Health CommitteeWritten evidence from the Royal College of Physicians (SC 23)

Summary

A. Coordination in Health and Social Care

The RCP advocates an integrated model of care in which traditional professional boundaries are broken down so that health professionals can manage patients using integrated care pathways designed by local clinicians.

Successful multi-professional team working is essential to an effective modern healthcare system and to the management of individuals’ medical conditions.

B. Barriers to Integrated Care

Separation between social and health care presents a barrier to continuity of care.

The RCP recommends that Health and Wellbeing Boards (HWBs) embed secondary care physicians in their structures and establish robust mechanisms for obtaining clinical advice and input.

To support the development and dissemination of good healthcare practice in care homes, there needs to be multi-agency and multi-professional national leadership, with greater physician involvement.

The current tariff and payment structures reward episodic and disconnected care. The RCP believes that the needs of older people would be better met if there were a tariff structure that better reflected clinical complexity.

The current informatics structure undermines the vision of patient choice and an outcomes-based health service. The RCP recommends an information system that gathers standardised person-level data and develops a single person-level record.

C. Challenges Facing the Acute Sector

In the acute sector, poor service management and design introduces a number of barriers to the provision of appropriate, high quality care centred around the needs of the patient.

The balance between specialism and generalism in acute settings is crucial if we are to meet the demographic challenges facing the health service and deliver the best quality care for patients.

Patients, including older people, are not getting the care they deserve at night, weekends and bank holidays. The RCP recommends that any hospital admitting acutely ill patients should have a daily visit from a consultant.

There must be a more integrated regulatory approach to cooperation, choice, quality and safety. Both Monitor and the CQC must also increase clinical involvement in their structures.

The RCP also urges the government to plan for the recommendations from the current Francis Inquiry to be embedded in the regulatory process.

D. Shared Decision Making

Personal health budgets are one tool amongst many and—whilst there may be a limited set of circumstances in which they are a useful, welcome tool – there will be many occasions when they are not the most appropriate approach.

A. Coordination in Health Services and Social Care

1. Good care needs to see the patient and their experience in the context of their lives, social support, relationships, cultural experience, gender and a range of other factors. Supporting care for individuals, including older people, is a wider societal issue. The provision of services should support people as long as possible in their own homes. Living productive independent lives, requires close integration between health services, social care and the voluntary sector, recognising that most support to older people is given by family and friends.

2. The RCP advocates an integrated model of care, where traditional professional boundaries are broken down so health professionals can manage patients using integrated care pathways designed by local clinicians. This approach is set out in Teams without walls, a joint RCP, Royal College of General Practitioners and Royal College of Paediatrics and Child Health publication, that includes existing examples of integrated care. Teams without walls identifies a number of key components in the provision of integrated care:

Population health needs and inequalities are considered at the planning stage.

Communication and service gaps are identified. Patient involvement is an essential part of this.

The service knowledge of local clinicians and public health data are essential.

Clinical leadership is required for successful commissioning—involving both generalists and specialists.

Regulators should inspect for improvement based on care pathways, as well as regulating organisations.

Commissioning must:

(a)commission pathways, delivered by teams, working in networks;

(b)promote partnerships, leadership and enthusiasm in its local clinicians;

(c)set boundaries, support clinical innovation and monitor its effectiveness;

(d)use evidence that is valid, reliable and reproducible; and

(e)ensure that local clinicians are enabled by its process and not hindered or inhibited by it.

3. Successful multi-professional team working is essential to an effective modern healthcare system and to the management of individuals’ medical conditions. This is particularly true for older people with long-term conditions. This includes holistic plans for diagnosis, treatment, rehabilitation, support and long term follow up. Failure in communications between healthcare professionals has a negative effect on the communication between staff and patients, relatives and carers.

4. Good liaison between GPs, specialist physicians and social care professionals in the management of patients is essential if their needs are to be met. Integrated working allows patients and their carers to benefit from specialist knowledge (including early referral for more specialist opinions and diagnostic tests when needed), the general care provided by GPs and primary care teams, and the help and support provided by those working in social care. An integrated social and clinical approach should support anticipatory care planning, including preferred place of care and end of life plans.

