in primary and community settings. At the BGS, we agree with our colleagues in the Royal College of General Practitioners that General Practice has been chronically underfunded, that GPs and Community Nurses face a significant workforce shortfall. We also acknowledge that whilst NHS primary care services still score highly on several indicators, that current models of primary and community care aren’t quite right for our ageing population.
In particular, those patients with multiple long-term conditions, with frailty or dementia aren’t well served by services based on single diseases, short consultations and reactive rather than proactive mode. The time is right to move towards more person-centred, co-ordinated and age-proof models. This includes a clear focus on better support for those living with Dementia and support for the c 5.5 million carers for older people in England – many of whom are older people themselves.
The report also makes clear the need to provide a better range of integrated community services which can “wrap around” people to support them at home or help them get home sooner.
To deliver some of these initiatives new models of primary care may be required, including federations of general practices, or in some cases general practices run by acute hospitals. Hospital specialists might work more at the interface or in community settings to support these models.
With regard to urgent care, the Five Year view acknowledges that whilst some specialised services are better concentrated on larger sites, smaller district general hospitals will still be vital cogs in the wheel, though they might tie into local integrated care organisations.
After several years of concerted awareness raising, influencing and BGS reports such as Quest for Quality, Failing the Frail and Care Home Commissioning guidance, finally, we now have someone in national service leadership making the health care of care home residents an explicit priority and discussing the need for input from the full range of primary and community services to residents – including geriatricians. The BGS is explicitly mentioned in this regard.
All of this has real relevance to our speciality and to better care for older people. For instance, many of our members are delivering much of the day to day activity in those smaller DGHs where older people form such a big part of the bed occupants. Geriatricians are increasingly working in the community and in nursing homes or at the interface between primary and secondary care (see for instance the recent Kings Fund Report of the work in Leeds led by our president-elect, Eileen Burns). We have a stake in helping support people with Dementia and carers better. And we are often on the receiving end of problems caused by poorly co-ordinated primary and community care, or a lack of access to those responsive services closer to home. And at the hospital “back door” more joined up services would help prevent older people being marooned, harmfully in hospital.
What’s not to like in all this? Mainly, the detail of delivery. I will give just two examples among many. The aspiration to move towards fully transportable shared electronic records accessible to patient is welcome but no-one has ever made this happen at scale in England yet and we have suffered serial costly failures. Same with support for carers – how? And with how much money?
Talking of money, whilst the report acknowledges that there will be a £30bn shortfall by 2022 – it talks about finding £22bn of that in efficiency savings. This beggars belief. Most of the easy wins have already happened. The Kings Fund has been clear that we need an additional £4 bn or so each year in additional funding just to maintain services at current levels whereas the Five Year Forward View is only talking about £8bn – perhaps frightened of upsetting our political masters and being overambitious. But if we are going to ask for an uplift, let’s ask for the full amount with no equivocation rather than pretending more big efficiencies can be delivered at pace.
Finally, it’s great to hear Simon Stevens put out the nuanced message that we can’t impose change top down, but at the same time we can’t have “1000 flowers blooming” – in other words, we need to tailor new service models to local circumstances and allow local service leaders to develop them. But we can’t have a free for all, where each health economy re-invents the wheel instead of learning from, adopting and implementing best practice models. He isn’t very clear, in our new system, whose job it is to ensure best practice is implemented. At the moment, no-one is taking clear ownership. In my view specialists medical societies such as the BGS and colleges such as the RCP should take a leading in role in helping our clinical colleagues learn from successes elsewhere and in setting out clear statements on “what good looks like” preferably in partnership with NHS England. The Hip Fracture Database, Stroke Strategy and Dementia Strategy and Action Alliance or the Frail Safe movement are great examples of how to make this happen.