Older people kept out of hospital by joint working

Health and social care agencies in Essex are joining forces to prevent older people having to go into hospital

When Brian Bailey, 73, had a nasty fall after contracting a urinary tract infection, his family rang 999. But instead of being whisked into hospital, he was assessed and treated at home and a plan was put in place for his rehabilitation without him needing to leave his own front door.

Elsewhere, Bailey would have found himself in A&E and then being monitored on a hospital ward. But he lives in Southend, where the local health and social care agencies are doing things rather differently.

Meeting the care needs of older people is the biggest long-term challenge facing the NHS and local government.

Experts agree that far too many older people end up in hospital unnecessarily. A recent report by spending watchdog, the Audit Commission, found that while there are more than 2,500 emergency admissions a year for every 10,000 people aged 65 or over – a ratio higher than one in four – some parts of England have admissions as high as 3,700 per 10,000. After allowing for local factors, some areas have up to 50% more admissions than would be expected.

The total annual cost of emergency admissions for older people in England is £11bn, the Audit Commission says, but £132m could be saved immediately if all areas with higher-than-expected rates made reductions.

Cost savings

South-east Essex, comprising Southend, Castle Point and Rochford, used to have a high rate. In 2008-09, there were 9,624 admissions into acute care of people aged 65 or over at a cost of £22.8m. Forecast spending for this year is £21.5m and admissions are 20% down on 2010.

It’s a remarkable change and, judging by Bailey’s experience, a popular one. “I’ve had the most wonderful help,” he says. “Everyone has been truly marvellous.” His wife, Pam, adds: “The hospital is a great place if they can make you better, but it isn’t the right place for Brian.”

Following that 999 call, an emergency care practitioner (ECP) was first on the scene at the Baileys’ home in Shoeburyness. He diagnosed the infection and summoned the therapy and recovery team, which arrived within 20 minutes. Bailey’s needs were identified and an action plan agreed.

With the help of regular visits from a physiotherapist and other professionals, and using equipment installed by the team, Bailey is working towards weekly rehabilitation targets and his ultimate goal of being able once again to get upstairs to his own bed.

Falls are the chief reason for hospital admission of older people. Since last September, a “community falls car” driven by an ECP has been responding to selected emergency calls on behalf of older people across south-east Essex. By the end of March this year, it had attended 966 calls, of which 756 resulted in treatment on the spot and only 210 led to a hospital admission.

The car is just one aspect of a “care of the elderly” programme devised by NHS and council agencies, with input from the voluntary sector and users of services, to redesign services to meet the needs of the ageing population in the Southend area while reducing expenditure on hospital and residential care.

Other innovations include: a community geriatrician scheme, offering the kind of multi-disciplinary care and support of people in their own homes that they would get in hospital; a “filter” team, including GPs, nurses and social workers, at Southend hospital’s A&E department, to help prevent unnecessary admissions; and a day assessment unit at the hospital, a specialist falls team and a 25-bed intermediate care ward to help people prepare to return home after an admission and to help prevent their readmission.

The major innovation is the Spor – a single point of referral by which GPs and others can engage the focus of all health and social care agencies on the needs of an individual older person who can be assured of action within two hours in urgent cases.

“This will really make a big difference,” says Dr Sarah Zaidi, a GP leading one of the local clinical commissioning groups being set up under the government’s NHS reforms. “Before, there were 20 different numbers and 20 different forms to fill. That’s why the easy thing to do, if you were concerned about someone, was to send them up to the hospital.”

The Spor, based at the offices of the former NHS South East Essex primary care trust (PCT) in Southend, is open seven days a week. In its first few weeks this autumn, referrals from the hospital outnumbered those from GPs by seven to one. But referrals from GPs are now rising.

Zaidi admits that many of her fellow GPs do not know enough about non-hospital care and support. She points out, too, that many older people expect a hospital referral. “A lot of patients presume that if their doctor has sent them to hospital, then the doctor has done a good job.”

Mel Badenhorst, who is leading for Southend council on the older people’s care programme, says that because of this, it is important to establish that someone diverted from hospital is not only satisfied with the experience, but that they know why they were treated in a different way. “It’s not just a case of ‘Are you happy?’ but ‘Do you understand what happened to you?'”

Taking account of all strands of the programme, including fewer admissions to residential care, a total saving of £7.3m was initially forecast for 2011-12 across south-east Essex. That has been revised down to £3.8m, partly because the hospital admissions that have been avoided so far have typically been relatively low-cost. Fewer admissions of more complex cases, such as stroke, have been avoided than had been anticipated.

The programme is now being adjusted to place more emphasis on dealing with cases of greater complexity in the community. A joint commissioning strategy across health and social care is planned for next year, with budgets on each side aligned as a step towards the funds being pooled fully.

Could Southend be a role model for other areas? One factor undoubtedly is a positive history of joint working across health and social care in south-east Essex – something that is by no means universal. Another is relatively sophisticated information technology: the Care Trak system enables identification of the precise costs of one individual’s care package, and care history, relative to others.

Alison Alsbury, who as interim programme director for 12 months until May this year played a key role in developing the approach, thinks the main challenge is getting commissioners of services to see the big picture: how the whole system needs to work in strict co-ordination to deliver a multiplicity of forms of care and support to a group of people with complex needs.

Alsbury says effective clinical decision-making lies at the heart of the NHS reforms. “Add in the professional judgment of social care colleagues, a commitment to partnership and an intelligent approach to commissioning, and there is perhaps a way forward that can achieve accountability, quality of care and competition.”

For Katherine Kirk, chair of the South Essex PCT cluster, the task is to ensure that the new clinical commissioning groups buy into the approach. “The key to me is communication; I think we have a lot to learn about communication,” says Kirk. “We need to be collecting as much feedback as possible. We have to manage patients’ expectations, but they have a right to expect services that meet real need.”

Waiting game

The wide variation in the number of older people admitted to hospital as emergencies is repeated in the number of days they are kept on wards before discharge, according to the Audit Commission report, Joining Up Health and Social Care.

While hospitals in some parts of England, such as East Anglia and Devon and Cornwall, keep emergency patients aged 65 and over for as little as half the time expected, others in areas such as Hull and north Lancashire keep them up to 70% longer than expected. Differences may be attributable to local practice or availability of post-discharge support services.

Variation in the number of older people admitted to residential and nursing homes is even more pronounced, the commission says. In Surrey and Norfolk, the annual rate of admissions to care homes is between 15 and 63 for every 10,000 people aged 65 or over. In Somerset and County Durham, the rate is between 82 and 116 – a difference of up to eightfold.