Experience of the Better Care Fund in Leicestershire
The strategic goals cannot be faulted. The challenge that achieving them will pose to our health and social care economy cannot be underestimated.
Evidence
The evidence suggests that integrating across the health and social care economy can improve quality of life, reduce length of stay in hospital and reduce readmissions to hospital. There is no robust evidence to support the political imperative that Better Care can and must reduce hospital admissions.
There is a naïve assumption that rising health care costs due to long term medical conditions are “preventable”. The sad facts of demographic change suggest otherwise. As our ageing population increases, we are now seeing more people spending longer with one or more chronic diseases before finally succumbing.
Frailty
There is a politically driven assumption that patients suffering from “Frailty” can be kept at home and emergency admissions avoided by putting in more social and community health care. This assumption depends on a deliberate misunderstanding of the nature of Frailty. As people with multiple chronic diseases age they become increasingly vulnerable to minor injuries and infections. Frail patients are liable to a “catastrophic” decline in their functioning. Rapid access to hospital care, including diagnostics such as chest x-rays, is necessary if we wish them to recover. The use of the term “resisted” admission during the presentation should ring alarm bells.
Care in the community
Improved care in the community can reduce length of stay after admission. Patients who spend more than a few days in hospital “de-condition”. Being able to go home quickly and safely after a catastrophic exacerbation of a chronic illness has to be good practice. If the local hospitals were able to offer the kind of joined up care needed in a crisis, we might be able to move some of the ‘beds’ into the community. It should be noted that, compared with the rest of Europe we already have a very low hospital bed base. Our geriatric beds were exported to the community long ago with many elderly people being cared for at the end of their lives in residential and nursing homes. The quality of that care, too often disconnected from specialist geriatric input, has to be a concern.
“Avoided admissions”
The Better Care team in Leicestershire have managed to hang on to their funding despite failing to meet their target of 2100 “avoided admissions”. They are claiming to have prevented 1700 admissions through innovations such as the Intensive Community Support and Loughborough Older Person’s Unit. This figure is at odds with the number of actual hospital admissions which continues to rise. Readmissions at 30 days are static in NHS West Leicestershire CCG and continue to rise in East Leicestershire and Rutland CCG. The term “avoided admissions” is one to be taken with a dose of healthy skepticism.
Community Hospitals
The Community Hospital Configuration does sound promising, with two 21 bed wards proposed for each quadrant of the County. This will include ‘sub-acute’ beds with geriatrician input specialising in the management of Frail patients in crisis.
Social Care
It is somewhat disturbing that the Better Care presentations made no mention of professional care agencies and care homes until challenged by Councillors. Admissions from care homes are a continuing problem and, clinically, should be easier to solve than admissions from patients living at home. Given the importance of social care in this equation it is most disturbing to find Adult Social Care absent from the presentation team.