Select Committee on Health Minutes of Evidence


Memorandum by United Kingdom Home Care Association Ltd (DD 36)

PROFILE OF UKHCA

  The United Kingdom Home Care Association (UKHCA) comprises around 1300 provider offices of home care services, throughout the UK: large and small; voluntary, not for profit, private and statutory. Our members deliver in the region of 50 million hours of home care annually.

  The objectives of UKHCA are to promote and develop the quality of home care provision.

  UKHCA are members of several umbrella bodies concerned with home care, including the Joint Advisory Group of Domiciliary Care Associations, the Continuing Care Conference, the Independent Care Organisations Network.

This submission has been prepared by

  Bill McClimont, Chairman of the UKHCA and Director of Corporate Affairs for Nestor Healthcare Group, who attends meetings of the DoH Strategic Commissioning Group for social care, on behalf of UKHCA and currently holds positions in a number of other bodies, including:

    —  General Social Care Council—Council Member.

    —  TOPSS England, (the former NTO for personal social services)—Board Member/Trustee.

    —  Recruitment and Employment Confederation —Chair of Nurses and Care workers Division.

    —  British Healthcare Trades Association—Council Member.

PROFILE OF HOME CARE SERVICES

  204,000 people employed in England alone—equal in size to the whole of the UK motor industry or the hotel sector—more than the police services. 3.5 million hours of direct care for half a million elderly and disabled people every week. 75 per cent of the activity is delivered by the independent sector.

  In addition to local authorities there are around 2500 outlets for home care services, in England, mostly small local operations. More than half have only one office and 66 per cent deliver less than 1,000 hours a week. At the other end of the scale, there is a handful of organisations with 50 or more branches. Only 14 per cent are voluntary or not for profit but these do include some of the larger providers.

  Figures do not include NHS provided community services, nor independent sector nursing services, physios etc, although two per cent of the total are personal care services bought by the NHS. Home healthcare, mostly nursing or nurse led services, is one of the fastest growing areas but we have no reliable figures yet.

  Home care services are not new; Although there has been dramatic growth in local authority services and local authority purchasing, since 1993, there have been independent services around for over 50 years. It is useful to note that much of the service provided until the mid 1980s was home nursing, especially post discharge work.

  We are not talking about "home helps", in the sense of cleaning, shopping and laundry. Even within the social care definition, only 15 per cent of care hours involve practical tasks and most of that is delivered as part of a package of personal care or other specialist services. Over 60 per cent of independent providers offer skilled services for dementia, physical or sensory disabilities and hospital discharge. Half offer learning difficulties support and 45 per cent offer specialist services for rehabilitation or mental health.

1.  SUMMARY OF CONCLUSION AND RECOMMENDATIONS

  1.1  If one per cent of people in receipt of home care were admitted to or remained in hospital, a further 5000 beds would be required. The opportunity to ease bed pressure by well targeted home care could have a correspondingly positive effect.

  1.2  Greater integration of emergency healthcare and primary care with rapid response home care would yield substantial benefit. We recommend greater use of GP services in A&E, direct links for all GPs, (especially out of hours services) to rapid response and appropriate protocols to directly refer/commission.

  1.3  Home care offers flexibility and innovation, which can complement and extend existing capacity. DoH should make available to local authority and health commissioners, more information on availability of existing services or service models, especially in telemonitoring, rapid response and supported discharge.

  1.4  To avoid a collapse in home care capacity and consequent additional pressure on the NHS, Government should provide sufficient additional funding, to local authorities, to enable an increase of at least £1 per hour in care worker pay, at a total cost of around £110 million.

  1.5  Government should give priority to restoring home care to most of those who have lost eligibility. This implies a need at least to double the current volumes of publicly funded home care. In round numbers this would mean an extra £1,600 million annually.

  1.6  DoH should eliminate elements of draft National Minimum Standards and Regulations which have cost but no quality benefit. For example, Domiciliary Care Agencies should be allowed to operate on an integrated basis with related services.

