The NHS Five Year Forward View set out a range of models of care that local areas are being encouraged to develop over the next few years. The planning guidance for 15/16 begins to set out how the NHS will put the Forward View into action.
Closer links with the community
The Forward View offers hope particularly to smaller hospitals, many of which find themselves losing highly specialist services to larger acute providers and facing increasing numbers of unplanned medical admissions. The rise in unplanned admissions during this period has put significant financial and operational pressure on these trusts. These trusts have been considering their future viability. For many the answer appears to lie in developing closer links to community services. Acute hospital trusts that took over community providers are particularly well placed to offer more integrated services including intermediate, step down and rehabilitation.
Integrated teams without walls
I recently visited Darent Valley hospital in Dartford where I spent time with their integrated discharge team. This multidisciplinary team operates across the hospital, identifying patients at the front door who might be able to be supported home thus preventing an admission. The occupational therapists, physiotherapists and nursing staff have access to a geriatrician and the liaison psychiatry team to give advice and make rapid assessments. They work closely with on-site social workers who are able to put in reablement packages on the same day. The back door team work with those patients who were admitted to ensure they are kept as mobile and functioning throughout their stay and that as soon as they are medically fit they can be discharged.
The team face an uphill struggle with a range of factors preventing them from discharging those who are medically fit. Although the trust has commissioned intermediate care beds in a local BUPA facility and the local CCG are commissioning a local third sector provider to provide specialist domiciliary dementia care, they continue to have patients who are medically fit for discharge but who remain in an acute bed. The lack of community beds and domiciliary care has been highlighted as one of the many complex factors that account for the challenges acute hospitals are currently facing in managing increased activity levels. Delays in assessing patients for continuing care funding are also causing patients to remain in hospital until either the NHS or local authority agree who will pay for the care. This example of a team without walls brought home for me the urgent need for closer working between staff across the hospital and in the community.
Reconfiguration or redesign?
While redesigning care is essential to delivering improvements for patients, sometimes more fundamental changes are needed to how services are organised and managed. The Dalton Review sets out options for new organisational forms such as specialist franchises and management chains which could also enable smaller hospitals, through working in new partnerships with other organisations, continue to provide safe, effective local services to their populations. Such organisational changes are not a panacea and reconfigurations of clinical services have been shown to take time. The King’s Fund’s review of reconfiguration cases referred to National Clinical Assessment Team found the evidence underpinning the changes is often lacking.
Evidence and engagement needed
But successful change requires more than evidence. The public need to be involved in a debate about what they can expect from their hospital in future and the trade-offs between what is available locally and those aspects of their care for which they may have to travel further. It will also mean changes for NHS staff. They may have to be more flexible to work across the traditional boundaries of the hospital and community, rotating across multiple sites and networks of care, working collaboratively with colleagues from the voluntary sector and other professional backgrounds, and taking responsibility for the whole pathway or package of care not just the episode they themselves deliver.
As the Fund’s report points out there remains a paucity of evidence to support services changes: how they stack up financially, what levels or type of staffing are needed and for what time periods. This is why it is vital that as the new models of care are developed that there is a more systematic approach to testing and evaluation as the Forward View commits to. But it will be important for the local NHS to engage their communities in shaping and designing services that are fit for the future.
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