Supplementary written evidence submitted by David Sandbach (DEL0306)

My name is David Sandbach and I am a retired NHS CEO.

I  believe that Care and Nursing Homes are undervalued assets which could become part of the service offering made by the NHS for rehabilitation purposes and as a means of avoiding A&E / emergency inpatient admissions. The NHS and the DHSC need to change their attitude to these assets if the  acute hospital service is to thrive in a post Covid19 era.

Introduction

For many years NHS leaders have underestimated the role the Care & Nursing home sector can be play in safely delivering elements of acute hospital care.

NHS leaders need to change their attitudes towards the Care & Nursing home sector. NHS leaders must increase their appreciation and understanding about the role that this sector can play in the national Health and Care ecosystem.

Care and Nursing Homes are fantastic social assets which should be nurtured and developed to ensure the NHS 5 Year plan is implemented to the benefit of all, both old and young.

Facts

      The care homes sector is worth around £15.9 billion a year in the UK[1]

      At any one time there are around 410,000 residents in the care and nursing home sector.

      In comparison as at March 2020 the NHS had 102,186 general and acute beds available.[2]

      There are around 5,500 different providers in the UK operating 11,300 care homes for the elderly

      The sector is dominated by very small operators. 80% of care home providers operate only one home

      The average age of residents is 85.

      The 85+ age group is expected to increase, mid-2016, there were 1.6 million people aged 85 years and over,2% of the total population. By mid-2041 this is projected to double to 3.2 million, 4% of the population.[3]

      During  2016 / 17,[4] on average, care home residents attended A&E 0.98 times per resident, and on average were admitted as an emergency 0.70 times p.a.

      The overall number of emergency admissions from care homes in 2016 / 17 was estimated at 192,000 admissions i.e. 7.9% of the total admissions for people aged 65 or over.

      It is estimated that 41% of emergency admissions from care homes are for conditions that are potentially manageable, treatable or preventable outside of a hospital setting.[5]

      There is an emergency service usage differential between care homes and nursing homes:

Impact of Covid 19 and NHS capacity.

Already there are signs of concern regarding the impact Covid 19 will have on the medium and long term future of NHS services:

Health Foundation:

Returning NHS waiting times to 18 weeks for routine treatment [6]

•                      Returning the NHS to ‘normal’ is hugely important but poses significant challenges. For example, treating patients with enhanced infection control arrangements will reduce the volume of patients that can be treated relative to normal.
•                      For planned hospital care, this challenge has to be seen against a backdrop of growing waiting lists and waiting times. In January 2020, before large numbers of COVID-19 hospitalisations, a total of 4.4 million patients were on the waiting list – around 730,000 of whom had waited more than 18 weeks.

Nuffield Trust: [7]

Collaboration & additional capacity

By repurposing the role and tasks expected of the Care and Nursing Home sector it will be possible to relocate work which is normally done in district general hospitals.

As a result, it is possible to create additional physical capacity in the acute hospital sector.

The net result will be:

A)      A reduction in the numbers using A&E services and emergency admissions from care and nursing homes

B)      Some mitigation regarding the problems associated with nosocromial infection – less overcrowding in hospitals and other NHS facilities.

C)      Restitution of some capacity needed for planned surgery.

D)     Improved standards of clinical care in Care and Nursing homes.

The ways in which these results can be achieved require an open mind and close partnership working on the part of:

1)      Acute hospitals

2)      The Care / Nursing Home sector

3)      Local Government

4)      Primary care practitioners.

Cont.

Proposals for change - a two pronged approach:

1)   REHABILITATION OUTSIDE OF ACUTE HOSPITALS

2)   ADMISSION AVOIDANCE

1)      Hospitals should contract with the care / nursing home sector for on-going rehabilitation of patients who are likely to become stranded i.e. 7+ days in hospital.

“Bed-based intermediate care: Somerset Care and Yeovil District Hospital” [8]

Headline results from this project have included:

• 402 admissions to Cookson’s Court by April 2017; nearly 600 to date
• 98 per cent of people were discharged home from Cookson’s Court
• 42 per cent of patients required a reduction in their predicted home care packages upon discharge
• Service costs c. £1m p.a. to deliver
• We estimate £1.6 million savings in ongoing care costs to the local authority
• The project has also resulted in reduced elective cancellations, and income protection of an estimated £1.9m in 2017/18.

