Sunday, 28 April 2013

The ‘bed blockers’ who can make or break the NHS - practical pathway mapping urgently needed.

Andy Burnham, Shadow Secretary for Health has now outlined his ‘ideas’ for additional healthcare reform if Labour should win power at the next election. He was quick to state that these are just ideas at this stage but confirmed that he is identifying a ‘clear direction of travel’ for his policies.

The main thrust of his ‘direction of travel’ was to merge social care with the NHS. It would be hard to disagree with Burnham’s assessment that ‘Councils and the NHS don’t work well together’ and most involved with care would endorse a ‘fully integrated system’. His concept of one owner for the responsibility physical, mental and social wellbeing is worthy. But is it workable? What does fully integrated care mean? And how can we make this a reality?

Burnham is absolutely right that a major challenge facing NHS hospitals are the elderly patients who need ongoing care but have no current need for the acute care for which most hospitals are designed. This vulnerable section of the community make up between a quarter to a third of hospital occupancy at any one time which explains why they are sometimes referred to as ‘bed blockers’.

In the same way that that increasing the number of lanes in a motorway can only ease traffic congestion if the slip roads lead somewhere, so NHS improvements can only work if there is a suitable onward referral route for patients ready for discharge. Many patients stuck in acute hospital wards no longer need hospital care but need to continue their convalescence with ongoing care in the community. This care can take place either in their own homes with additional support or in a community care facility.
When I was working on stroke improvement initiatives in North West London, we made fantastic progress on providing specialist targeted care for stroke patients. The London Stroke Model defined that stroke patients should be admitted to hyper-acute stroke units within stringent time limits from the initial call for an ambulance. After up to three days of intensive treatment and therapy these patients would be transferred to stroke unit where the specialised care would continue. This system works extremely well, with every stroke unit in North West London reaching the required standards for accreditation and additional funding within a few months. Stroke patients received world class diagnosis, assessment and urgent treatment, vastly improving their chances of not only survival, but retention of a good quality of life.
An additional bonus was that each hospital that reached and maintained the required admission times would earn significant uplift in their tariff. Every stroke patient not admitted directly to the specialist unit would count against the hospital. As part of the accreditation process, I joined inspection teams in hospitals to ensure that these stroke units met their targets for accepting stroke patients. The most challenging aspect of applying this stroke model was freeing up beds in these units to enable new patients for admission. Time and again, a patient who no longer required specialist care but needed community support would languish in their hospital bed because there simply was nowhere else to go. In one stroke unit, we had a patient, a homeless man, who was well rehabilitated and no longer needed intensive therapy, but had been in the unit for 66 days (the average length of stay in a stroke unit is around 20 days) because he simply had no home to go to. (We actually threw a leaving party for him when he finally had somewhere to stay). This bed blocking creates a damming effect (and damning for that matter) on the entire system, back to the moment when an unfortunate patient first has a stroke.

Burnham’s ideas of an integrated system are coming from a good place but his direction of travel is fundamentally flawed. Burnham’s ideas are:
·        NHS leads on the physical, mental, and social wellbeing of patients
·        Councils should hold the budget and define the health and wellbeing strategy to make a better link between health and social care
·        NHS should lead on provision, council lead on strategy and commissioning

Opposition is a luxury in politics. You can make bold statements without actually providing an explanation of how highfalutin’ claims can be made real. Burnham’s plans sound like a rehashed, but even less workable solution than the current Health and Social Care Bill, currently being led by The Health Secretary, Jeremy Hunt.

Yes we need more integration between health and social care.  But let’s not make life even more complicated than it is already. Councils are NOT the right bodies to set strategy for healthcare but they should lead social care, and maybe public health. Integration is needed at the interface between the two. To try to reform all at once is terrifying and unworkable.

What we need is multidisciplinary pathway mapping – from cradle to grave, from diagnosis to cure, from acute to chronic care. Individual responsibilities to be defined for each area of care and ownership identified for coordination and cooperation.

Mr Hunt and Mr Burnham – if you would like a lesson in clinical and social pathway mapping, I would be more than happy to oblige.


Rob Dickman said...

Burnham is a fraud. Paul Corrigan sets it out well....

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