  1.7  Government should provide specific funds to cover those Standards which will be truly beneficial to the service users which the measures seek to protect.

  1.8  Organisations providing home nursing should be required to register with the Commission. We urge the Secretary of State to use Care Standards Act, Section 42 power to bring such organisations into regulation.

  1.9  Home care commissioning should be based on agreed, individual user outcomes, with greater flexibility for users and providers to agree details of service delivery. Local authorities should be encouraged to recognise the value of short term rehabilitative interventions.

  1.10  Where possible, new services should be commissioned on a "fee per case" or other "payment by outcomes" basis. Where time limited or rehabilitative services are required, use may be made of a "planned taper".

  1.11  Telemedicine and telemonitoring is the most exciting, growing, open ended element of what is becoming available in home care. It can impact on capacity to an extra-ordinary degree, as well as delivering safer, and better outcomes by enabling earlier intervention and reduced waiting times. DoH should ask those working on developing National Service Frameworks for priority conditions to give particular attention to the benefits of continuous telemonitoring of at risk patients and groups.

  1.12  A new presumption should be introduced—perhaps a Patient's Charter Standard—that all health and care services, acute or long term, will be delivered while the patient remains in their normal place of residence, without specific, objective justification for admission.

  1.13  Specific funding should be available for acute hospitals to utilise early discharge services. This should be based on individual patient outcome and should make provision for clawback on readmission.

2.  REGULATORY ISSUES

  2.1  UKHCA is delighted about the introduction of proper, consistent, fair regulation. We campaigned hard for it and worked hard to develop a set of minimum standards which were right for users and providers of homecare and about which we felt a real sense of ownership.

  2.2  The draft Standards and Regulations published by the DoH contained significant potential problems, which we hope will have been put right in the final version, which should have been published by the date of our oral evidence.

  2.3  We estimate the annual cost of implementing the Standards and Regulations, as drafted, would be approximately £405 million. Of this, around £150 million represents requirements which will have disproportionate cost, with little or no benefit for users. (detailed breakdown of estimates, for the independent sector is at Appendix 1.)

  An example relevant to this inquiry is that we believe Domiciliary Care Agencies should be allowed to operate on an integrated basis with related services.

  Integrated provision of practical support, nursing care, aids and adaptations and other related services complements the work of Domiciliary Care agencies, benefits customers and reflects Government policy to break down barriers between health and social care.

  Proposals for Agencies to have separate workspace, certified accounts, personnel records and management from all "other business" will lead to poor service for customers, substantial extra costs, reduction in local competition and disappearance of valuable local services, particularly in rural areas. We do not recognise any quality benefit for users, arising from this requirement.

  R2.1  We recommend DoH should eliminate elements of draft National Minimum Standards and Regulations which have cost but no quality benefit.

  2.4  The step change in quality of service, resulting from regulation, will make a significant contribution to improving quality of life, for many thousands of vulnerable people. However, it is essential that unavoidable costs are fully funded by Government. Without funding, the Standards cannot be achieved and the sector will be severely disrupted.

  2.5  This would have serious, direct consequences for users and also have major consequences for NHS hospital demand. Even a small reduction in home care capacity would immediately affect admission and discharge rates, as well as the volume of acute hospital work which can be handled on a day case basis.

  2.6  If one per cent of people in receipt of home care were admitted to or remained in hospital, a further 5,000 beds would be required. The opportunity to ease bed pressure by well targeted home care could have a correspondingly positive effect.

  2.7  Margins achieved by Domiciliary Care agencies are extremely low by commercial standards. Some smaller providers report operating losses mitigated only by cross subsidy. Consequently, the overwhelming majority of the extra costs will need to be passed on to customers. Most will fall on the public sector, as the largest purchaser, with the remainder being supported by elderly and disabled people.

