Management of long-term conditions – Call for Evidence

Comments on
Submission From The Royal College of Physicians of Edinburgh
UK Parliament: Health Committee
Management of Long-Term Conditions – Call For Evidence

Introduction:

Hospitals are seeing increasing number of medical admissions.  The increase in numbers is multifactorial with demographic changes accounting for less than half of this rise.

As hospitals decrease their bed numbers, they must reduce their length of stay (LoS) to compensate. This LoS needs to drop even further due to increasing admissions.  As a consequence of this, elderly patients may leave hospital with poorer functional capacity and fail in the community.  This leads to re-admission and the creation of a vicious cycle that may ultimately lead to 24 hour care.

The key to assessment of the older person is the Comprehensive Geriatric Assessment (CGA) carried out by the multidisciplinary team including the consultant.  Geriatricians are now one of the largest medical specialities in the UK and they provide significant input into acute GIM on call.

Over the last few years there has been a shift of resources from secondary care to primary care.  A greater emphasis has been placed on preventative care in the community.  However, there are challenges set in the most at risk population in primary care.  These are:

1. Multiple co-morbidity
2. Polypharmacy
3. Cognitive impairment/dementia
4. Assessment of capacity
5. Legal and ethical issues
6. Carer support
7. Palliative and End of life care

General practitioners have been set up to provide preventative care, with the creation of Quality Outcome Frameworks (QoFs).  However, the evidence to say that QoFs have a significant effect in improving care is limited (Cochrane data base Sept 2011).  Good primary care also involves the rational use of hospital based resources which is achieved through the GP gate keeping role. Unfortunately, the new GP contract and the loss of normal out of hours care means that for a significant part of the week an elderly person will not be looked after by their primary health care team.

Intermediate care (IC) was first described in the literature in 1985, and over the years many different models of intermediate care have been proposed/developed.  The evidence for supporting intermediate care is variable and the studies are small, with different outcomes being looked at and with differing methodologies being used.  Therefore this makes generalisable conclusions problematic in suggesting that intermediate care can be used to stem hospital admissions.

There is, however, clearly an opportunity to shift focus more into the community.  Hospital clinics in all specialties are full of patients on long term follow up for ‘review and monitoring’.   This can only be successful if there are clear pathways for patients and properly supportive networks across the care sectors.

Answers:

