Care in the community can only go so far, especially for frail older people, and financial frameworks need to recognise that. Demographic and medical change bring a flow of demand that cannot and should not be simply switched off
Andy Burnham continues to flesh out his vision for integrated out of hospital care to prevent acute deterioration, and maximise independence for the elderly and long term sick.
But does the shadow health secretary’s reasoned aversion against an acute centric care model underestimate the crucial part that hospitals will play in the frail elderly care pathway?
Once again, the acute tariff is blamed for giving a financial incentive to admit older patients rather than to keep them well at home.
‘Hospitals and communities are operationally “full”’
If this was ever true – and the doctors who take the decision to admit are rightly disconnected from profit and loss calculations – it is certainly not the case in the current system of emergency care.
Hospitals and communities are operationally “full”: general and acute bed occupancy regularly exceeds the recommended 85 per cent to reach 99 per cent.
Elderly acute admissions are a huge liability in these circumstances, and acute trusts are penalised not only through the marginal tariff but also through fines for both missed accident and emergency targets, and knock-on slippage against elective waiting times and cancellations.
Medical outliers are a daily reality that leads to lost elective income and expensive specialist beds blocked for weeks. And some commissioners have quietly ditched payment by results for block contracts now anyway.
Hospitals across the country are therefore admitting older patients in very acute need, in spite of loss they bring rather than because of any profit motive.
Acute trusts are also arranging and funding community care “virtual wards” to free up beds, even though they are not paid for the whole pathway.
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As NHS Providers has argued, the financial framework is now more of a penalty on acute providers than a reward for the treatment of illness.
The clinical definition of frailty is the elevated risk of catastrophic decline in health and functioning caused by a cumulative decline in physiological systems – by definition creating an increased risk of hospitalisation.
Research suggests frailty may be affecting not just more older people, but also younger ages, especially in deprived communities.
Whole person care in the community should target and attempt to prevent the acute need that frailty generates, but it is not yet seen as a preventable condition.
Given these demographic trends and the needs of people living with frailty, the next government needs to recognise that acute need and acute care in hospital will be an inevitable and necessary part of whole person care.
‘The next government needs to recognise that acute care in hospital will be an inevitable and necessary part of whole person care’
Poor hospital care, where patients with social needs are abandoned on corridors or unfriendly wards, must be rooted out and remodelled with a wraparound service as described by Burnham’s plan.
But hospitalisation is not always a failure, and good quality acute care for the elderly should be opportunity to rescue and rehabilitate, integrating with the new national entitlement to reablement that Labour has proposed.
This should be a crucial part of pathway for care of the frail older people, rather than always a failure of it.
Redesigned dementia friendly elderly care wards can be an example of good hospital care. A shift on this ward is enough to see how difficult this care can be, and how challenging it can be to plan the discharge for these complex patients.
As one of our gerontologists told me: “Thinking older people shouldn’t come to hospital is inherently ageist and potentially deprives them of care they need.
“So let’s give them high quality safe and expeditious care in surroundings that are old people friendly and get them home quickly.”
‘Demographic and medical change bring a flow of demand that can’t be simply switched off’
The strategic risk that faces all parties is that the consensus on integrated care, while bringing the right vision and values, does not deliver a cashable dividend from reduced acute needs to spend on social care or district nursing.
Demographic and medical change bring a flow of demand that cannot and should not be simply switched off.
Averted additional cost is a more realistic aim: managing care in community and in hospital together, as a seamless pathway, with the hospital as an important part of the integrated care organisation.
Joe Farrington-Douglas is a strategy adviser for a foundation trust and former policy adviser to the Labour Party. He has written this piece in a personal capacity