Picture this. It’s mid-winter. You’ve managed really well since your fall last year, but today you’re not feeling quite right—you’re dizzy and under the weather. Getting through to your GP is hard, and you don’t like to bother them anyway, and your spouse thinks you should go to A&E.
At A&E there are lots of doctors and nurses, rushed off their feet, and you wait. You can’t quite remember, when they ask you, the names of all the pills you are supposed to be taking, and you are feeling more poorly as each hour goes by. So, when they say they aren’t sure what’s wrong but want to admit you, just to be on the safe side, you see that it’s probably for the best.
And so a journey begins, which at its worst can mean staying too long in a bed while the system tries to organise the extra care needed when you get home. Sometimes this takes so long people become weaker and unwell again.
Improving the quality of care for people at risk of both unplanned hospital admissions and delayed returns home has been a priority in the NHS for some years, and is seen as key to the NHS’s survival this winter. These people are generally—but not exclusively—likely to be older, with several conditions.
So in February, the government set the NHS a target of reducing daily delays in discharging people from hospital to around 4,000 by September, after hitting a high of 6,660. The logic was sound: delays in getting people home has a knock-on effect throughout the hospital, putting pressure on bed occupancy in wards, and making it harder to admit people from accident and emergency departments—which is when patients can be stuck on trolleys. The latest data suggest that although delayed discharges have fallen, the 4,000 target has been missed, and emergency admissions are creeping ever upwards.
How then to affect real change? The recent CQC State of Care report warned that the whole system is at full stretch, particularly where different services have to work together. Clearly, the NHS is starved of funds, so more money would help. But beyond money, it’s about enabling staff to think of new ideas and make change and it’s worth looking though some recent schemes set up to tackle the problem.
There are plenty of examples of new and effective approaches to avoid unnecessary admissions in the first place, and get people home faster and more safely. In Sheffield, a team based in a hospital worked with community services to pilot a scheme in 2012, supported by the Health Foundation, which aimed to arrange assessment of older people’s care needs while they are at home, rather than while they wait in hospital. “Discharge to assess” has worked well—in 2015, the hospital reported that over 10,000 older patients had been discharged home in an average of 1.2 days compared with 5.5 days three years ago. Another team in South Warwickshire has also found that they could reduce the time spent in hospital, based on close collaboration between health and social care teams.
"In February, the government set the NHS a target of reducing daily delays—it failed to meet it"Progress is also possible in the equally difficult task of reducing the risk of hospital admissions among the most vulnerable when alternative help should be on offer. Care home residents in Rushcliffe in Nottinghamshire receiving a combination of dedicated GP visits, support from the voluntary sector, and more input for care home managers and community nurses were 23 per cent less likely to be admitted to hospital in an emergency than similar patients in care homes with no equivalent scheme.
Faced with positive examples such as these, the temptation on the part of policymakers is to tot up the likely savings at a national level and roll out the programmes everywhere. This is risky, for two reasons. First, the context of each scheme matters just as much as the new service or way of working. In the above examples, teams had spent several years building relationships between professional groups. “Please give us more time” might seem enormously frustrating from the point of view of a patient or carer, but it is important to understand that at the heart of these new projects is a huge amount of complexity and uncertainty.
As recent research has shown, improvements in hospital treatment for serious conditions has meant more people surviving strokes or heart attacks that might have killed them a few years ago, but these issues leave them at greater risk of subsequent health problems that might need hospital treatment.
And here is the second risk of jumping to quick fixes: we are still not clear what proportion of hospital admissions might be “avoidable” or what combination of services people will need (or for how long) after leaving hospital to enable them to live as well as possible. While it is certainly right for the government to focus on “delayed discharges” for patients who need social care, channelling £1bn this year to local government, the state of the social care market is fragile. The State of Care report highlighted just how uneven provision is in the care home sector, while home care services are even more volatile, with 30 per cent staff turnover rates and hundreds of small home care companies appearing and disappearing every month.
There is no doubt that this winter will either be tough, or very tough, depending on the severity of seasonal flu and the weather. The crisis will be visible first in A&E departments. NHS hospitals, the place of last resort for an overstretched system, must be able to provide the staff and beds needed to ensure patient safety. The question is whether the immediate demands of winter can be balanced with the slower, more complicated work that has taken root in some parts of the country, which needs to be given time to grow.
