Primary care nurses and community services as a whole have a vital part to play in preventing avoidable hospital admissions. The government spends £140 billion on older people, mostly on pensions and welfare, with around 5% being spent on social care. This figure accounts for up to 60% of the total NHS budget on hospital care and predominantly on older people therein.1
Workload pressures affecting the daily lives of nurses, in a climate of change, pressure and reform, make for a difficult balance between feeling positive about adding value and making a difference to people’s lives, and fending off feelings of burnout and stress.
Being proactive and taking the initiative has to be central to ensuring people are offered ‘wrap-around care’ that is local and anticipatory, therefore providing the best care possible for people in older age in avoiding hospital care. The confidence, experience and clinical judgement delivered in a virtual team-like way must be the best approach to managing risk for people who often end up in hospital.
Opportunistic checks, screening and continual assessments of those receiving care in routine consultations are a valuable way to maintain a level of overseeing and even ‘watchful waiting’ to monitor progress and recovery.
Introduction and context
Currently there is data that suggests one in four (and sometimes one in three) beds in hospital are occupied by someone with dementia,2 most of whom need not have ended up there and who in all probability will be there longer than they need to be. This is often due to difficulties in putting together an adequate care package to facilitate discharge or organise onward care, including a short- or long-term placement in residential care.
In a context where we must ‘do more with less’ and deal with the whole system challenge associated with the Quality, Innovation, Prevention and Productivity (QIPP) agenda, the only real course of action is for us all to unite against the common enemy, the dominance of acute district general hospitals.
Official Department of Health statistics3 tell us that there were over 630,000 hospital admissions in England alone in November 2011, with the biggest percentage being non-elective or unplanned admissions, mostly for those aged over 65, and a significant subset being patients with cognitive impairment. The agenda and actions required are self-evident when considering this data. Annual hospital admissions are in excess of 15 million, which accounts for around a quarter of the population of the UK.
The question is, how do community and primary care ambassadors and advocates unite to form an effective and energised potent weapon to address this major drain on NHS funding?
Some suggested actions might include:
1. Hearts and minds: being motivated and inspired and encouraging our teams to take on this challenge is the foundation to building a strong spirit for more dynamic care and treatment for patients and reducing admission risk.
2. Self-care and empowering patients: enabling patients to be more able to self-manage and be active partners in care can have a massive impact on hospital admissions. It can also give skills and confidence to patients in supporting themselves and other family members.
3. Care closer to home and at home: enabling real commitment to this through strong partnership work with colleagues, other care providers, families and communities as a whole.
4. Care and treatment as local as possible and as specialist as necessary: make real the aspiration to deliver more care and treatment locally - including using more local resources such as minor injury units, emergency care practitioners and rapid response teams. There is a growing realisation that primary care and secondary care need to work together to develop programmes and pilots, such as reablement schemes, to prevent readmission, virtual wards where the most vulnerable are identified and given special proactive attention, and also newer ‘hospital at home’ projects designed to unite health and social care to avoid preventable admissions.
5. Find and work with new partners: the independent sector, local stakeholders, pharmaceutical and equipment providers as well as third sector and voluntary groups which are established and trusted locally, can offer new energy and enhanced support to mainstream services.
6. Thinking outside of the box and being creative: we have for too long been limited in our roles and responsibilities and are not encouraged to take initiative in accepting key worker status with some of the more high-risk admission patients.
New technologies, such as telehealth, may make a significant contribution to addressing hospital demand. Paul Burstow, the then health and social care minister, spoke about three million admissions being prevented saving £1.2 billion using the technology in a speech earlier this year.4
7. More ‘can do’, less ‘yes but’: although this can easily be seen as a sound bite, there are always reasons not to do something. This too often prevents more enthusiastic initiatives being put in place to target, for example, those with long-term conditions where evidence suggests there is a higher than usual risk of admission.
8. Caution regarding ‘paralysis by analysis’: there have been too many planning meetings and forums for the well-intentioned without an urgency to make things happen. Nursing historically has applied a more practical urgency to making changes that directly impact on care to patients. In the current context, more action - less planning and more doing - needs to be the order of the day.
9. Not allowing lack of money to prevent enthusiasm for innovation: don’t let the expression ‘this idea needs to be properly commissioned’ stop you from making ‘small tests of change’ focused on service improvement, benefitting patients and preventing hospital admissions where this is appropriate.
