The NHS discriminates against people’s need for out of hours care, but improving joint working could keep people out of hospital for longer, writes Michelle Mitchell
The NHS is a national institution that most of us hold dear − it is hard to think of many other state-provided services that could have been celebrated in the Olympics opening ceremony. Part of our fondness is down to a belief that everyone arrives at its door as an equal: regardless of their wallet, age, race or social background, they will receive the same high-quality standard of care.
‘Having a health service that waxes and wanes with the passing hours is completely at odds with the human condition, where illness and injury do not respect a 9-5 schedule’
But time after time, it has been shown the system effectively discriminates against those who need help outside normal office hours.
Need to see a consultant late on a Saturday night? You may, if lucky, reach one over the phone. Medically ready to leave hospital on Friday night but need a social care package in place to ensure your return home is safe? You’ll have to wait until Monday morning for a social care assessment. Your existing condition suddenly worsens during the night? Try and pick your way through the patchy world of out of hours care.
Of course, having a health service that waxes and wanes with the passing hours is completely at odds with the human condition, where illness and injury do not respect a 9-5 schedule. It is clearly unacceptable for a patient’s fate to be determined by the clock − figures collated by Dr Foster show 88 per cent of acute trusts had up to 20 per cent higher death rates at the weekend.
Challenges to 24/7 care
But there are huge obstacles in creating a truly 24/7 NHS system. For example, tackling the current problems of delayed discharge at weekends due to the lack of a social worker to assess someone for care needs would not only require more weekend shifts for social workers but potentially back office staff, senior NHS staff and consultants, too.
‘At a time when the NHS is expected to make year on year efficiency savings, we cannot ignore the fact that 24/7 care would mean at least some additional staff costs’
Age UK analysis earlier this year showed that a million NHS days had been wasted due to waiting for social care provision, so such a move could potentially save money for the NHS but would require more investment from the social care system.
With healthcare and social care working in two separate systems with separate budgets, and with the lion’s share of potential savings for the NHS and most of the costs picked up by social care, there may not be sufficient incentives for such a change.
The cost of change
But an absence of social care support at the weekends must urgently be recognised as unacceptable practice. With many local authorities cutting social care budgets, it may be necessary to release NHS money to fund interim support − though given the financial pressure the service is under, this is not an ideal situation.
At a time when the NHS is expected to make year on year efficiency savings, we cannot ignore the fact that 24/7 care would mean at least some additional staff costs. The only real alternative would be to spread people’s hours more intelligently during the week, as already happens with junior and mid-level staff. But that would take a huge amount of goodwill from a workforce that hasn’t had a real terms pay rise in three years.
‘Good knowledge and planning not only avoids distress to the individual, but also reduces the associated cost to the NHS’
Commissioners need to start building expectations of 24/7 service into contracts and holding providers to account. Quality should be measured at all times of the day − not just daytime − and commissioners should ensure they get down to hospitals at the weekend to see if what is in place is working.
There are many obstacles but the current situation is unacceptable, so a way forward must be found. One way is to put energy and focus into personalised care. Equal access to treatment should not merge into one size fits all.
So, for example, when planning care for an older person, medical staff should take time to make sure they are aware of the patient’s living and family circumstances. The question should not be “what would any given person need at 2am and how can they get it?” but “what does this person need and how can it be incorporated into their day to day life?” An older person who is mentally alert and has good support networks will have very different care needs to someone with dementia living alone.
Planning to prevent crises
Good knowledge and planning can avert many crises. It not only avoids distress to the individual, but also reduces the associated cost to the NHS. Care should be organised to ensure an individual is supported to remain as independent as possible, while knowing where to seek support or help in a crisis.
‘Crucially, we need to change NHS thinking and make sure the system works hard to keep people out of hospital for as long as possible’
As part of this, we need much more definitive and intelligent use of shared decision making. This means asking people what they hope will result from treatment and what would help deliver these aims, whether they understand the risks and benefits and what support their family and carers need. And those decisions will need to be reviewed as the situation changes, if the patient’s health improves or declines, or their financial or family circumstances change.
Primary care providers need to be much more proactive in their care of frail older people. The lack of quality 24/7 care becomes such an acute problem because lots of problems are allowed to build up to a crisis, whether through lack of primary care or inadequate social care support. Early intervention would help avoid crises, or at least diminish their impact.
Keeping people out of hospital
Lastly, but crucially, we need to change NHS thinking and make sure the system works hard to keep people out of hospital for as long as possible. So a frail older person could be proactively managed at home with a clear care plan for their multiple long term conditions, be regularly assessed, with a clear idea of how to get urgent help, receive good social care support and ideally be under the supervision of a community geriatrician.
In the event of a more serious or urgent medical issue, hospital may well be the most appropriate option. When that happens, the hospital must be under an obligation to fully assess and address the needs of the patient and certainly not make them worse (incidents like falls are far too common in what should be a caring environment). In this scenario, there will be some cost to the NHS but the patient is now further from a crisis than they otherwise would have been.
Sadly, this vision is a long way from the current reality, where older people can receive minimal or no support, or they could be taking inappropriate medication for long periods without review and could end up having a fall and serious fracture due to the side-effects or the absence of falls prevention support. The net result? The hospital gets a neat tariff payment for the hip replacement and ships them home without addressing the medicines problem or making sure the chances of readmission are reduced through ensuring necessary support is in place.
This is an approach lacking not only in compassion, but one that is also financially flawed − scrimping on the cheaper low level interventions to allow a situation to build up into a full blown distressing crisis that is expensive for the NHS. The system needs to get smarter.
Michelle Mitchell is charity director general of Age UK