Written evidence submitted by the British Geriatrics Society (PRI0075)
1.Introduction
The British Geriatrics Society (BGS) is the professional body of specialists in the healthcare of older people in the United Kingdom. Membership is drawn from doctors practising geriatric medicine including consultants, doctors in training and general practitioners, nurses, allied health professionals, researchers and scientists with a particular interest in the care of older people and the promotion of better health in old age. The Society has more than 3,000 members who work across England, Scotland, Wales and Northern Ireland. Our members are passionate about the care of older people, especially those living with frailty and multiple long-term conditions who have complex needs.
The BGS welcomes this opportunity to present a submission to the primary care inquiry launched by the Commons Health Select Committee.
2.Imperative to provide effective healthcare for older people
Older people are the core business of the NHS, whether they are living at home, in the acute hospital setting or in care homes.
The increasing number of people living to old age and the likelihood of older people with frailty requiring care from primary, secondary health and social care systems means that they are a key group whose care must be effective, efficient but also personalised and sensitively delivered.
If we don’t get care for this group right, the evidence is clear that costs to the health and social care service rise, with a greater dependence on the most expensive components of care - acute hospital admissions and long term residential and nursing home care.
For an illustration of how services can fail to deliver outcomes desired by an individual, their family and the ‘whole system’, despite best efforts of all concerned at each stage of the patient’s journey, please take just over 4 minutes to watch Mrs. Andrew’s Story: https://www.youtube.com/watch?v=Fj_9HG_TWEM
3.What works in the care of older people
We have clear evidence for “what works” in the care of older people (in terms of reduction in risk of acute hospital admission and long term care home admission), and new models of care offer opportunities for collaborative working between agencies based around primary care. There is increasing interest in closer working between primary care and secondary care services to provide a seamless pathway of care for older people to support them and their families. Such primary care led services are designed to ensure that older people receive care to avoid hospital admission unless that is clearly clinically indicated and to ensure that there are smooth transitions into and out of hospital once the older person is medically stable.
Community geriatricians are a key resource in the care of the most frail and those with complex needs. There is robust evidence that Comprehensive Geriatric assessment by a team with the right skills means that the person at the centre of care is more likely to be alive and living in their own home, rather than in a care home or be admitted to hospital, within the next 6 months. The number of people needing to receive the intervention to provide this outcome is nine. This “number needed to treat” is a standard way in which outcomes for medicines or interventions are expressed and such a ratio is one with which any pharmaceutical companies would be delighted.
However, it is clear that there never could be enough geriatricians to care for all the older people who might benefit from such an assessment. Hence community geriatricians in the UK and primary care and community services have collaborated to test out innovative approaches in the provision of care to older people. This submission will mainly focus on quality and standards for the care of older people and on the examples of new models of care which have been tested out by geriatricians and GPs.
4.Vision for primary care in the future
Our vision for a future primary care service for older people will be focussed on a pathway of care which supports older people to remain well as they age and which identifies those at risk of frailty. It will support them to manage early frailty and provide custom built support to them and their families to mitigate the effects of moderate or severe frailty, ultimately working to support that person as they come to the end of their life in their preferred place of care, as shown in Figure 1.
Figure 1: Person-centred care
Source: Oliver, David et al, (2014) Making our Health and Social Care Services fit for an ageing population, London: King’s Fund
Frailty can now be identified either by measuring certain characteristics (such as grip strength and walking speed) or by using data in a GP’s record to produce a “frailty index”. This gives us a new opportunity to identify and stratify the GP’s population of older people and offer them access to appropriate support.
This approach has been referred to as a “Frailty pathway” (older people don’t like the term “Frail” but it is commonly used in all the scientific literature on the topic, hence is used in this submission). Many older people who are frail also have multiple long term conditions and all have complex health and social care needs. In essence, our vision for the future of primary care in relation to the care of frail older people and those with multiple long term conditions and complex needs is of a move from reactive care, often heavily dependent on secondary care. Studies conducted by a range of bodies including The King’s Fund, The Health Foundation and the University of Birmingham have demonstrated the benefits of a shift of this kind in our approach to community care.
5.Problems in secondary care for older people
Heavy dependence on secondary care is undesirable for many reasons, not least that it is a very cost in-efficient way of providing care, and that older people themselves rarely welcome a hospital admission unless they recognise that they are seriously unwell. There are (of course) opportunity costs of acute hospital bed occupation, especially when the number of patients admitted outstrips supply of beds and patients are “out-lied” in other specialties’ beds, with an impact on elective care.