5. As highlighted in Teams without walls: "the use of patient pathways (some of which need to be developed and others adapted to local circumstances) as the building blocks for services is recommended, with the right balance between prevention, early identification, assessment, intervention and, when necessary, long-term support. This will have implications for commissioners, providers and regulators of services.”

6. The RCP agrees that the system of funding for social care needs to be reformed so that it is fair and affordable. We support further exploration of the recommendations made by the Dilnot Inquiry.

A.1 Strategic engagement and coordination

7. The separation between social and health care presents a barrier to continuity of care. The arrangements for discharge and access to social care support must be improved. Delays in discharge from hospitals, sometimes pejoratively called “bed blocking”, with negative impact on dignity and outcomes, remains an all too common phenomenon. Innovative approaches, such as the shared budgeting approach being explored in Torbay should be encouraged, evaluated and disseminated.

8. If we are to achieve more integrated health and social care services, it will be crucial that the proposed new healthcare commissioning arrangements fully involve a range of health and social care professionals. Clinical Commissioning Groups (CCGs) must build strong working links with Health and Wellbeing Boards (HWBs). The NHS Commissioning Board (NHS CB) should assess the extent to which CCGs have collaborated with other professionals and integrated primary, secondary and social care and public health in their annual assessment. Strong professional networks should be established and developed to further enable a wider range of specialists to feed into commissioning decisions. A network of the appropriate specialists should always be involved in commissioning decisions that affects the services they provide.

9. Local authority-led HWBs will play an important role in coordinating health and social care services. The RCP recommends that HWBs embed secondary care physicians in their structures and establish robust mechanisms for obtaining clinical advice and input. Secondary care specialists—together with public health experts, social care professionals, GPs and lay representatives—must be involved when assessing needs via the Joint Strategic Needs Assessments, and when setting priorities via the Health and Wellbeing Strategy. Likewise, establishing links between local HWBs and any emerging clinical networks and clinical senates could be an important step.

10. Patients should be empowered and enabled to be involved fully in commissioning decisions of both CCGs and the NHS CB.

A.2 Care in appropriate settings

11. The RCP believes that everyone has the right to appropriate care in appropriate settings. The focus on exploring opportunities to offer care “closer to home” in community settings and delivering care in innovative ways in order to better meet patients’ needs and wishes is welcomed. However, older people must have ready access to care in acute settings when necessary.

12. Similarly, the RCP has identified that discharge summaries provided when a patient leaves hospital need to be improved—the new Department of Health discharge toolkit is based on our work done by the RCP’s Health Informatics Unit.

13. Acutely ill older people are often poorly serviced by lack of speedy access to appropriate assessment/treatment (with or without direct geriatrician involvement), multiple transfers of care, and lack of skills in the general medical needs of older people in medical admissions units and other services. The gatekeeper function of the GP needs to be re-examined, to look at the reasons why referrals have been delayed when it would be appropriate to do so, or when diagnosis and care could be better given in the community (perhaps with additional support).

14. The PANICOA (Preventing Abuse and Neglect in Institutional Care of Older Adults) report highlighted “almost unanimous view expressed by all staff that the acute hospital is not the ‘right place’ for older people.” The study concluded that “the prevalence of this view results in the physical environment, staff skills and education and the organisational processes acting as barriers to delivering dignified care to older people”. If staff do not think older people should be in hospital, then care suffers. Older people often need to be in hospital if they need access to specialist care, investigations and management.

15. Hospitals have not been designed to meet the needs of frail older patients or patients with dementia. Therefore the care setting itself is often not conducive to the provision of dignified care. The PANICOA study describes acute hospital wards as “confusing and inaccessible” and says that they are “not fit for purpose” as a place to treat those over 65. This needs to change, so that older people are treated appropriately in hospital when they need to be there and staff attitudes need to change to accept that older people need hospital care when appropriate. However, more care can also be given in community settings to avoid hospital admissions.

16. People with complex health and social care often need a key worker who can help them navigate through their health and social care provision.

