INTEGRATED CARE - BACK TO THE FUTURE?
By Lynda Gauld, Director, Baccus Consulting
The most recent figures on births and deaths from the National Records of Scotland (NRS) (‘Births, deaths and other vital events, fourth quarter 2018’) shows that the number of births during that period is the lowest number recorded since civil registration began. And yet according to the same body, the Scottish population continues to grow.
“The population of Scotland on 30 June 2017 was 5,424,800. The population has increased every year since 2000 and in 2017 was the largest ever seen.”(1)
They go on the highlight their projection in the growth of Scotland’s population stating that the fastest growing age group in Scotland is projected to be those 75 and over, increasing by 79% between 2016 and 2041.(2)
Figure 1 - Scotland’s Population 2017 (NRS 2018)
Life expectancy has risen in recent decades and the likelihood of death before 65 has significantly reduced; health and social care spending on those over 65 with at least one long-term condition continues to rise, but questions remain around the efficiency and effectiveness of service provision for this increasing older age section of the population.
The concept of health and social care integration had been mooted for some time and the legislative changes here in Scotland have had a long gestation. We know from recent reports by Audit Scotland that the financial challenges have been a major barrier to speedy reform, but an equally challenging barrier is our outdated model of care delivery, focused on ‘disease palaces’; the hospitals and institutions delivering episodic care via siloed pathways with limited shared access to patient information.
This model means that older people find themselves admitted to acute clinical settings, often for longer periods than is medically required.
Terms such as ‘delayed discharges’ and ‘blocked beds’ often grab the headlines, but the NRS also shows that the trend for smaller households in Scotland is driven by the numbers of older people living alone(3), often in accommodation unsuited to their care needs.
Figure 2 - Scotland's Population 2017 (NRS 2018)
This increases their risk of trips, slips and falls and so they are admitted to hospital with a tendency for them to bounce between different places of care; home, respite and acute in a non-linear fashion.
Figure 3- Places of Care for Older People (Deloitte Centre for Health Solutions)(4)
Nonetheless, whereever the place of care, the largest proportion of care is provided by informal carers and by social care providers. Homecare providers and care-home providers employ predominately lower-skilled care staff and with the increasing complex health needs of this section of the population, the low level of skill and training fails to equip them for the associated healthcare requirements. Currently the time spent caring for frail older people is inverse to the amount of formal training received.
Figure 4 - Time Spent Caring v Formal Training (Deloitte Centre for Health Solutions)(5)
So what needs to change? What can be changed? The number of frail older people is rising faster than the system can currently cope with or adapt to. If we are to improve outcomes, this will require better integration, not just between the health and social care sectors, but across the various silos currently operating. This is necessary to reduce hospital admissions, to help self-manage long term conditions, to reduce the risk of falls, to improve medicines management and reduce poly-pharmacy, to provide supported discharge and, above all, to provide rapid response and ‘point of crisis’ triage and so help to prevent the aforementioned bouncing between places of care.
Chronological age and frailty are not necessarily correlated and it is known that there are factors which influence the ability of an older person to maintain their independent living and so increase their risk of frailty. Yet while healthcare professionals will be able to identify these risk factors, as we have seen above, the bulk of ‘care time’ for the older person is with carers who have received less formal training. It’s widely recognised that a single fall, a family bereavement or simple challenges in self-management of a long-term condition can start an older person on a journey to becoming increasingly frail and decreasingly independent.
I’m sure we can all cite examples of this in our own family or network. My widowed mother lived in sheltered housing a couple of hundred miles from me. She had previously had strokes and suffered transient ischemic attacks, she lost her eyesight and was latterly registered blind. She was in receipt of the maximum package of social/personal care available to her, four visits per day. Her last daily visit was between 7pm and 8pm and her first between 7am and 8am, leaving her in bed for up to 14 hours at a time. She stopped drinking around 5pm, terrified of having to get up to the toilet in the night and falling, something which happened on a few occasions where she lay all night. I noticed on her care notes that her carers had reported she was ‘confused and muddled’ in the mornings, dehydration can have that affect.
Each time she fell she was admitted to the local acute hospital, then she might eventually go onto a ‘step down’ setting; every time she was in the acute hospital she would be decanted to various wards to alleviate pressure on the beds, adding to her confused state.
Each time she was discharged she showed further signs of increased frailty and yet the risk factors were there, had always been there and despite my advocacy, she remained in her flat with carers four times a day; carers who provided personal care, so no cooking, but she was now completely blind. Despite her initial reluctance, I moved her into a care home. Although she died nine months later, she was happier and healthier than she had been in years - my only regret is not doing so sooner.
Despite being in sheltered housing, her accommodation was no longer suitable for her due to her decreased mobility and sight loss; despite getting the maximum care package, she was still at risk of falling and consequently, to increased confusion. She spent the last 5-6 years of her life becoming increasingly frail and decreasingly independent and she wanted to retain as much independence as possible – don’t we all?
Much of this can be prevented. We know the risk factors for frailty in the older age group, we know that as the numbers and severity of these factors increase, the older person is more likely to experience more frequent hospital admissions and greater difficultly in returning to their previous environment.
Integration of services is about much more than health and social care, much more than shared budgets and resources; it’s about joint working, it’s about suitable housing, it’s about providing a care package that suits the individual and their unique circumstance, it’s about identifying the risk factors to frailty and taking steps to mitigate.
Maybe though, it’s about going back to the birth of the NHS:
Figure 5 - Pictorial Plan of the New Health Service (Your Health Service pamphlet 1948)
“Although the new Act takes away the important hospital powers which the local authorities formerly possessed, it gives them correspondingly wide powers in other directions………Some authorities will arrange a domestic help service in homes where it is needed because there are children or old folks, or illness in the home.”(7)
(1)https://www.nrscotland.gov.uk/files//statistics/nrs-visual/rgar-2017/rgar-2017-infographic-booklet.pdf - accessed 27 March 2019
(3)https://www.nrscotland.gov.uk/files//statistics/nrs-visual/rgar-2017/rgar-2017-infographic-booklet.pdf - accessed 27 March 2019
(7)Idib (page 21)
By Lynda Gauld, Director, Baccus Consulting
NEW PRIME MINISTER, VAT, INTEGRATED CARE, CARBON CUTTING, SNP AND SCOTTISH TRANSPORT
This year we will pass a milestone in achieving one of our key targets in our bid to be the country’s greenest ferry company, cutting our carbon emissions by 5%.
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