If 10% of the 11,300 care homes in the UK adopted this method of working the results would be:

a)      A saving of £180,800,000 available to LA’s for re-investment in social care services. (113 x £1.6 million)

b)      A reduction of elective cancellations, and income protection of an estimated £214,700,000 at 2017/18 prices. (113 x £1,900,000)

On a nominal average cost of £2,500 per operation this means 21,500 more operations could take place. The English share of the 21,500 cases would amount to circa 2.5% of the current cases waiting over 18 weeks.

Cont.

2)      Local hospitals to provide a virtual A&E and virtual Geriatric service into care / nursing home premises. This can be done using video conferencing and digital health monitoring equipment.[9]

Below is an example of what can be done.

Below is a calculation showing how a system such as the Call9 system would impact on attendances at the A&E departments run by Shrewsbury and Telford Hospitals NHS Trust.

Number of care and nursing home beds in Shropshire = 5,130 @ estimated 95% occupancy = 4,873 people.

4,873 x 0.98 = 4,776 A&E attendances generated from the population resident in Shropshire care and nursing homes.

40% of 4,776 = 1,910 A&E attendances p.a.

By treating people who are resident in nursing homes using a Call9 type system it is highly likely that emergency admissions will decrease. Below is an indicative calculation showing by how much.

4,776 x 0.7 = 3343 @ 40% = 1,337 cases which are for conditions which need not be treated in hospital.

NB a mobile ‘in home’ version of the Call9 service could be offered on a partnership basis with the NHS. [10]

Please see Appendix A.

Care and Nursing homes are under used assets.

With a little imagination and some goodwill, these important facilities can be repurposed to deliver clinical and rehabilitation services as well as the traditional ‘safe residential’ environment currently expected by the public and local Social Service Departments.

The two pronged approach i.e. Rehabilitation and Admission Avoidance noted above will:

a)      Improve the overall quality of health service available to residents in Care and Nursing homes.

b)      Improve the skill base of people working in care and nursing homes and enhance the status of staff in this sector.

c)       Improve the strength and ability of older people sufficient to get them home and functioning well.

d)      Reduced odds of deconditioning as a result of a long stay on a hospital ward. See Appendix B.

e)      Substantially reduce the odds of Care and Nursing home residents needing to go to hospital as emergency cases.

f)        Improve the management of the end of life care process in Care and Nursing homes i.e. no need to bounce very poorly people back and forth between their residence and hospital. Please see Appendix C

g)       Create capacity in RSH and PRH which can be used to keep surgical waiting lists / RTT target under control.

The Covid 19 crisis has shown me that there are lots of front lines and that care workers in Care and Nursing homes are just as brave and dedicated as their cousins in the NHS.

If asked by NHS leaders I am sure the Care and Nursing home sector will change and accept new tasks and expectations in order to meet a new future in a new world of health and social care.

2nd June 2020

APPENDIX A

Below is a slide from a presentation I made to Shropshire CCG & ShropCom personnel in December 2013.

Unfortunately the senior personnel responsible for strategic thinking did not understand what kind of community model was (still is) needed for the future of health services in Shropshire.

Had this model of service delivery been adopted when I suggested it, the Shropshire health eco system would be in a better position to cope with Covid 19 cases in care and nursing homes and the impact of Covid 19 on RSH and PRH would be a lot different than it has been.

APPENDIX B

SOURCE: https://improvement.nhs.uk/documents/2898/Guide_to_reducing_long_hospital_stays_FINAL_v2.pdf

APPENDIX C

The data below shows that very old people in Shropshire who attend A&E are likely to be hospitalized and then discharged.

This is not a very sensible way to deal with people approaching the end of their life if other alternatives can be provided.

Source: http://www.shropshiretogether.org.uk/wp-content/uploads/2016/06/Older-Peoples-Needs-Assessment.docx