Improved co-ordination critical to improving older people's care

This set of resources comes from an independent commission set up by the NHS Confederation in March 2015, to explore issues and potential solutions for improving urgent care provision to older people.

This is an area of concern for commissioners for a number of reasons, including:

The risk of iatrogenic harm from unnecessary admissions
Delayed discharge
Unwarranted variation in the quality of care
The risk to individuals of losing independence and of social isolation.

Methods

The Commission, which involved a number of notable names specialising in care for older people and urgent care, started with a series of focused questions to set the scope of their work (you can see these on page 9 of the final report). These questions considered:

Perspectives on what optimal care looks like
Priorities for transformation
Implications for providers of care
Workforce requirements
Enablers of transformation.

The Commission sourced information from a literature review; a call for evidence; and site visits. The resource now available includes: the final report, the literature review, an infographic and a series of case studies. The NHS Confederation commits to maintaining and adding to the resource, and plans webinars, interviews, additional case studies and site visits to support local health economies to learn and apply lessons locally.

Patients often experience variation in the quality of care across different services.

Findings

The final report opens with a story which shares experiences of excellent and poor care, clearly articulating the urgent need to address current variation in quality and demonstrating that an integrated and patient-centred service is achievable and already happening in some areas. This gave me a sense of frustration that the knowledge and learning to achieve this is present within the NHS yet inconsistency and examples of poor practice are still experienced.

Whilst acknowledging that local contexts differ and models of care cannot necessarily be transferred into other settings, the Commission shares important learning from a series of case studies. These aren’t necessarily groundbreakingly new but do offer important reminders to local health and care economies planning change:

Staff buy-in is essential to make change happen and stick
Relationships are key to integration and these take time to build and maintain
Technology is an enabler not the solution
Recruitment can be a challenge for new or expanded roles
Information must follow the patient
Continuous improvement is important to maintaining quality
Change seems to work best incrementally rather than as a big bang
Robust governance and decision-making is needed to empower staff to make changes
Community resilience is important and projects involving communities in making changes seem to fare better.

The report also highlights that where evidence is lacking (and there seems to be a dearth of evidence on preventative interventions) this should not delay action. For me, this emphasises the need for good local evaluation, using realist principles, to understand what works for whom and why.

A big bang approach to service improvement seems less effective than incremental change.

Recommendations

The Commission set out 7 key principles which should guide the design and implementation of care to the older population, focusing on:

Patient-centred and co-ordinated care, through integration, care navigators and patient/carer involvement
Case finding and care planning including escalation plans to manage crises
Proactive care, focusing on preventing crises
System-wide approaches to planning care to avoid perverse incentives and unintended consequences
Multidisciplinary teams with the right skill mix, including the use of generic workers
Collaborative leadership
Monitoring the quality of services, through appropriate metrics, such as a balanced scorecard to monitor experience (patients and staff); wait times; health outcomes.

Much of these can be seen in the plans for the New Care Model vanguards (in England) which suggests a mechanism for capturing and sharing learning in a more systematic way across the health and social care sectors.

Multidisciplinary teams are essential to co-ordinated care wrapped around the patient.

Commentary

There are some useful lessons here for transformation programmes to consider. Here are some thoughts from me:

How are “older people” defined and what is really known about the health needs and goals of this population? The report warns of the dangers of seeing older people only in terms of poor health
What learning from the case studies is transferable to your local context?
What are the key risks to health for older people locally? How are these being addressed?
What more could be done to prevent crises, e.g. falls?
How can you better involve communities, patients/carers and third sector agencies in designing and delivering care?
What is the long term vision?
How are you monitoring and evaluating care for older people?