COMMISSIONING AND PATHWAYS
Healthcare
not just closer to home – but in the home
Dr Huw Charles-Jones, who chairs West Cheshire CCG, tells NHE about the work it is doing with other organisations and agencies under the ‘Altogether Better’ community budgeting pilot, and about the ‘Hospital at Home’ initiative to cut unnecessary A&E admissions among older people.
T
he shift to clinical commissioning is not happening in a vacuum: the new CCGs are
having to deal straight away with the funding pressures in the NHS, and need to find care configurations that work better for patients but are also cheaper.
The UK has seen a rise in emergency admissions outstripping what demography alone would suggest, which West Cheshire CCG chairman Dr Huw Charles-Jones says has “many causes” and requires “societal change”.
He said: “There’s an expectation amongst people for an immediate response: if they’re concerned, they want to be seen quickly and easily, they don’t want the uncertainty of GP appointments, or out-of-hours doctors, they want an instant response. That means the default position for a lot of people has been to pitch up at A&E.
“There are issues about access to primary care and what’s available in the community, with people’s working hours and their expectations, which general practice hasn’t really dealt with. There’s been some expansion in expanded hours, but we still don’t have that 24-hour service that the rest of the world works to. It’s a five-day week model.
“The 2004 GP contract, when out-of-hours was taken off GPs, led to things like the closure of Saturday morning surgeries, and made access harder.”
He noted that different people have different reasons for treating A&E as a default option: from working age people who struggle with access to primary care due to inflexible hours, to older people who can be especially difficult to get out of hospital once they are in, to young families with immediate concerns and a need for reassurance about a child’s health.
This can be exacerbated by doctors themselves, Dr Charles-Jones said: “You’re often dealt with,
20 | national health executive Jul/Aug 12
say in paediatrics, by quite junior doctors who are fairly risk-averse and tend to admit children when they may not need to, and when it could be managed far better elsewhere.
‘Too much investment in acute care’
“We’ve not invested enough in the community in terms of what’s there for older people, so again concern means A&E. With older people, the way hospitals manage risk is very different to the way general practices manage risk. It’s much more medicalised: you need to do tests, therefore they need to go into hospital, and that takes time.
“Once you get an older person into hospital, it can be hard to get them out: they often then
pick up hospital-acquired problems, or become less mobile, less independent.
“It’s a societal change in what we expect, but in my view, there’s been too much investment in acute care rather than in community services, or simple changes in people’s homes to prevent admission in the first place.”
This can often be where multi-agency approaches can help, he suggested, and is one of the aims of the ‘Altogether Better’ community budgeting pilot. Cheshire West and Chester is one of four ‘showcase’ areas looking at how to pool a budget of between £3-4bn from over 150 local services, and in which the CCG is working with the local authority, housing, emergency services, probation, colleges, government departments, acute hospitals and the third sector across a number of ‘themes’. These include helping families with complex needs, developing early years support, helping people get involved in decision-making, making communities safer, encouraging growth, helping the unemployed, avoiding unnecessary hospital admissions, and shifting to evidence-based policy approaches and strategic commissioning models in public services.
Dr Charles-Jones spoke about Altogether Better at the recent Local Government Association annual conference in Birmingham.
Hospital at Home
The local health community had already been working on a novel way of cutting admissions among elderly people before Altogether Better was even announced. This was the ‘Hospital at Home’ programme, led by GPs and nurses, which treats people in their homes.
Although it currently only has capacity to treat 12 patients at any one time, it has had phenomenal patient feedback, Dr Charles- Jones said.
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