  2.8  Care homes closures have got a lot of publicity, lately. Many more will occur in domiciliary care if local authorities continue not paying viable prices. Home care providers don't have the capital invested in bricks and mortar, which tie residential providers into the market. Just as homecare can grow quickly, it can also disappear, just as quickly. If the standards are not funded properly, either providers will withdraw or the NCSC will close them because they cannot achieve the standards, at the price on offer.

  R2.2  We recommend that Government should provide specific funds to cover those measures which will be truly beneficial to the service users which the Standards seek to protect.

  2.9  Nursing services, in the home, are becoming more prevalent, especially with the increase in intermediate care and hospital or hospice at home. Such services are not obviously regulated by the CSA.

    —  Domiciliary care agencies are defined as providing personal care services, not nursing.

    —  Nurses agencies are defined as employment agencies for the supply of nurses, not as service providers.

    —  Independent medical agencies are defined as "including the services of doctors", which many nursing services do not.

  2.10  The distinction between nursing and personal care is notoriously difficult and the definition of nursing being applied to care homes might suggest that many tasks, performed by nurses, are not considered as nursing but as personal care. However, we believe it is self-evident that, if personal home care is to be regulated, users of home nursing deserve equal protection. Conversely, it would be important for organisations providing home nursing to know whether doing personal care tasks, in support of a nursing package, means they are required to register.

  R2.3  We recommend that organisations providing home nursing should be required to register with the Commission. We therefore urge the Secretary of State to use his Care Standards Act, Section 42 power to bring such organisations into regulation.

3.  RECRUITMENT ISSUES

  3.1  Recruitment and retention of staff has now become a severe problem even in areas where unemployment is relatively higher. This has already had a severe impact on the capacity of the sector to receive patients discharged from hospital.

  3.2  Providers are often unable to accept further work, unless they can recruit more staff but are unable to attract or retain staff, usually resulting from inability or unwillingness of local authority commissioners to pay a rate adequate to offer decent conditions. The majority of providers express a wish to improve pay and conditions but were unable to do so. Unless the issue is addressed, current capacity will be eroded, placing further pressure on hospital and other institutional beds.

  3.3  In late 2000, UKHCA undertook a study of the workforce in the independent sector. This showed:

PER CENT OF PROVIDERS EXPERIENCING DIFFICULTY WITH RECRUITMENT BY REGION OF OPERATION (n=275)

South West
South East
Midlands
North
All areas
81
87
66
68
73


  3.4  Anecdotally, the situation is thought now to be worse. Competition with other employers is a key reason for the difficulty with recruitment. Many of these "competitors" were previously paying at levels below the current National Minimum Wage but are now "fishing in the same pool".

  3.5  We do not believe we will begin to solve the workforce crisis until the government has grasped this nettle and funded home care adequately, and local authorities ensure that the quality of care for service users is central to their purchasing practices.

  R3.1  We recommend that Government should provide sufficient additional funding, to local authorities, to enable an increase of at least £1 per hour in pay, at a total cost of around £110 million.

4.  COMMISSIONING ISSUES

  4.1  Other aspects of "normal" home care commissioning and purchasing are unsuited to discharge services, as well as having a negative influence on retention. These centre around allowing flexibility, autonomy and professionalism of care workers and provider managers to work with service users in adjusting the content and timing of care packages, without constant, expensive refer-back to commissioners.

  4.2  Care home packages are not subject to this wasteful, bureaucratic process and this inflexibility is directly related, in surveys of users, as a major reason for dissatisfaction with services. It also impacts on the job satisfaction and perceived status of care workers and managers.

  4.3  Assessments of need focus on specifying mechanistic tasks which need to be done for/to the service user, rather than on more positive outcomes or on working with users to promote independence. A King's Fund paper referred to "care workers whose role is to support individuals enabling them to lead a full life in the community".

  4.4  Such "enabling" services are virtually never commissioned for older people, who invariably get minimal task-based services. Home Care Regulation encourages better practice, in this area, but commissioners will need to change the way they work to enable providers to meet the requirements.