One of the most serious consequence for the individual (and for the whole system), is that inevitably a period of hospital stay produces a risk of deconditioning and worsening of function and ability to perform activities of daily living- that it to look after oneself. This deconditioning can affect physical and mental functioning. We know that 10% of skeletal muscle strength is lost for every 10 days of bed rest. For a frail older person this can mean the difference between being able to rise independently from a chair or bed (and therefore being able to go home) and being dependent.
Cognitive deconditioning is a particular risk for people with dementia- such as the recent sad and high profile experience of the journalist Nicci Gerrard’s father. This is not only potentially catastrophic for the older person themselves (and their families) but also results in a huge burden on the health and social care system. Recent bed census data shows that, in many acute hospitals, up to 50% of medicine, medicine for the elderly, orthopaedic and vascular surgery beds are occupied by patients who are medically fit for discharge. Recent reductions in social care funding mean that there are more ‘Delayed Transfers of Care’, more tension between health and social care, making strategies to find solutions which require close joint working more difficult.
We wish to see a move to a primary care led team supported by community health (nursing, physiotherapy, occupational therapy, and other services as required) and social care with consultant community geriatrician support. This primary care led team will know their local population of older people. Using risks stratification tools, they will stratify the population and offer services appropriately tailored to the needs of those individuals. Primary care will also have a crucial role in opportunistically identifying people at risk of decline in routine consultations, for example, following bereavement, or recovery from a significant illness.
Older people becoming frail will be offered advice and support on self-management through primary care services. This may be generic- such as exercise, nutrition, remaining in good mental health, or may be specific to the long term conditions that person may be living with; however advice on long term condition management will be tailored to that individual and their co-existent other long term conditions and general life challenges, rather than exactly the same advice that would be offered to a 45 year old with the same conditions. Older people who have dementia may need the support of their family or local volunteers to maximise their opportunities for self- management, and often a more imaginative approach will be needed to ensure that an older person’s “assets” are used to the full.
6.Older people with moderate and severe frailty
Older people living with moderate or severe frailty will be supported by integrated teams led by primary care. Geriatrician support when needed will allow evidence based best practice for those identified as at risk of destabilisation, with consequent risk of hospitalisation or premature admission to long term residential care. When older people are appropriately admitted to hospital, the primary care led team will in-reach with their knowledge of that person’s usual situation, wishes, function and environment and will “pull” the older person back home (wherever appropriate) once medically stable. Those people who are not yet independent enough to return directly home will move to a local facility which is jointly clinically managed by primary and secondary care physicians working in an integrated way with community health and care teams. This will afford a period of rehabilitation and recovery. The location for this will be geographically reasonably proximate to the older person’s own home and will be in either a community hospital or other intermediate care facility. It will be jointly commissioned and managed by social care and primary care in its commissioning function (Clinical Commissioning Groups).
7.End of life care needs
Ultimately as frailty progresses, the older person will be given an opportunity to discuss their end of life preferences, such as where they prefer to be cared for. This opportunity will be offered to people, whether they remain in their own home or have moved to long term residential care. Older people living in residential care are at especial risk of inadequate access to a range of health services.[1] They are in need of proactive planned care which affords opportunities for medication reviews, long term condition management with recognition of co-morbidity and of revised goals of treatment as they approach the end of life. They must be given opportunities to express their wishes regarding their care at the end of their life. Although such services are not widely available throughout the country, there are several examples of excellence in care home medicine, often based on collaboration between GPs, skilled community nurses (such as community matrons) and community geriatricians.
8.How does Primary Care need to change to develop such services?
Currently we would observe that some primary care leaders are enthused and engaged by the possibility of “doing things differently “and by the new permissions CCGs feel they have grasped. However, some GPs as providers of care feel they are struggling with the burden of demand and have no capacity to engage in debates about how they might work differently. At the same time there is a definite view that they cannot continue to deliver services in the same way as they traditionally have.
Some of the proposals of the Five Year Forward View point the way forwards. GP practices providing care working together as “Federated models” will allow services and back office function efficiency crucially without loss of primary care’s personal knowledge or relationships with individual patients. Practice federations can allow scheduled time for planning of proactive care and can participate in co-operative contractual arrangements between provider organisations. Such contracts can be put in place in ways which incentivise joint working and collaboration between agencies.
There is currently a sense “on the ground” that CCGs have permission to test out new models and “do things differently” whereas there seems to be less freedom for social care services to innovate. This may, of course simply reflect natural anxiety about the challenge of providing more care for more older people with complex needs with a shrinking budget.
9.Quality and Standards
BGS can support aspects of quality assurance. We have produced guidance on NHS care for people living in care homes and much of this pertains to primary care services. We have led the development of Intermediate Care services and annual audit of its services. These data can be used to inform service development, for example by allowing comparison of number and location of beds provided, and staffing and support to such beds. BGS works with the Care Quality Commission currently to help in education and support for its inspectors.
