BBC radio 4 Today’s programme for 13/05/2015 http://www.bbc.co.uk/programmes/b05tllvh picked up on two of the big themes that will be central to concerns in Health and Care for the foreseeable future.
The first is a cry for help from care staff working for a private sector care company. Staff have drawn attention to the fact that they are being expected to “clip” the times on Home visits, to make it possible for them to travel to their next appointment, and have on occasions been told to leave a patient who has fallen, where they are, on the floor, with the door open for the emergency services to come in. I suspect that we will see much more of the same. The interview then went on to talk with Andrea Sutcliffe from the CQC. John Humphrys from BBC Today characteristically went down the path of blaming the individual care providers and demanding that they should be penalised. I think he is missing the point.
The second is that the Academy of medical royal colleges is asking GPs and the public to avoid asking for unnecessary interventions. The £22bn cost savings that the NHS has agreed to make, in order to get the £8bn injection of cash from the government (from a source that is not yet specified) will mean that the health service has to stop doing things. The interview with Dame Sue Bailey of Aomrc shows that Aomrc advocates working closely with patients to help them understand when interventions may be of limited value.
Both of these items show the financial pressures on our health and care systems are huge, and show that meeting the growing needs of the next few decades is going to be pretty challenging.
From the view point of Stafford it is clear that the problems in our acute NHS, both at the time of the exhaustively documented local problems in 2006/7 and now, is that there are many people within the hospital system who would be better off being “somewhere else” if the “somewhere else” exists.
Successive governments (and perhaps also voters) for the last two decades or more have dodged the questions of where should frail elderly be cared for, by whom, and how should we pay for it.
There is broad acceptance that the only way the NHS can be made to cope is by much closer integration with the social care services. The details of what that should look like are in many cases still to be worked out.
So far it seems that the only people who have fully grasped the implications of the fact that to cope acute hospitals must discourage unnecessary admissions, and must discharge patients more quickly, are the entrepreneurs offering private sector care schemes. The result of that is that we are seeing the growth of a whole range of social care providers, with care staff, often on minimum wages, being forced to travel some distance between one “customer” and the next. Even if these schemes sincerely wish to provide excellent services, the cards are stacked against them.
We need to understand what integration really means, and we need to think carefully about realistic ways of delivering an integrated service.
Private sector care providers have a simple objective. They need to get into homes for the time specified by the person paying for the care, and deliver the specified service. What an integrated service needs is for the care providers to be a key part of the whole business of monitoring the health of the individual, calling in additional help when required and doing what is necessary to help prevent the individual from having to go into acute care. An integrated service also requires that if an individual is discharged from hospital they can receive the additional help they will need during a period of rehabilitation.
Do the private sector companies that exist now have the necessary skills and motivation to play this role?
To me this seems to be a key moment. The Health service is changing and the care service must change too. Do we know what we want to see? How can it be made to work for both the individual “customers- patients” (I don’t even know what words we should be using) and for the individual carers providing these services.
As care shifts from hospitals into people’s homes, there will be a constant stream of stories about people left after a fall, without food, without company, without access to WCs. We know this will happen. What are our views on this? Is there a better alternative?
It is a depressing picture, but we have to find our way through this. For me there are at least some pioneering projects pointing us in better directions. I would strongly advise that people should read Atul Gawande Being Mortal http://atulgawande.com/book/being-mortal/ This matters because it looks at the distressing effects of unnecessary treatments, and looks at different ways of providing the essential social care that we must provide.
I would also advise looking at the Buurtzorg model http://www.kingsfund.org.uk/sites/files/kf/media/jos-de-blok-buurtzorg-home-healthcare-nov13.pdf This very local approach is where I would wish to start in the process of building integrated care that works.