10. Being heroic: fortune favours the brave when it comes to adding value. Bravery is needed to make a difference to patient-centred outcomes and to give better control and choices about accessing care and treatment.
11. ‘Don’t ask for permission ask for forgiveness’: when trying to make a positive change, sometimes it’s a case of just getting on with it – without putting yourself at risk of breaches of management processes and policy of course. Ideally any innovation should be shared and sanctioned by line managers and fellow clinicians prior to implementation.
12. Identify the top care themes leading to unplanned, avoidable admissions and devise a concerted local solution focused plan: these could include long-term care management plans, urinary tract infection-focused awareness, raising the profile for a local fall prevention campaign, adapting the ‘virtual ward’ principles used to identify the most vulnerable people to admission, and improving data sharing between out of hours services, ambulance services and domiciliary care providers.
13. Support primary care teams in compiling risk registers: people who are at high risk of hospital admission can be better identified. These include the very elderly, those in older age with significant co-morbidities, and those with a history of admissions and symptom exacerbations. It is reasonable to work with colleagues to devise and develop registers using practice population profiles to support this.
14. ‘Track and trace’ recent hospital admission patients: With the help of commissioner colleagues, public health experts and the Departmnt of Health (DH), the care and treatment of such patients can be reviewed in a multi-disciplinary team manner.
15. Enlist local carer teams, individuals and families: the example currently gaining a lot of favour and popularity is the establishment of Dementia Friendly Communities where local campaigns can lead to better uptake of support and early diagnosis for people, that in turn can reduce the risk of admission and help train local people to be able to help and support.
16. Support community reablement work: this should include adapted expert patient programmes to support more assertive management.
17. Work with residential care and nursing homes: residential care is undoubtedly part of the solution to the volume of admissions if it can be used differently for some vulnerable people, such as for respite. Partnerships to improve support plans for the very elderly and frail, especially those with cognitive impairment, is vital to making this a viable option to stop admissions to hospital.
18. Advance Care Directives and Advance Decisions: enabling more people to avoid unnecessary hospital admissions at the end of life.
No one is saying that this is easy - but the fact is that most people, particularly the elderly, and especially those with dementia, often don’t do well in hospital. We have a duty of care to seek ways to safely and responsibly reduce and manage their admission risk. We already have the tools, it’s simply a case of using them
The sentiments in this article can be dismissed and underplayed, but the battle lines are drawn; more nurses are being subjected to restructuring in our changing NHS, and unless we control our hospital activity flows, we are all likely to suffer. NHS bankruptcy could be the result of not heeding the signs of a system in distress.
Some Key Themes
Current training access
It can be hard to access training that does not directly and specifically relate to particular care needs, eg, long-term management, immunisations, travel health and children’s health care, etc. ‘Keeping people out of hospital’ (KPOOH) and ‘getting people out of hospital’ (GPOOH) are much more generic areas of focus, so there will need to be a culture shift in some practices to seeing, for example, practice nurses taking on more of an outreach type role. This could involve assuming roles that offer assertive outreach to older people, and more active follow-up to patients following discharge to reduce readmission rates. Some areas are addressing this need with training, and a need for extended role modules for nurses to assist this is becoming clear.
Modules need to be developed by bodies such as Skills for Health and Skills for Care. In all regions there are leads for both of these organisations where perhaps we should exert pressure and influence.
It might be argued that the Nursing and Midwifery Council (NMC) has a role in supporting this new priority as do the Care Quality Commission (CQC), so again an emphasis on training and skilling-up the workforce does need a greater focus to support the 18 suggested action principles above.
Individual nurses and nursing teams with a special interest should be supported and encouraged within and outside of local primary care teams. The Quality and Outcomes Framework (QOF) remains a key influencer regarding priorities for GPs, practice nurses and community nursing teams, therefore ensuring a greater connection with hospital care and admission rates is vital.
Leadership, Ownership and Partnership
Most of us would agree that clarity of purpose, inspiration and motivation to change and passion and loyalty to the NHS are key imperatives to addressing best care. These characteristics are best achieved where there is a strong leadership, ownership and partnership working. The suggestion is that we each consider these three elements as central to our success and survival toolkit, particularly in making the most impact on hospital admission reduction.
