Enabling people to live independent lives, with meaning and purpose, within their own community, is a fundamental principle of social justice and an important hallmark of a caring and compassionate society.
Demographic changes, alongside a decade of difficult finances, means this is one of the 3 biggest challenges facing Scotland – alongside economic recovery and climate change. The extent of the challenge we face in caring for older people, along with our approach to meeting this challenge, have been set out in Reshaping Care: a programme for change 2011-2021 .
Older people and people with long term conditions are major users of health and social care support services in both the statutory and third sectors. Although the full social and economic costs of long term conditions in Scotland is not known, it is estimated that costs for mental health problems alone are around £8.6 billion, or 9% of GDP .
Enabling and Intermediate Care are a core element of our strategy to re-shape our health, care and support services for older people and those with long term conditions.
Intermediate Care supports the key objectives to enhance independence and avoid unnecessary admission, or stay, in hospital or a care home by providing a ‘bridge’ or transition through services at key points of crisis in people’s lives.
There is growing recognition of the important contribution made by Intermediate Care not only in Scotland but in the rest of the UK and internationally . In Scotland, the Joint Improvement Team (www.jitscotland.org.uk) provided funding for five Intermediate Care ‘demonstrators’ in 2009/10 to increase the pace of development and to develop practical tools and solutions which could be shared across Scotland.
Comments on
Scottish Government
Consultation on Maximising Recovery and Promoting Independence - Intermediate Care’s contribution to Reshaping Care
The Royal College of Physicians of Edinburgh (the College) is pleased to respond to the Scottish Government’s call for comments on the final draft of the Intermediate Care Framework.
The College recognises that changing demographics and the resulting shift in pressures on health and social care services, combined with an extended period of financial restraint mean that it is necessary to raise awareness of the challenges being faced.
However, the College feels that this framework is in danger of pursuing a strategy of admission avoidance which is not evidence based. Whilst the aspiration of the framework to reduce acute hospitalisation of older people is laudable,1 the philosophy behind this policy is based on two unproven principles – that care of frail older people outwith acute hospitals will be less expensive and, crucially, will also be at least as effective as hospital care.
Definition of intermediate care
The definition of intermediate care given in the framework2 is overly long and open to interpretation. As an alternative example, a more concise working definition is referenced by the Joint Improvement Team:
“Intermediate care can be described as those services that do not require the resources of a general hospital, but are beyond the scope of the traditional primary care team”3.
Integration of health and social care
There is general consensus that the development of intermediate care services, from both the perspective of the user and those involved in delivering care to older people, would be simplified by the unification of health and social care budgets and management.
Inappropriate admissions and the acute sector
The College is concerned that a damaging misperception is emerging in Scotland regarding the level of inappropriate admissions. We would like to reiterate that no patients are admitted to hospital without being clinically assessed as requiring care.
It is therefore important that there is recognition that a fine balance exists between promoting avoidance of unnecessary admission of older people and restricting appropriate access to best care at times of medical need.
Whilst the aspiration of the framework to reduce acute hospitalisation of older people is laudable,4 the philosophy behind this policy is based on two unproven principles – that care of frail older people outwith acute hospitals will be less expensive and, crucially, will also be at least as effective as hospital care.
The policy framework is founded more on the “social” than the “medical” vision of dependency and care needs in older people. That is, it underestimates the significance of disease and illness in the problems of older people, and therefore the need to have medical services as a key component of older peoples’ services.
As the frameworks currently stands, it risks replacing care in acute hospitals – with clearly defined governance structures and quality standards – with care in “other facilities” of unclear or non-existent clinical governance and quality standards. Without equivalent governance structures there is a grave risk that the care provided in such alternative settings will not equal that provided in the acute sector.
If intermediate care for acute illness is to develop, it must be demonstrably as effective as hospital care for frail older people. The “Managed for Improvement” section5 makes no reference to any medical quality outcome indicators. Many patients and their carers will not accept acute care in other facilities if medical or key safety outcomes (e.g. falls rates or healthcare associated infection rates) are explicitly worse.
The table on p7 suggests that if an older person is too unwell to be managed in their own home, there will be a “step-up” to a “community facility”. No description of these facilities is given. They are presumably to be within current care homes or community hospitals. The quality standard for review by a doctor or nurse-practitioner is noted as “within 24 hours”. Given that the current acute care review standard is 4 hours, this seems an unjustifiably long period. This again reflects the “social” rather than “medical” model of thinking applied to the policy framework.
Geriatric services
To fully execute a service as suggested in this document there would need to be a substantial increase in the amount of Consultant time devoted to the community geriatrician role. This alone would require an increase in Consultant numbers.
The evidence base which exists for inpatient comprehensive geriatric assessment appears to be being ignored and severe pressure is being put on inpatient geriatric services with a 12% cut in bed days for the over-75s being proposed within the next 3 years.
It therefore seems necessary to pursue a policy of improving comprehensive geriatric assessment in hospital, supported by early discharge schemes and reductions in delays for social services to provide for reductions in bed days, in addition to undertaking additional studies of community based geriatric services until there is a solid evidence base to suggest otherwise.
Accuracy of diagnosis and providing “care that is reliably safe”
Another concern is the ability to make accurate diagnosis at home in the absence of hospital resources. In particular the suggestion in one scenario that a confident diagnosis of infection requiring intravenous antibiotics can be made at home after 4 pm on a Friday in a confused elderly lady6 seems contradictory to current medical experience and good practice. The NHS quality strategy itself which is a supporting document states that we have to provide “care that is reliably safe”.
Similarly the current availability of a specialist MS nurse to accompany a geriatrician to see a disabled patient in a remote location within 24 hours and the ability of this team to make clear diagnostic plans without radiology or further investigations seems extremely unlikely7. Lastly although there is reference to dementia in some parts of the paper the worked examples give no prominence to the issue of capacity (Adults with Incapacity) in acutely confused patients with dementia.
Conclusion
The College feels that this framework is in danger of pursuing a strategy of admission avoidance which is not evidence based. Care should be taken not to rush into a situation where patient safety could be compromised until there is clear evidence that care of patients outwith acute hospitals will be less expensive and, crucially, will also be at least as effective as hospital care.
1 p.8, Maximising Recovery and Promoting Independence- Intermediate Care’s contribution to Reshaping Care
2 p.6, Maximising Recovery and Promoting Independence- Intermediate Care’s contribution to
3 Oxford and Anglia Intermediate care Project, 1997 http://www.jitscotland.org.uk/action-areas/intermediate-care/
4 p.8, Maximising Recovery and Promoting Independence- Intermediate Care’s contribution to Reshaping Care
5Ibid, p.27
6 Ibid, p.46
7 Ibid, p.44