Healthcare not just closer to home - but in the home

Source: National Health Executive Jul/Aug 2012

Dr Huw Charles-Jones, who chairs West Cheshire CCG, tells NHE about the work it is doing with other organisations and agencies under the ‘Altogether Better’ community budgeting pilot, and about the ‘Hospital at Home’ initiative to cut unnecessary A&E admissions among older people.

The shift to clinical commissioning is not happening in a vacuum: the new CCGs are having to deal straight away with the funding pressures in the NHS, and need to find care configurations that work better for patients but are also cheaper.

The UK has seen a rise in emergency admissions outstripping what demography alone would suggest, which West Cheshire CCG chairman Dr Huw Charles-Jones says has “many causes” and requires “societal change”.

He said: “There’s an expectation amongst people for an immediate response: if they’re concerned, they want to be seen quickly and easily, they don’t want the uncertainty of GP appointments, or out-of-hours doctors, they want an instant response. That means the default position for a lot of people has been to pitch up at A&E.

“There are issues about access to primary care and what’s available in the community, with people’s working hours and their expectations, which general practice hasn’t really dealt with. There’s been some expansion in expanded hours, but we still don’t have that 24-hour service that the rest of the world works to. It’s a five-day week model.

“The 2004 GP contract, when out-of-hours was taken off GPs, led to things like the closure of Saturday morning surgeries, and made access harder.”

He noted that different people have different reasons for treating A&E as a default option: from working age people who struggle with access to primary care due to inflexible hours, to older people who can be especially difficult to get out of hospital once they are in, to young families with immediate concerns and a need for reassurance about a child’s health.

This can be exacerbated by doctors themselves, Dr Charles-Jones said: “You’re often dealt with, say in paediatrics, by quite junior doctors who are fairly risk-averse and tend to admit children when they may not need to, and when it could be managed far better elsewhere.

‘Too much investment in acute care’

“We’ve not invested enough in the community in terms of what’s there for older people, so again concern means A&E. With older people, the way hospitals manage risk is very different to the way general practices manage risk. It’s much more medicalised: you need to do tests, therefore they need to go into hospital, and that takes time.

“Once you get an older person into hospital, it can be hard to get them out: they often then pick up hospital-acquired problems, or become less mobile, less independent.

“It’s a societal change in what we expect, but in my view, there’s been too much investment in acute care rather than in community services, or simple changes in people’s homes to prevent admission in the first place.”

This can often be where multi-agency approaches can help, he suggested, and is one of the aims of the ‘Altogether Better’ community budgeting pilot. Cheshire West and Chester is one of four ‘showcase’ areas looking at how to pool a budget of between £3-4bn from over 150 local services, and in which the CCG is working with the local authority, housing, emergency services, probation, colleges, government departments, acute hospitals and the third sector across a number of ‘themes’. These include helping families with complex needs, developing early years support, helping people get involved in decision-making, making communities safer, encouraging growth, helping the unemployed, avoiding unnecessary hospital admissions, and shifting to evidence-based policy approaches and strategic commissioning models in public services.

Dr Charles-Jones spoke about Altogether Better at the recent Local Government Association annual conference in Birmingham.

Hospital at Home

The local health community had already been working on a novel way of cutting admissions among elderly people before Altogether Better was even announced. This was the ‘Hospital at Home’ programme, led by GPs and nurses, which treats people in their homes.

Although it currently only has capacity to treat 12 patients at any one time, it has had phenomenal patient feedback, Dr Charles-Jones said.

He told NHE: “It’s had 100% satisfaction ratings. I’m not exaggerating, it got staggeringly good patient and carer feedback.”

Explaining the genesis of the idea, he said: “The pressure was that the hospital was struggling with the number of elderly people with complex problems who tended to stay there. Many had dementia or needed end-of-life care. Hospital wasn’t a great place for those people: they’re people who are not going to get better. You’re just trying to improve their quality of life – you’re not going to cure them, and they’re stuck in an acute hospital bed. With the best will in the world, an acute hospital is not set up to look after them.”

Breaking down barriers

The idea was developed by Partners4Health, especially its medical director Dr John Hodgson and head of clinical services Linda Gorst. Dr Charles-Jones used to be part of the company but left because of the conflict of interest when he became chair of the CCG.

He said a community-based ‘hospital’ was a “great idea”, adding: “It made everyone come together. It broke down barriers, as to set this up we needed to get the acute hospital consultants on board, the GPs, community staff, nurses, community matrons, social care and we had some mental health input too.

“We all had to come together to decide how this would work and agree admission criteria, agree clinical pathways. It was incredibly difficult – a lot of egos had to be massaged, and it was hard to get hospital consultants to accept that GPs could actually manage patients in a reasonable way! Once we got it off the ground – there was some scepticism among GPs as well: ‘why are you doing what we do?’ But this is a step up – IV fluids, IV drugs, 24-hour care – GPs can’t provide that.”

