By Gordon Blackwell, The National Health Intelligence Service
Whenever possible, patient care is being moved away from hospitals into the community, so that, within the league table of healthcare facilities, the hospital could become but a shadow of its former self. The movement is part of a bigger reform agenda to be able to provide more health services by a more diverse range of providers – giving greater patient choice and more convenient access THUS THE TREND is unstoppable and now, with the current focus on hospital-acquired infections, the hospital has become the place almost of last resort. Virtually all conversations about going into hospital involve some mention of MRSA. It seems almost certain that, if it were possible to design an ideal healthcare system from scratch, the current range of 1,000 bed hospitals would not exist. Instead there would be small acute facilities, to which the primary care staff would send patients, only if all else had failed.
The inference is that the present balance of power and allocation of resource is inherently unstable – and conventional wisdom indicates that, given time, unstable systems ultimately collapse – vide the Soviet Union and apartheid. If one tries to position the creation of Foundation Hospitals as a way of stabilising the acute sector, then perhaps the reports of the £4 million overspend at the Bradford Teaching Hospital only six months after it was declared financially sound, and the failure of the Fundacion Hospital in Madrid – which was the initial inspiration for the concept – seem to show that they may not be an ideal solution! As far as alternate sites are concerned they serve two purposes, to stop patients having to go to hospital and to allow them to leave sooner. The Walk-in centres, of which there are now 54 in England, with another 28 in the pipeline, are basically alternate primary care facilities, although they do take the pressure off hospital A&E departments. Secondary care admission can be avoided by using rapid assessment/diagnosis schemes for patients that may be referred from GPs, A&E, NHS Direct or social services. Then, if necessary, access to short-term nursing support, therapy and personal care in the patient’s own home can be provided on a 24- hour basis, backed by appropriate contributions from community equipment services and/or housing-based support services.
For longer-term care a range of differing hospital- at-home systems have been set up, as real alternatives to hospitalisation, giving intensive support in the patient’s own home. But the key alternate site development has been the establishment of diagnosis and treatment centres (DTCs) with some 70 already open or being built. These are acting as very effective rivals to hospitals. They offer planned procedures, primarily to reduce waiting lists, for example for hip operations and cataract removal, and they are developing a unique culture offering a more pleasing “patient experience,” influenced not a little by the involvement of the independent sector As an example, South West London’s Local Delivery Plan (LDP) illustrates the extent of such changes. Here, St George‘s Hospital will be a main tertiary service provider, including specialised surgery and trauma, with some hospital-based acute services for the local population that cannot be provided in local care centres or DTCs.
The SHA is participating in the national and London work on the development of DTCs in partnership with the independent sector, and is planning for a new way of managing acute services in the longer term, with a focus on specialties where capacity is of greatest concern. Specific programmes are being developed for Orthopaedics and Plastic Surgery. This will build onto and incorporate the changes from the DTC programme with the independent sector, the planned shift to primary and community care provision and the plans of other SHAs, including Surrey/Sussex that will impact on the delivery of care in SW London. An example of the thinking at PCT level is provided by North Liverpool PCT which, in its Local Delivery Plan, says that it is involved with the Diagnostic and Treatment Centre developments at both Broadgreen and University Hospital Aintree and with an ambitious partnership with the private sector to redevelop services provided in the community.
It is planning to develop Primary Care Resource Centres in the community to meet the needs of the local population, accommodating some services that have traditionally been provided in the hospital setting, freeing up hospitals to provide services which need their high-tech support staff and beds. The overall aim is to bring those services that do not need to be provided in a hospital setting, into the local community where they are more accessible. These two examples show how the changes are being fashioned by local forces to provide solutions to meet real local needs and with the aim of producing a more rational spread of resources, and avoid hospitalisation whenever possible. They also demonstrate how much market intelligence is available in the published documents. As far as the “early discharge” alternatives are concerned the following schemes come under the general heading of “intermediate care”:
- residential rehabilitation facilities - giving short-term programmes of therapy in a residential setting, such as a community hospital, rehabilitation centre, nursing home, or residential care home. They are used for people who are medically stable but need a short period of rehabilitation to enable them to re-gain sufficient physical functioning and confidence to return safely to their own home
- supported discharge - a short-term period of nursing and/or therapeutic support in a patient’s home, typically with a contributory package of home care support and sometimes supported by community equipment and/or housing-based support services. This enables earlier transfer of care from an acute hospital and allows a patient to complete their rehabilitation and recovery at home
- day rehabilitation - a short-term programme of therapeutic support, provided at a day hospital or day centre. This may be used in conjunction with other forms of intermediate care. Day hospitals can also provide a one-stop rapid response service with both specialist and multidisciplinary input.
Here as example of local planning as cited in the Local Delivery Plans of PCTs:
Halton PCT - sees the development of intermediate care and community services to prevent unnecessary admissions and support appropriate early discharge. The PCT has committed itself to an innovative international collaboration sponsored by the Department of Health involving United HealthCare a major health care provider based in the USA.
Charnwood PCT – talks of accelerated development of intermediate care service for the elderly through transfer of resource from secondary care, to deflect admissions and accelerate early discharge
Haringey PCT - has the Whittington Respiratory Early Discharge Scheme – offering community based nursing, physiotherapy and occupational therapy service to ‘at risk’ patients for up to 6 weeks post discharge. It acknowledges that services focused on promoting independence in old age – rehabilitative services, admission prevention and early discharge services – need to be strengthened.
The so-called reimbursement system, under which social services are fined if they delay discharge through not being able to provide adequate support, has had the effect of cutting delays. In October 2004, the Commission for Social Care Inspection (CSCI) produced a report ‘Leaving Hospital – the price of delays’ to look at people’s experiences of leaving hospital under the new system and to assess how well the system is working. It found much good practice but also insufficient focus on choices and opportunities for older people leaving hospital, with wide variations between one part of the country and the other. Although the amount of extra time that people spend in hospital because their council hadn’t arranged care almost halved between October 2003 and January 2004, and in the best areas, people get the choice of a full spectrum of care services with good access to rehabilitation and intermediate care, such ideal provision was not universal.
The pressure is therefore on to raise standards and again a variety of local solutions are being sought. So the pharmaceutical companies need to know how to find their patients who traditionally would be in hospital, and who is deciding what drugs they should have. Then they will need to keep up-to-date with local provision and understand how the pattern of acute service provision is changing. Of course because of the detailed nature of the NHS planning and reporting systems, there is much data available, but it can be time consuming to find. Because of this, the National Health Intelligence Service at www.nhis.info has developed unique access to all the on-line documents, backed by structured knowledge about the way the NHS works. A tailored search, for example combining “LDP” – to focus on local planning documents – with “treatment centres,” will locate all such documents that discuss the way the centres will be incorporated into the pattern of care. To learn how this can save you time, and alert you when new documents are published, email email@example.com for information. The ever-changing environment provides many alternative opportunities, but without an effective data source, the competition may get there first.
|Contact Gordon Blackwell, The National Health Intelligence Service at www.nhis.info