10.Demand and Access
The move from a reactive crisis based response for frail older people to a proactive case finding and planned approach allows for scheduling of care which reduces pressure on services and provides a team of staff who can appropriately provide support. Thus the GP as “back stop” when all else fails, often with recourse to little other than an acute hospital admission in a crisis situation will be transformed into a team of people with relevant skills and experience who work together. Clearly crises cannot be completely avoided- for example, even the best attention to falls risks cannot remove the risk of falls altogether. However a new model of care would include an urgent community based response (for example to a fall or an episode of mild delirium) and thus primary care would have resources other than an urgent home visit with a path to hospital to utilise.
Scheduled time for team based proactive care is likely to improve staff recruitment and retention and is essential to manage service demand.
11.Funding and Commissioning
Ways of Commissioning which promote whole person/ whole journey funding and remove perverse incentives at transitional points (for example between hospital and community care, or between health and social care) need to be implemented. An example of this is the Year of Care model which has been at least partially tested. Commissioning structures such as commissioning from an Accountable Care Organisation where a number of providers of care are held to account for the patients’ care are also promising.
However, talk of this being a driver to merge/ change provide new models of commissioning are extremely concerning to those who are working in the service and are very aware that the NHS cannot cope with another major re-organisation. Thus change must be built on a platform of what has already been developed. Destabilisation or “starting again” would be catastrophic.
12.Future Models of Care
The service description above indicates a future model of care. We feel a strengthening and acceleration of the work which has been done in some areas to build models of primary care- led commissioning of integrated health and social care teams, closely linked to voluntary sector services which are really focused on the needs of the individual patient and their families, will deliver better care. Community geriatrician input is also an important component of integrated care teams.
We have identified places where early examples of such work are being implemented. These services are forerunners of the New Models of Care alluded to in the Five Year Forward View.
However, to produce wholescale change requires a much larger scale vision by many health and social care commissioners.
As an organisation whose members care for people who require services from many different providers of care, we see many more risks than benefits in competitive tendering for contracts. We recommend an approach based on co-operative and close inter-agency working, with (of course) appropriate holding to account of individual agencies for their part in service provision. New models of funding such as “year of care funding” or tariffs for a patient’s care may be helpful. They may drive integrated care and align incentives so that primary care providers working with community staff such as district nurses or social workers and secondary care specialists all work together to support patients to stay as well as possible and to avoid hospital care unless this is the most appropriate clinical pathway- and to expedite discharge as soon as the patient is clinically stable. Some of the new forms of contracts currently described to tie together providers of care may be appropriate.
13.Workforce Issues
We believe this model would improve staff recruitment and retention which is currently a major issue for primary care. Many parts of the country face crises due the combination of incomplete recruitment and early retirement of GPs. The impending loss of staff due to plans for many doctors in training to move to other countries to practice, alongside recruitment and retirement issues, is a potential disaster for the whole of the NHS.
Clearly a portion of the primary care workforce focused on the needs of frail older people would require appropriate training to provide the requisite skills and expertise. The BGS and its members are a resource for primary care, both informally on a local basis and in co-operation with others in the development of training opportunities. Examples include an on-line Comprehensive Geriatric Assessment training package, involvement with Keele University in the development of training resources for primary care and in the re-invigoration of the Diploma in Geriatric Medicine in conjunction with the Royal College of Physicians. The BGS can also signpost to other training resources.
Staff working alongside doctors in new models of primary care will need to work in different ways. Our members have experience of workforce skills development in many professional areas and different parts of the country:
- Working to define the competencies of Advance Nurse Practitioners for Older people thus quality assuring such roles (Nottingham).
- The development of “Frailty practitioners”: staff who have skills in basic physiotherapy, occupational therapy and nursing stems allowing a single assessor to identify the needs of an older person without the need for many pairs of feet up and down the patient’s garden path (New Forest).
- Set-up of rotational training posts for nursing and therapy staff between community and acute hospital posts so that new staff have an understanding of all parts of the health and care system, promoting the seamless pathway of care we have advocated (Manchester).
- Models of Care Home Support by nurses with specific training, especially in end of life care discussions and planning (Liverpool).
14.Conclusion
In summary, therefore, the Society recognises the immense asset that General Practice is to the NHS. It sees general practice as the essential foundation for enhanced services from a range of integrated professionals and from the voluntary sector which, if brought together with shared information (with due regard for information governance and with necessary solutions to IT constraints), can deliver better care for frail older people, and those with multiple long- term conditions and complex needs. If supported by secondary care physicians implementing Comprehensive Geriatric Assessment, there is good evidence to demonstrate that improved care would be provided to older people; and we can reliably predict reduced demand on health and social care services.