Since it went live at the beginning of this year, not only has patient feedback been unprecedented, but the GPs are really behind the idea too, although Dr Charles-Jones admitted there remain some “rumblings” among hospital consultants.

He said: “Our relationship with A&E is very good, which is important, and excitingly now we’ve got the ambulance service using it as a divert. If they get called to a nursing home, instead of taking that person to A&E, they’ll call Hospital at Home, which guarantees a two-hour medical assessment that allows the ambulance service to be reassured that they’re leaving the patient safely.”

Collaboration and commissioning

Dr Charles-Jones was enthusiastic about the amount of collaboration now happening under the Altogether Better model. He said health had some concerns early on that it would be the ‘junior partner’, but said the amount of progress from a position 18 months ago where there was “pretty much nothing at all” has been “dramatic”.

He told NHE: “That’s not to underestimate the problems or how hard it is to bring these cultures together, but a large amount of joint working is taking place.”

He went on: “There is no way in this current climate of a flat-line NHS and a falling budget for social care that we’re going to survive, unless we start working together and change the way we do things.

“It’s slowly dawning on people that we just can’t go on with this hospital-centric approach. It just isn’t affordable, and the only way to make things work is to have alternative provision, which has to be community-focused, and has to be done jointly with the local authority, and other public services – fire, police, we all bring different things.”

He gave the example of work by the fire service that can have an under-appreciated outcome on health and social care: for example, on home visits to elderly people to fit smoke alarms, noticing frayed carpets that could present a trip hazard and mean an emergency admission and everything that goes along with it.

He continued: “A big cause of A&E winter attendances is elderly people putting their bins out. Not gritting streets – just pushing bins out, and breaking their wrist or hip. The answer’s not a medical answer, it’s a social answer: how do you help elderly people put their bins out. But the health economy gains are huge, as are the gains for the individuals.”

West Cheshire CCG is in the first wave of clinical commissioning groups in the authorisation process, and has been operating in shadow form for quite some time. We asked Dr Charles-Jones what the mood among his colleagues was like on the progress so far, and whether clinical commissioning was turning out to be how he imagined it would be.

He said: “We’ve got some very talented managers and we are optimistic – but we’re not naïve, and don’t think it’s going to be easy. This is a very difficult time that we’re going into, but we do feel that getting clinicians involved in commissioning decisions has been really effective. You can see that in our contract discussions with our providers: it’s dramatically better when you have clinicians talking.

“Joint commissioning with local authorities is really positive – there are still some concerns about how we relate to Health & Wellbeing Boards and so forth, but generally speaking, we feel quite positive about what we’ve done so far and where we’re going. But we don’t think it will be easy.”

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Gitali   27/09/2012 at 14:02

Before the UK health leadership sleepwalks into yet another ideologically charged non-evidence based "project", let us be also aware of the cost implications of this "Healthcare at home" approach (the publication of data against the official dogma is probably a bit easier nowadays than medieval Europe, they are still not the most favourite with journal editors). Evidence 1: Goossens L et al. "Cost-effectiveness of early assisted discharge for COPD exacerbations in the Netherlands". Paper P1299 presented at the Eurpopean Respiratory Society meeting on Sunday , 02 September 2012 shows that "no clear evidence was found to conclude that either treatment was more effective or less costly" and "After three months follow-up, differences in effectiveness had disappeared. The difference in quality-adjusted life years (QALYs) was 0.0054 (CI: -0.021; 0.0095). early assisted discharge saved costs from a healthcare perspective, but not significantly: -Eur 168 (CI: -1253; 922). From a societal perspective, total costs increased, due to higher informal care costs: Eur 908 (CI: -553; 2296)." With the efficiency savings and cuts in the social services, the possibility of delivering healthcare at home in the UK seems an untenable option given that social expenditure increased by nearly 3 times with this "lovely" idea of healthcare at home. Evidence 2: Dalay S et al."Efficacy and safety of applying the British Thoracic Society (BTS) criteria to determine appropriateness of follow up in general respiratory clinics" Paper P1303 presented at the Eurpopean Respiratory Society meeting on Sunday , 02 September 2012 [] showed that the future of sustainable Long Term Condition management is specialist-led integrated care. It also showed that "Patient-focussed, multidisciplinary approach to long-term respiratory conditions allows accurate diagnosis and appropriate discharge planning to take place using the BTS criteria". It is high time that the financial pressures in the whole economy are reckoned with and "lovely" soundbites are supported by evidence (a difficult ask from subjects of a nanny state)

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