Northamptonshire’s integrated care partnership is helping frail elderly people stay at home, says Stuart Shepherd

Knowing somebody who can move a bed downstairs, get in some groceries, and sort out the transport from hospital can often be the difference between a frail older person going home from hospital or having to go in to residential care. But it isn’t always easy to achieve.

However, the impact of the whole system multi-agency approach to urgent care adopted by the Northamptonshire Integrated Care Partnership national pilot has begun to make it possible.

It allows for what Northamptonshire County Council corporate director of health and adult social services Charlie MacNally describes as lots of pragmatic and trust building work.

“We have broken down unhelpful barriers and turned ‘It’s not my business’ attitudes into ‘it’s everybody’s business’,” he says. “Everyone involved with that older person’s wellbeing wants them to be in the most appropriate setting and we are now commissioning a local voluntary agency to support them during the first three days post discharge.

“The primary care trust added £100,000 to the £250,000 that we originally put in and since December 2009 this simple and effective intervention has saved 1,000 bed days. The key to it all is the trust and that’s both organisational and personal.”

“Being part of the partnership allows us to move away from an institutional need to prove our performance to [being] our own regulator,” adds Mr MacNally. “We all look at the whole system and see what needs changing. That can require organisations to make compromises that may disadvantage them, but it balances out.

“There are also disagreements but they are the test of a mature relationship and a part of coming to understand each other’s pressures.”

To substantially reduce hospital admissions and improve discharge rates among older people, agencies have been forced to look at both provision and commissioning practices.

As well as committing case management, physiotherapy and occupational therapy support to newly built specialist care centres, which go live this autumn with beds funded by health, the council has also had to challenge voluntary sector providers to put forward tenders that evidence the focus and impact of their services.

At NHS Northamptonshire, the business case has been predicated on a reduction in acute hospital flows that allows for reinvestment in community based services and for conversations with the acute trusts about staff redeployment. Geriatricians who had been exclusively hospital based will now also work in the community at the interface of both services.

“In a partnership, designing new pathways to keep people well at home means getting providers to the point where they are happy to give things up for the greater good,” says director of strategy and system management Richard Alsop. “You also have to stack it up to make sense financially for each of the partners.”

Working formula

Yet in spite of these hoops the integrated care partnership has clearly found a working formula.

“I have never quite seen a series of service change proposals that have such strong and cross sector clinical buy in,” Mr Alsop says. “I think it is a strength to capitalise on and offers us all some learning we shouldn’t lose sight of post white paper.”

The newly expanded community based intermediate care team is already in place and ready to start delivering those plans that come out of the individual comprehensive geriatric assessments.

The geriatrician support - psycho-geriatricians will be available too if required - will be available to teams in the county’s casualty departments and medical assessment units as well as to the discharge teams, the intermediate care team and the many GPs involved with proactive case management.

Holistic assessment

“We will reduce the numbers, but we are not trying to stop all frail older patients going to accident and emergency, because that will never happen,” says the partnership’s programme director Julie Passmore.

“Now though, when carers and patients do become distressed and call for an ambulance, this approach will see them receive care planning based on a holistic consultant level assessment.

“The evidence for this model, which is clinically designed and led by the partnership board, is that getting the decision making done by those with the highest levels of clinical skill gives you much better outcomes for patients,” she says

However, this is not investing for quality alone. Delivering the benefits outlined in the business paper is essential.

“We have to reduce the burden on the acute sector, reduce the cost to commissioners of the flow to hospital, care for people in the community and deliver the return on investment,” says Mr Alsop.

“Without savings to the health economy this isn’t a success.”

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Partnership Plans

Northamptonshire Integrated Care Partnership plans over the coming 24 months:

  • Prevent 2,000 emergency admissions a year for elderly frail patients - 16 per cent of all emergency admissions for this group
  • Prevent 30,000 bed days for elderly frail patients - 20 per cent of all bed days for this group
  • Prevention of 4,800 excess bed days - 15 per cent of excess bed days for elderly frail patients
  • Forecast gross savings £5.9m
  • Forecast return of investment 1:1.7