Healthcare delivery
dependent on a healthy, productive workforce. It says that in 2025, 2.8 million people were economically inactive due to long-term illness. The proactive vision to reduce the amount of time in ill health must be focused on these people. In all of the objectives that the mandate identifies, there are many implicit challenges. The elephant in the room, in all of this, is that
there is no mention of social care and readers of this journal will have read many times of the difficulties of patient flow through hospitals and back to the community without significant change in the social care system. Without resolving this issue, it will be problematic for the acute sector to become more efficient and for community-based schemes to be realistically effective.
Challenges for implementation Monitor has provided some papers4
not only
reviewing the main issues but also considerations for providers and commissioners as they view their current troubles of tight finances, unceasing demand and capacity constraints with a view towards moving more patients towards care in the community. Monitor has highlighted five challenges which are worth reviewing: 1. Ensuring the scheme targets the intended patients.
2. Meeting the needs of higher severity patients. 3. Recruiting, managing and motivating the right staff.
4. Building credibility and scale. 5. Collecting data to evaluate effectiveness and setting payment incentives.
Challenge 1 - Ensuring the scheme targets the intended patients One of the core considerations of this particular challenge is to ensure that patients who would otherwise need an acute hospital bed are treated elsewhere. To achieve cost savings, the NHS will need to close acute beds and make sure that they are not filled by otherwise unmet need. They cite an example of a scheme where this is already in place, at Northwick Park, where patients are picked from A&E, given treatment, and transported home. This scheme is part of the suite of solutions called admission avoidance.
A further scheme described is to reduce
length of stay by careful onward care planning, with clear pathways and established endpoints and protocols to ensure patients do not stay where they are receiving treatment, longer than they need. South Warwickshire NHS Foundation Trust has a scheme whereby a patient can only stay on their ‘discharge to access’ scheme for up to six weeks. When they are discharged from the pathway, they are moved onto care under
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their GP, self-funded care or local authority care. Care co-ordinators are key to the success of this pathway by ensuring that, at every stage, they are followed and delivered the appropriate ongoing assessments and treatment.
Challenge 2 – Meeting the needs of higher severity patients Patients who have care for their complex needs (both health and social care requirements) may be more difficult to treat in the community. It may require teams to adopt different ways of working and different attitudes to assessing risk. The paper describes multidisciplinary teams that are able to organise themselves to respond quickly to patients who have immediate needs, deploying senior staff able to make rapid decisions. The main considerations required to respond
quickly and effectively are: l Comprehensive assessment skills, followed by early consultant and multidisciplinary review, which increases the likelihood that complex conditions are accurately recognised, and appropriate treatment plans put in place.
l Rapid diagnostic tests so that a comprehensive assessment may be undertaken quickly.
l Effective triage for higher risk patients so that patients with complex needs are speedily recognised and their care and treatment is escalated.
Multidisciplinary teams of consultants, nurses therapists, and possibly also dieticians and pharmacists, working closely together, can meet the complex need of patients and also may have to co-ordinate care across acute, community and social care organisations. The key to this is that this care can be delivered at home or in the community. The report also highlights that some of
these teams have ready access to advice from acute care, should they need it. It may mean that higher levels of clinical risk may be taken, although it will require clear governance
relationships. In addition, the seniority of the members of the team is likely to be high, leading to high quality decisions.
Challenge 3 - Recruiting and motivating the right staff Anyone reading this article will recognise that the right staff working in the right way are essential for treating acutely unwell patients in the community. Working alone in the community with patients who are very unwell is very different to the support for individuals working in hospitals and requires competence and confidence at a high level. Recruitment issues complicate this development. Training courses do not yet address these changes to ways of working. Appropriate job propositions and role definitions will help to recruit those with the right skills, as well as appropriate remuneration. Monitor suggests that service leads need space to trial, evaluate and embed successful change. Much of the success of some of these schemes will depend on how pressurised the schemes are from the centre, and under what timescales. It also suggests that some elements of
cross training between different professionals can help to ensure efficiency and subsequent patient benefits. Reablement schemes are easier to recruit to,
as they need a lower grade of staff. Reablement refers to the care received after experiencing an illness or injury. The main aim of reablement is to allow people to gain or regain their confidence, ability and the necessary skills to live as independently as possible, especially after an illness, injury or deterioration in health. Reablement consists of daily visits from
specially trained staff with a focus on observing, guiding and encouraging the individual to do things independently. This helps rebuild their confidence and any skills that may have been lost when the individual was unwell with their injury or illness.
Most individuals who receive reablement care do so for around one or two weeks, although it is
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