• Warning over long-term plan’s community services proposals
  • Outgoing NHSE director and geriatrics society express concern, including over PCN specs fallout
  • Next steps for delivery expected to be announced soon

Older people’s care specialists, including an outgoing national clinical director, have raised concerns about “rowing back” on long-term plan commitments on community services. 

The geriatricians say draft primary care network specifications and the fallout over them is evidence of the problem.

It comes after the NCD for older people and person centred integrated care, Martin Vernon, a geriatrician, was not reappointed by NHS England, and was replaced at the end of last year by a GP and local commissioner, Adrian Hayter.

The LTP said the NHS would in future provide “community health crisis response services within two hours of referral”, “reablement care within two days of referral”, and “NHS support to all care home residents by 2023-24”. It also “guaranteed” that “real terms funding for primary and community health services [would] grow faster than the rising NHS budget overall”.

British Geriatrics Society chief executive Sarah Mistry told HSJ: “We are watching very closely to ensure there is no rowing back on the initial commitments in the LTP and the very thorough and evidenced work that [was] put together.

“As we are moving into the implementation, we will be watching to ensure the original ambitions are adhered to.”

She said there was a risk promised funding would not materialise, be diverted into other services, or be spread “too thinly and the money could go into community services [generally] rather than developing these specific services”.

As NCD since 2016, Professor Vernon led development of the community health and older people’s care aspects of the LTP for NHS England and Improvement, under the banner “Ageing Well”.

He said the current row over the PCN specifications — which look set for a significant rolling back of requirements by NHSE — means “there is now a risk of not delivering on all of the original Ageing Well commitments which specifically focused on better supporting older people with complex conditions, including those with frailty and dementia”.

He added: “This is crucial to get right for the wider NHS given the increasing numbers of older people with multiple long-term conditions in need of support in their communities and in care homes and who are presently unable to leave hospital in a timely manner following an unplanned admission.”

Both the BGS and Professor Vernon, a consultant geriatrician in Greater Manchester since 1999, were concerned the draft specifications, published shortly before Christmas, gave a version of the proposed “anticipatory care” service (see box below) that was too broad, rather than focusing on frailty, which has evidenced tools and interventions.

Networks row

Professor Vernon said this may have contributed to the concerns being raised by GPs. He said: “The [LTP] specifically committed to building on routine frailty identification… It is disappointing to see that the existing focus on frailty identification and intervention in general practice since 2017, designed to improve patient and system outcomes for a growing group of vulnerable older people now appears at risk of being lost.”

In relation to another part of the specs, on “enhanced care in care homes”, Professor Vernon said it set out an ”unnecessarily specific service model… and it is unrealistic to expect these important services to be developed quickly”. He added the spec “focused too much on reducing unplanned care” and said evaluation of the model had found the services take several years to embed — longer than given by NHSE.

For both specs, he said the proposed “success measures concentrate on NHS process metrics and do not include personalised outcomes without which it may be difficult to gauge patient level impact”, and risked “inadvertently widening health inequalities”.

HSJ understands NHSE’s Ageing Well team has now filled most of its posts and NHSE is expecting to announce plans for the programme for 2020-21 in the near future.

An NHSE/I spokeswoman said: “The [LTP] commitments to the Ageing Well programme have not changed and it is making great progress. The PCN and community health [standard contract] specifications are currently out to consultation and we welcome a wide range of views and feedback.”

What is the “anticipatory care” service?

Anticipatory care enables doctors to provide proactive, preventive care to patients with high needs or who are at risk of significant problems by analysing a population and dividing patients into different levels of risk using tools like frailty indices.

The draft specifications would have seen this service start in 2020-21, when PCNs would have had to appoint a clinical lead for the service, start building a list of priority patients, and develop a multidisciplinary team to start coordinating care delivery to this cohort. Further delivery requirements were to be staged over the following three years.