A.3 Doctors and care homes

17. There needs to be multi-agency and multi-professional national leadership, with greater physician involvement, to support the development and dissemination of good healthcare practice in care homes. Action is also needed to address the unacceptable level of medication errors in care homes. The Royal College of Physicians, National Care Forum (on behalf of the Care Provider Alliance), the Royal College of General Practitioners, the Royal College of Psychiatrists, the Royal Pharmaceutical Society, the Royal College of Nursing, the Health Foundation and Age UK are currently exploring this issue. The project, Working together to develop practical solutions: An integrated approach to medication safety in care homes, aims to develop thinking around: how health care clinicians can support staff in the care home setting to reduce the incidence of errors and near misses; and how to treat and care for people living in care homes to ensure that they are protected from harm. The aim of the project jointly to develop a set of practical tools to help residents, doctors, pharmacists and nurses to provide safer care and reduce the incidence of medication errors and near misses in care homes.

B. Barriers to Integrated Care

B.1 Tariff structure

18. The current tariff and payment structures reward episodic and disconnected care. The incentives/disincentives of Payment by Results need to be re-balanced to bring integrated specialist and generalist care closer to the patient’s home. In the current system it is often financially easier to admit the patient rather than manage them outside hospital or to commission separate specialist services in primary care, thus avoiding the full tariff price of a consultant-delivered service in an outpatient clinic.

19. The RCP believes that the needs of older people would be better met if we moved to a tariff structure that better reflected clinical complexity. In order to encourage integrated working, consideration should be given to moving towards a system in which payments are received, not for single episodes of care, but over the longer term (eg annually or by pathway), thus encouraging the prevention of readmissions, etc. Teams without Walls offers a simple way of dealing with this issue “by designing, commissioning and paying for new, cost-effective, service pathways which are beneficial to the patient… [The Department of Health] could explore the concept of payment by pathway (PbP) for an episode of care, and annual payment by condition (a PbC) for long-term conditions.

B.2 Data and information

20. The current informatics structure undermines the vision of patient choice and an outcomes-based health service and acts as a barrier to the provision of joined up services across health and social care settings. The RCP’s Health Informatics Unit has identified the following key issues with current health information and data structures:

(a)Disparate recording systems and reporting methods for different clinical specialities and hospital departments (eg separate recording systems for diabetes, cancer, etc). This acts as a disincentive to holistic care.

(b)Managerial targets have focussed attention at an institutional level, where performance has traditionally been judged. This has built barriers across primary, secondary and social care, providers and even departments. This in turn makes data sharing, integrated analysis and the management of patients across care settings difficult.

(c)Concerns about the validity of individual patient data collected by the main record level databases, especially from the clinical perspective. These databases—Hospital Episode Statistics (HES) and the Patient Episode Database Wales (PEDW)—were originally designed to monitor activity and health trends across the service, and to allocate resources. As such, they are most effective when analysed at an aggregate, national level, rather assist with the management of patients.

(d)Information on patient experience, where collected, is usually subject to separate information gathering exercise (eg questionnaires, etc). This makes it difficult to build a holistic, integrated and ongoing picture of the care patients receive, balanced against clinical outcomes.

21. The RCP recommends that we move to an information system that:

(a)gathers standardised person-level data and develops a single person-level record;

(b)embeds clinical standards into data collection and quality indicators;

(c)revises requirements for data collection so that they focus on clinically valuable information and the basic building block of health care—the patient-professional interaction;

(d)“mainstreams” the collection of information on patient experience and perspectives;

(e)synchronises records and enable data sharing, comparison and integration across providers, boundaries and specialties; and

(f)universal introduction of standards for structure and content of records.

22. The integration of information about health and social care services would be of benefit not only to patients and carers, but also to commissioners and service planners, including HWBs.

B.3 Reconfiguration

23. There is evidence that the consolidation of specialist services can bring better quality—this is usefully outlined in the recent King’s Fund report on the topic, to which the RCP contributed. Although issues surrounding reconfiguration are complex, it can also be argued that having a wide range of services on-site helps with managing the increasing levels of co-morbidities faced by a growing elderly population.

C. Challenges Facing the Acute Sector

24. e face rising levels of medical admissions and chronic disease, an ageing population and, as a result, increasing numbers of patients presenting with multiple conditions and a background of frailty and dementia. The service must adapt if we are to meet the challenge of providing holistic care for patients, including older patients, with co-morbidities and complex needs. In the acute sector, poor service management and design introduce a number of barriers to the provision of appropriate, high quality care centred around the needs of the patient. Existing evidence has repeatedly shows that the following must be in place if we are to deliver high quality care that meets the needs of older patients:

(a)Adequate staffing numbers, with sufficient time available to care for patients, including those with complex needs (eg dementia, frailty and communication difficulties).

