At Independent Age, we often hear from people from older people and their families when things go wrong. They’ve just found out the cost of the dementia care they need, they are unhappy with the care home the local authority has identified, they are angry about an unsafe discharge from hospital or the delays to one because of a lack of care to support a safe return. They are very complex cases including living with a variety of multiple conditions, dementia and social isolation, identifying a mix of financial needs, housing, home adaptation, social care, welfare and health needs. Of course, we know these are the worst cases and that we are contacted as a last resort, in crisis, to help set things right. And I hope that that is what we do – advise people of their rights, advise them on best practice, and help them exercise choice.
The reports on unsafe and delayed discharge are shocking. People sent home alone in the middle of the night with no care in place, families not told, the inevitable revolving door of the A & E department seeing them wheeling back in in a worse condition than before. Or the older person stuck in a hospital bed for months because of a failure to plan discharge, disputes about who will pay the care home bill, or being told last minute they have to go, threatened with eviction, charging or legal action if they don’t.
As a result, we see A & E departments creaking at the seams at peak times (every season is winter), regularly missing their 4-hour wait targets, ambulances queuing outside, corridors full of gurneys. Staff working heroically hard, with in-depth data and escalation processes to head off peak demand and overflow.
We popularly believe this is because too many people are turning up with a twisted ankle or a sore thumb, but the reality is simpler, demand is increasing (as it is globally) and our hospitals have fewer beds to transfer patients to and there is less social care in place to allow rapid discharge of the frail and elderly. At peak times of pressure, at the weekends the 111, 999 and ambulance services have an empty directory of services to send people to so they are carted off to A&E, the only place open to see them.
The reality is that the last place an older people wants to go when they have had a fall (for instance) is hospital. They don’t want to go there and they certainly don’t want to stay there. Add in the dimension of an older person with dementia falling in a care home in the middle of the night and you have to question whether arriving in an A & E department is really going to be good for them at all. And if an older person is having an episode the chances are they have a number of co-morbidities at play, multiple prescriptions interacting, which a traditional A & E department, with its processes to assess, diagnose and treat are poorly set up to handle. Until that is, Bruce Keogh, NHS England’s Medical Director’s review which has prompted significant changes to the emergency care system building on considerable advances already made by individual hospitals. Hospitals are recognising that the older people who make 60 percent of admissions need something different. Hospitals like Leicester have set up a ‘frailty front door’ and many others have established multi-disciplinary hubs more suited to supporting multiple long term conditions, - the pharmacy, OT, dentistry, eye clinics, physiotherapy, GPs and community nurses to handle these admissions, support treatment and effect rapid discharge. These developments in Urgent and Emergency care are hugely welcome – though the shortage of geriatricians points to a systemic training failure that has to addressed. The demand isn’t going to get any lighter.
However, there is more to be done in admissions avoidance, coordinating GPs, community services, social care and involving the third sector. Because the best solution to demand is to ensure the maximum number of older people avoid entering hospital at all. It has to be the last resort since we know that every day an older person is lying in hospital the more muscle wastage (sarcopenia) occurs, undermining recovery. Effective discharge, planned for from the outset, also relies on the same level of coordination – of social care, GPs and community services to ensure a frail older person has the right support – either at home or in residential or nursing care.
There are three fundamentals that need to underpin admission avoidance and effective discharge of older people:
- person-centred care – respecting and consulting older people themselves on what they want and where they want to be (whilst ensuring families are also consulted and advocacy set up for those without capacity) to achieve the best outcomes and experience for them
- healthy and well-funded social care services working alongside side well funded NHS and community services
- integrated health and social care services that enable delivery of support in the community, effective coordination and care pathways, between GPs, community services, hospitals and social care delivered in partnership with older people and their families.
Before we can do that someone is going to have to explain to the public that they need to love social care as much as the NHS and that we need a new social contract about what we are prepared to do for ourselves and, crucially, pay the state to provide through our taxes. And with a decreasing proportion of the population in work to pay those taxes that’s going to be a tough debate. There’s just no point blaming hospitals and being shocked by the admissions and discharge figures month by month and year on year. Let's try harder to keep older people out of hospital in the first place.