Firdaus Adenwalla is a consultant geriatrician in ABM University Health Board. He is part of the Neath Port Talbot Acute Clinical Team providing an intermediate care service for the community.
The media reminds us daily of how our health service is not keeping pace with our changing world. The negativity around health care, hospitals overflowing, not enough doctors, not enough nurses, GP practices closing, and the list goes on. Increasing demand, improved technology and our increased life expectancy, all compound the notion that our health service cannot meet our needs.
Professionals working in the health service are being told to be more efficient and with less money to go around, service reconfiguration is a must. The old saying if you keep doing the same then you will get the same. It feels like an insurmountable challenge but it can be done.
I would like to present the work of a small advanced practitioner led team (supported by myself) who have proved that it is possible to meet the needs of patients whilst reconfiguring service. They are called the Acute Clinical Team and work within a Community Resource Team in a Welsh valley called Neath. This community has a nearly typical demographic spread but with a slightly higher percentage of deprivation and older persons than the average in Wales.
Their primary objective is to provide comprehensive care in the community, especially for the frail older person and as a result prevent avoidable hospital admission. Despite many hurdles they have managed to achieve this on a macro and micro level. Over the past 7 years the admission rate for unscheduled medical admission to hospital for people over 80 years, has reduced by 14% for their locality. Comparing this to the average increase in admissions of 7% for Wales overall, this is a very significant achievement.
Their patients are also very happy with the service that they offer. A recent survey of referrers and patients provides very reassuring reading; the service provides effective and timely care for their patients and carers/families.
“Having previously been admitted to hospital for intravenous therapy, I found this team to be a far more efficient, comfortable and friendly experience. Everyone was most helpful and being treated at home I felt I was just not a number on a list and not taking up valuable hospital space and time.”
They provide all manner of services/treatments (seven days a week) to their community, falls assessments, fluid replacement, intravenous therapies, sometimes just assessments and signposting onwards to other services as appropriate.
The challenges of providing such a service cannot be underestimated, especially providing treatments that have traditionally been delivered in the hospital setting . Good leadership, teamwork and medical support are essential elements to create and sustain a service of this nature.
Particular challenges include:
- Adaptation of policies and procedures from hospital working to the community setting
- Staff are primarily lone workers and need to be skilled and confident to enable them to provide good quality care, whilst working within their scope of competence.
- Providing a rapid response to referrals (often within 4 hours) whilst maintaining supportive services in other cases.
- The team has grown in size and confidence over the past 12 years; they started with three nurses and now have a workforce of 21. Referrals are also increasing year on year as GPs often refer very complex problems that they feel are best addressed by this team.
Some of the most important features of their success are:
- Patient centred care – patients have their care/treatment designed around their needs not what the service can provide
- Working closely with carers, recognising the vital role they play in providing care in the community
- Respect – for their patients who have reported back to their GPs how well they were treated
- Motivating team members to learn new skills and take on challenges in the community
- Breaking down barriers between primary and secondary care and thereby gaining the trust of clinicians working in hospital and the community
- Having clear lines of communication with all the healthcare workers looking after the patient including carers.
- Having robust clinical governance arrangements and always making it clear who is responsible for the patient.
It has not been plain sailing but a worthwhile voyage for all staff and the people they serve. It is far more rewarding giving care to patients in their own home where they can retain their identity rather than becoming a bed number on a busy hospital ward.