(b)Appropriate education and training so that we have a workforce with the right skills to deal with the current (and future) case mix.

(c)Better continuity of management of patients whilst in acute settings and across providers, with clear lines of accountability and better communication between staff, and improved flows of information across the system.

(d)Improved communication with patients, their relatives and carers, and better involvement in decisions about treatment and care, with care received in appropriate settings. This includes communication on difficult issues such as dementia, dying and disability.

C.1 Generalism in the acute sector

25. Acute hospitals need a workforce appropriately trained to deal with the acute medical intake and aftercare of these patients. The balance between specialism and generalism in acute settings is crucial if we are to meet the demographic challenges facing the health service and deliver the best quality care for patients. This means looking at who is best placed to look after the increasing number of complex patients who do not neatly fit within a single speciality. Assessments need to be done by someone with the requisite skills to work through a diagnostic process and judge which is the most important problem to be managed, and with what level of priority. This is important because there may be conflicts between best treatment options for all the conditions. Staff also need to be skilled in discharge procedures and liaison with social care.

C.2 Organisation of care in acute settings

26. The RCP is concerned with the mounting evidence showing that poor care is delivered to patients in hospital during out-of-hours periods. , , , , Currently too often too many junior doctors are covering too many ill patients with too few senior staff in attendance during out of hours periods. This results, at worst, in inadequate senior cover during the weekend and on bank holidays, leading to a higher mortality rate and more errors in care in hospitals at these times. At best, the result is a poor experience for patients who are required to meet the schedule of healthcare professionals, rather than being able to access services and care at a time that meets their needs. Patients, including older people, are not getting the care they deserve at night, weekends and bank holidays. In December 2010, the RCP released a statement on out-of-hours hospital care and the need for increased consultant cover. We recommend that any hospital admitting acutely ill patients should have on-site supervision by a consultant throughout the day. Hospitals need to increase the availability of senior doctors in acute admissions units, particularly at weekends.

27. In response to these issues, the RCP is developing a range of practical toolkits aimed at physicians and designed to improve the clinical management of the acutely ill patient (for more information see: http://www.rcplondon.ac.uk/resources/professionalism/acute-care-toolkit). This range of acute care toolkits include specific guides on:

(a)handover;

(b)delivering high quality care throughout the admission pathway; and

(c)the acute frail elderly and interventions to minimise conversion from acute medical unit admission to prolonged hospital stay.

C.3 Regulation

28. The RCP has been calling for a more integrated regulatory approach to cooperation, choice, quality and safety. The processes and approaches of Monitor and the Care Quality Commission (CQC) must be harmonised and streamlined. Although economics and patient safety must be robustly assessed against independent frameworks, with independent recommendations, CQC and Monitor should work together to ensure that trusts have a single direction of travel, in which patient safety and economics are better reconciled. The RCP would also urge the government to plan for the eventual recommendations from the current Francis Inquiry to be embedded in the regulatory process.

29. Regulation needs to be able to look across institutions and consider care pathways. Health regulation needs to be better joined up with local authority scrutiny processes.

30. Both Monitor and the CQC must also increase the amount of clinical involvement in their structures.

D. Shared Decision Making

31. Supported self care is an important component of integrated care. In order to make this a reality, patients “will need help to understand the system, how to self manage and how to use services appropriately”. The RCP agrees that there should be a greater personalisation of services and access to services. We stress that the personalisation of services is not dependent on giving patients’ and/or carers’ budgetary control—choice can be enabled through effective dialogue between patient and physician, against a backdrop of specialist and patient involvement in commissioning. Personal health budgets are one tool amongst many and—whilst there may be a limited set of circumstances in which they are a useful, welcome tool—there will be many occasions when they are not the most appropriate approach. The risks associated with personal health budgets—for example, service fragmentation—will need to be fully considered. We also urge an honest appraisal of personal care budgets where they are currently used, ensuring that we guard against replicating these in relation to health. Patients’ and carers’ desire for adopt personal health budgets, and associated administration, will also need to be fully considered.

October 2011

Prepared 13th February 2012