“We shall never have all we need. Expectations will always exceed capacity. The service must always be changing, growing and improving – it must always appear inadequate”
Recently, Clare Marx ( Royal College of Surgeons) said that surgeons and other medical staff increasingly feel they are failing the elderly:
“Cuts to local authorities’ social care budgets result in older people staying in hospital much longer than is necessary. Elderly patients, many of whom are living at home alone with little support, are regularly being admitted to A&E after falls or for acute infections. They then get stuck in hospitals because there is nowhere for them to go to continue their recovery.
“It is incredibly sad to see this happen, and we feel that we are failing our older people towards the end of their lives – when they deserve more dignity and greater support to stay in their own homes.
“Regrettably this has a knock-on effect for planned operations. I am hearing more and more regularly from colleagues who have had to cancel planned procedures because there aren’t enough beds free on wards to admit patients for their surgery. As a result the NHS is becoming increasingly inefficient. It is a vicious circle that won’t end until we properly resource social and community care.”
Since 2010, total funding for the NHS has only risen by 1% a year which has been inadequate to meet the impacts of inflation and increased demand. In 2013, following the Health and Social Care Act 2012, a new structure of over 200 Clinical Commissioning Groups was formed, including a greater emphasis on the principle of internal markets. The consequences of these changes are still being rationalised, and there is evidence that it is driving the wrong cross-boundary decision making. The NHS, as a notional entity, is more fragmented now leading to more expense, complication and inefficiency.
In the quote from Clare Marx she identified the biggest driver of the efficiency problem, which is the integration between the NHS and Local Authority Social Care, and the management of post-treatment recovery outside of the hospital. The average stay in hospital for acute, emergency beds is ~10 days. Just over 40% of beds are occupied by people whose stay has been greater than 14 days, of which 80% are over the age of 65. This amounts to 477 beds in Derbyshire. A high proportion of these people will not require continuing acute ward hospital treatment. After around 14 days the body starts deteriorating, and other health complications start to set in which is a compelling reason to minimise hospital stays. This model is not good for patient care.
Most people’s interaction with the NHS is just with their GP. There are 340 million visits per year, against 146 million visits to hospitals. Concern is often expressed about timely access to a GP and a focus on community based care seems to be a preference.
NHS England is expecting to experience a £22 billion gap in its funding by 2020/21. To bridge that gap 44 regions have been identified ( generally in line with county/local authority borders) who were requested to formulate a plan to transform the whole of health and social care which would mitigate this gap. These are the Sustainability and Transformation Plans (STP) – the local one is for Derbyshire.
The overall vision of the Derbyshire STP is to promote:
- Place based care – to encourage care options which are local, or in the home, rather than hospital based.
- Prevention and self-management – to promote health and wellbeing and avoid the need for expensive healthcare
- Urgent Care – ensuring that this is focussed on acute cases and avoiding the consequences of extended stays
- System efficiency – there are many inefficient boundaries. “Trading” between commissioners, hospital providers and GPs creates costly complication and drives wrong decision making
- System management – There are many different autonomous organisations even within the NHS, and it needs to be managed more as a whole, to reduce fragmentation.
The consequences of the above is expected to bridge the cost gap in Derbyshire of £219m. This shifts the emphasis from bed-based care to local, place-based care which will reduce the number of beds by 535 ( 100 of these are outside of the region). This represents a 30% reduction in the number of acute, emergency beds.
“Doing nothing” is not an option. There is a lot of unnecessary expense, and some of the patient care approaches are not fit for purpose, especially for those elderly people who are in hospital greater than 14 days. How much of the future growth can be funded by these savings is a moot point.
Comments on the STP
- Bed occupancy rates are currently ~90%. A safe level that avoids other health risks is 85%. Beds should only be removed when a long term rate of a maximum of 85% can be committed. This implies that the seamless working between hospitals and Social services is well-embedded before any beds are removed.
- This seamless integration with Local Authority Social Services, Voluntary sector and other community based non-NHS organisations is not addressed in the plan yet is a critical success factor. This will be a significant change in the process, procedures and organisations of these entities.
- Derby City Council’s cutting of all Voluntary Sector Grants is an example of short-termism which does not consider the consequences on the whole system
- Although there have been small developments through the Better care Fund since 1 April 2015, this needs to be stepped up significantly to make any tangible progress.
- There should be greater emphasis on a proactive process by which hospitals work in conjunction with GPs, local care support to actively ensure that no one spends an unnecessarily long time in a hospital environment.
- Whilst the allowed 2% increase in Council Tax helps to provide additional funding for Local Authority Social Care, anecdotally, it seems not to be enough. There needs to be a different formula for calculating the funding which recognises the benefits to the whole system ( inc NHS) – not just as a Local Authority Grant.
- Minimise the “internal market”/tariff principles/existing GP contracts which drives volume through hospitals and therefore exacerbates the bed occupancy rate. Measures and flow of funds should support the principle of place based not bed-based care. This needs to be addressed.
- The principle of a system based footprint, and governance, which reduces organisational boundaries suggests that the direction of travel is for less fragmentation of the NHS, not more. i.e. outsourcing specific services to private companies is counter to the vision of the STP.
- The engagement and communications strategy is key to the successful implementation of this plan. This is possibly the single largest element of the project to ensure that the public do not feel that “arbitrary” decisions are being made to close facilities, reduce beds. Transparent, consultative, accountability will assure a smooth progress.
- Engagement must be constant to capture any “unintended consequences” of what, at first appeared, sensible plans.
- The identified risks in the plan are extremely high level. Part of the engagement approach, and consultation should give greater clarity on the more detailed implementation risks, and the mitigation strategies – this will indicate potential alternative plans and strategies which also might require consultation.
- The STP does not highlight any requirements for change at the NHS England level which would help facilitate more efficiency / bureaucracy avoidance – some must exist. ( It is assumed that there are cross STP opportunities, as well)
Transformation which drives the NHS, Local Authority Social Care, and other organisations to work seamlessly together is not an option; it has to happen. Whilst this should not change the core principle of “free at the point of use” , it must be revolutionary in its approach. When the NHS was formed there were many naysayers – that is the nature of transformational change. This will take courage , as well as professional planning, and widespread support. In my opinion it is the only way forwards.