1. There is little scope to vary the current service responsibilities so that more people are treated outside hospital.  Significant changes would have to be made to primary care services ensuring better out of hours support.  Geriatricians would have to have job plans modified to support intermediate care (IC) solutions with consequent reduction of their input to the acute medical take.  To make IC most effective patients admitted to these beds must have full access to all investigations required.  This may involve elderly patients requiring adequate transport facilities readily available to access the investigations.  If more Geriatric Medical Specialists are involved in primary care dealing with these complex patients, then this has significant cost implications.  It is possible that in several areas increasing service provision may be delivered in primary care and there is scope for reconfiguration.  This has occurred, for example, in Diabetes but the experience is mixed.  The evidence is that service quality may deteriorate with rising glycaemic control in patients discharged to primary care.  The published evidence is that in the majority of studies HbAic rises in patients discharged to GP care.  In the best outcomes there is no difference between primary and secondary care outcomes but in no studies is there evidence of improved glycaemia in GP treated patients.
2. It is not felt that that the present local primary NHS services are geared up to look after people with multiple co-morbidities including long term conditions.  The primary health care team are used to dealing with single organ problems including practice nurses who have expertise in the management of, for example, asthma/COPD/diabetic clinics.  There is, however, a need for primary care to consider how patients with frailty can be identified and monitored in the community.  Social services will provide support for people with long term conditions by providing care packages.  The carers who deliver this care, while good, often fail to recognise when their client is deteriorating and becoming frailer.  Ultimately, a crisis occurs in the community leading to emergency admissions.  To address these problems, the primary care team should have systems that recognise the development of frailty and ensure that those patients are reviewed frequently in the community.  Similarly, carers for those people should be trained to look for changes and to seek help/advice at an early opportunity, thereby trying to prevent the crisis developing.
3. The new Clinical Commissioning Groups are in their infancy and discussions are taking place at local levels to support design of services.  It will be important to embed strong primary and secondary clinician representation at Regional Commissioning Board and CCG level.  It is important that significant resources should be available to facilitate the development of these new services otherwise they will never reduce avoidable hospital admissions.
4. In developing services, there is a great risk that care will become fragmented even for long term conditions.  It is likely that cherry picking of some areas will occur.  Geriatricians and social services have a long history of a team approach to patient care.  It is important that this team ethos is sustained across all sectors of care delivery.
5. Obesity is a significant problem and one that is increasing in size!  This problem needs to be addressed at a very early age in a child’s life.  The education of the child (and parents), and need for regular exercise should be ingrained from an early age.  This will involve major action from the government and should include adequate education on dietary intake.  There is also a need to specify in which co- morbidities the management of obesity will occur.  For example, obesity is relevant to IHD, hypertension and diabetes.  The clinical issues relate to the severity of obesity with a need for initial dietary treatment, drug therapy and surgery in extreme cases and thus the issue is probably best approached as part of treatment for the key co-morbidity.
6.    Stroke, heart failure, diabetes and palliative care services have been promoted as examples of integrated care.  The last in particular could be a model for other disease processes.  The hospital and community palliative teams are a combined service with heightened access to social care streams.  There is a common goal and a real effort made to provide a seamless service.  In diabetes there are many long standing examples of integration but this has also resulted in deterioration in glycaemic control in some areas.  Subsequent revision of protocols and the introduction of QOF targets improved matters.  There remains concern, however, that these changes required incentivisation of primary care and an increase in costs.   There are no examples as yet of which we are aware of successful integration of services across health and social care in England.  Northern Ireland does operate a successful integrated service and it would be appropriate to seek advice from colleagues in Northern Ireland.
7. The effect of the ageing population with long term conditions could be catastrophic for the NHS  as it stands.  The secondary care services are struggling to cope, and this is emphasised during a flu crisis or norovirus outbreak.  Appropriate primary care services supported by specialists (clinicians) in elderly care and allied health care professionals should be developed to offset this.  Patients who undergo a CGA are 25% more likely to be at home and alive 6 months later compared with those admitted and managed on other wards.  Elderly people who are in 24 hour care often suffer from fragmented primary and secondary care services.  A nursing home may have a number of GPs from different practices going in every day.  Admission to secondary care for that older person may lead to placement on an inappropriate ward.  Problems alluded to in the introduction [(i) to (vii)] are common in the nursing home patient.  These problems require time and an empathic approach being taken by the clinician with the person and their family.
8. There is a major interaction between mental health and long term conditions both in the patient and their families.  There is significant carer psychiatric morbidity in carers of stroke victims at 3 years post stroke.  Studies have demonstrated that mental health/psychology support is beneficial for the management of long term medical problems.  There is a significant lack of psychology support for people with mental health problems.  Perhaps the re-allocation of non-proven therapies eg homeopathy to proven psychology therapies may help the situation.
9. In certain diseases patients are being offered personalised services.  The stroke patient is discharged home with the stroke discharge team.  He/she will receive input from the team for a period of time and when stable/recovered is passed to the generic support services if required. Similar teams have been set up for patients with fractured neck of femurs and COPD.  Evidence from stroke demonstrates improved outcomes, shorter hospital stays and usually increased patient satisfaction.  There are also trials of personal budgets of care.  There is a widespread move to patient involvement in decision making - nephrology is notable.  In addition, in this specialty the shared care dialysis programme encourages patients to ‘know their numbers’ and contribute to their treatment (self weighing, opening packs, self needling, machine operation). There is evidence of better treatment compliance under this scheme.  There is also a concern that disparate members of the care team can all provide the same level of care.  There is some evidence that protocols can improve this.  Personalised services will require greater time input and planning.

Contact:

Dr A D Dwarakanath FRCP Edin
Secretary
Royal College of Physicians of Edinburgh
9 Queen Street
Edinburgh
EH2 1JQ

0131-247 3608
l.lockhart@rcpe.ac.uk