Links with long-term conditions (LTCs)
With over 15 million people in England alone having an LTC, and the number of people with multiple LTCs predicted to rise over the next ten years by a third,5 we will be faced with some very tough challenges in how we provide best care and best value. The current focus is on self-management, self-care and better support for independence and personal care packages where the patient and family have more influence and control of services received without an aim of producing better outcomes.
Diabetes alone accounts for between £2.3-2.5 billion on inpatient care. This accounts for around 11% of the total in patient care budget.6 Many diabetes experts argue that with more than 3 million diabetics and nearly 900,000 people undiagnosed, this contributes to a sizable proportion of the 65% of unplanned admissions to hospital. Many of these admissions are where neglected and progressed disease compromises positive outcomes.
Half of all GP appointments and 70% of bed costs are LTC-related, with around 70% of LTC patients able to be managed and supported to manage their own condition and largely avoid hospital care altogether.7
The King’s Fund report ‘Transforming our health care system,’8 released in 2011, endorsed a number of interventions as relevant to better self-care for patients (see Figure 1).
Current headlines relating to the huge increase in people presenting with dementia and cognitive impairment in primary care demonstrate a growing pressure on capacity across health and social care. The national dementia strategy, ‘Living well with dementia,’9 set out an ambition for providing better integrated care in 2008.
This has since been further endorsed by the Prime Minister’s Challenge launched earlier this year, where driving improvements, supporting better research and raising awareness through dementia-friendly communities are seen as vital. There is a strong evidence base for early diagnosis and enabling people to live well with dementia as the condition progresses. As previously mentioned, there are large numbers of people currently in hospital with dementia. One of the lead clinicians in our local acute hospital presented details that showed more than 200 beds out of 800 are currently occupied by someone with BPSD (behavioural and psychological symptoms of dementia) – this is a fairly typical picture for most large acute hospitals.
The key questions are:
1. What can community and primary care nurses do to address the KPOOH and GPOOH challenge?
2. Is the climate right for energy and innovation?
3. What does best practice look like?
4. How do we do better in supporting patient empowerment and self-care initiatives?
5. Can practice and community nurses do more to ensure true integrated care working with partners in local areas?
The debate on how we unite in this fight will go on. We must suspend so-called ‘silo working’ tendencies and set aside organisational and professional rivalry, and fears regarding restrictions on doing more.
Conclusion and what next?
Ultimately actions speak louder than words, and we are often overwhelmed with new guidance from all directions. Balancing the pressures of dealing with large clinical caseloads and the demands of busy lives with physical and emotional tensions carries significant difficulties.
The answer has to come from within the profession and individual nurses, nurse leads and teams. Forming nurse-based alliances to share solutions and ideas for change can be one achievable action.
Working with Nursing in Practice (NiP) to achieve this can also be an easily achievable next step. If there is a desire to contribute to this theme, getting involved via the NiP website, blogs and Facebook page can be a start – trading views and creating a virtual network of like-minded nurses may just give us better ammunition and armoury for the tough times ahead.
1. Charlesworth A. Money is already there to pay for social care reform. Nuffield Trust; 2012.
2. Alzheimer’s Society. Counting the Cost- caring for people with dementia on hospital wards. 2009.
3. Department of Health. Hospital activity statistics: 2012 HESonline. London: NHS Information Centre; 2012.
4. Department of Health. 3 million lives campaign – roll out of telehealth and telecare to benefit 3 million lives. 2012.
5. Department of Health. Improving the health and wellbeing of people with long term conditions – world class services for people with long term conditions. London: DH; 2010.
6. Kerr M. In patient care for people with diabetes; the economic case for change. London: NHS Diabetes; 2011.
7. Bupa home healthcare. Redesigning long term condition management for today’s NHS. Bupa; 2011
8. Kings Fund. ‘Transforming our healthcare system – 10 priorities for commissioers’. London: Kings Fund; 2011.
9. Department of Health. Living well with Dementia – the National Dementia Strategy’. London: DH; 2009.
George Coxon, RMN, is the specialist mental health advisory board member for Nursing in Practice, MHNA chair and regional lead for Wales, Director of CCH (care provider), the Independent Commissioning Advisor for Devon, and chair of the Devon Residential Care Quality Kit Mark.
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