  4.5  It has proved difficult to persuade local authorities, whose experience is of commissioning long term, task based "maintenance" packages, to address the variability and higher initial cost of short term, rehabilitative, or recovery services.

  4.6  For example, people discharged from hospital may need practical support services, as part of a package, as well as professional interventions or high tech solutions, yet local authorities tend to carry across policies of not funding such services for long term users into recovery services. Health commissioners seem generally more willing to work in this way.

  R4.1  We recommend that all home care commissioning be based on agreed, individual user outcomes.

5.  ELIGIBILITY FOR SERVICES

  5.1  We believe consistent underfunding of social care services, over the last 10 years, has meant that local authorities have tightened criteria on eligibility for home care, to a point where virtually nobody given home care ten years ago, would now be eligible. Correspondingly, everybody now eligible for home care would then have been placed in a care home. Predictably, we see this last aspect of change to be very positive.

  5.2  UKHCA believe that refusal to commission low dependency services, short term or long term, including practical support, is a key factor affecting the willingness of hospital professionals, informal carers and users themselves to contemplate the option of discharge to home.

  R5.1  We recommend Government should give priority to restoring home care to most of those who have lost eligibility. Based on the assumptions above, this implies a need at least to double the current volumes of publicly funded home care. In round numbers this would mean an extra £1,600 million.

6.  INNOVATIVE SERVICES

  6.1  Home care offers flexible and innovative services, which can complement and extend existing provision. It is likely that "new" services will be developed with "state of the art" care pathways in mind and maximise the benefits of such pathways. Established services are less likely they will do so. Established, busy services also have little time to "step back" and reconfigure, even if there are not capital investment constraints such as hospitals or care homes or vested staff group interests in retaining the status quo.

  6.2  It is significant that home based services are not constrained by geographic boundaries. We deliver low volume services, across boundaries, with greater economies of scale and can set up and deliver services in almost any area, on demand, without delays for special premises.

  6.3  It is wasteful, expensive, unnecessary and absurdly slow, for identical new service development to be duplicated by large numbers of authorities and trusts, especially where off the peg solutions exist. The recent creation of many new health bodies, threatens even more "re-invention of wheels".

  R6.1  We recommend that the DoH should make available to local authority and health commissioners, more information on the availability of existing services or service models.

  6.4  When introducing innovation, commissioners often cite constraints of underutilisation or of "double running" costs and concerns that contracted services will seek to prolong episodes of care beyond that which is clinically necessary.

  R6.2  We recommend that, wherever possible, new services should be commissioned on a "fee per case" or other "payment by outcomes" basis. Where time limited or rehabilitative services are required, use may be made of a "planned taper".

  6.5  Long existing independent home healthcare has focussed on patients whose need for healthcare is restricted to intermittent nursing tasks (by home visits). This is more recently being extended by services where the main need is to take regular observations (by telemonitoring), by higher dependency services, where equipment is becoming ever more portable and by fast response services to shorten stays or avoid admission completely.

  6.6  This improvement in availability of service is complemented by higher demand, for example from parents for their children or from the terminally ill. Other, better informed groups of patients with specific long term conditions are also beginning to challenge current models of healthcare delivery and expecting more consideration for a more normalised lifestyle.

  Case study:

  Middle aged male executive with severe (hospital acquired) infection. Received daily central line antibiotic treatment at home in evenings. Avoided admission and remained at work throughout.

  6.7  Vital to delivery of high tech services is integrated supply of adequate home support, particularly where informal care support is unavailable or not capable. Social services are not in a position to cover such short term need and it is doubtful that they should be expected so to do. Existing NHS district nursing services are not usually geared to providing this element, nor do they have the capacity. Independent services, however, routinely deliver the full range of nursing, personal and practical support as an integrated service. Where required, they can also now deliver medical, pharmacy and equipment elements.

  Case study:

  79 year old frail lady, with mobility problems, living in a rural area. