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Keeping people out of hospital: tips for nurses

In a context where we must 'do more with less' and deal with the whole system challenge associated with the QIPP agenda (that's Quality, Innovation, Prevention and Productivity of course - which I am sure you knew very well already!) 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 statistics1 tell us that there were over 630,000 hospital admissions in England alone in November 2011, the biggest percentage being non-elective or unplanned admissions mostly for those over 65, and a significant subset being patients with cognitive impairment. The agenda and actions required are self-evident when considering this evidence.

But 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 source of haemorrhage affecting NHS funding?

Some suggested actions might include:

1. Hearts and minds  - getting ourselves and our teams inspired to take on this challenge.

2. Self care and empowering patients to be more able to self manage and be active partners in care.

3. Enable  real commitment to care closer to home and at home.

4. Make real the aspiration to deliver more care and treatment 'as local as possible and as specialist as necessary' - including using more local resources including, for example, Minor Injury Units, Emergency Care Practitioners and Rapid Response Teams.

5. Find and work with new partners, the independent sector, local stakeholders, pharmaceutical and equipment providers as well as third sector and voluntary groups locally embedded known and trusted in local communities.

6. Thinking outside of the box and being creative.

7. More 'can do' and less 'yes but'.

8. Caution regarding 'paralysis by analysis' and too many planning meetings and forums for the well intentioned without an urgency to make things happen!

9. Not allowing the 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.

10. Being heroic - fortune favours the brave when it comes to adding value and making a difference to patient-centred outcomes and having better control and choices of how to receive care and treatment.

11. 'Don't ask for permission ask for forgiveness' when trying to make positive change.

12. Identify the top care themes leading to unplanned, avoidable admissions and devise a concerted local solution focused plan - eg, LTC management plans, UTI-focused awareness amongst the most susceptible, raising the profile for a local fall prevention campaign, adapting the 'virtual ward' principles used to identify the most vulnerable people to admission, improving data sharing between out of hours services, ambulance services and domiciliary care providers.

13. Support primary care teams in compiling registers of those at high risk of hospital admissions.

14. 'Track and trace' recent hospital admission patients and review their care in an MDT manner.

15. Enlist local carer teams, individuals and families to train to support local people.

16. Support community reablement work including adapted expert patient programmes to support more assertive management.

17. Work with residential care and nursing homes to improve partnership support plans for the very elderly and frail.

18. Make sure advance care directives enable more people to avoid unnecessary hospital admissions at the end of life.

No one is saying that this is easy - but the facts are that most people, particularly the elderly, and especially those with dementia, often don't do well in hospital and we have a duty of care to seek ways to safely and responsibly reduce and manage their admission risk. Tools and techniques are already in our toolkit, it's simply a case of using them. The sentiments in this piece can be dismissed and underplayed but the battle lines are drawn where more nurses are being subject to restructuring in our changing NHS. Unless we control our hospital activity flows we are all likely to suffer from the KPOOH failure should we not succeed in this task. NHS bankruptcy could be the result of not heeding the signs of a system in distress.   


1. DH - Hospital activity statistics:  Jan 2012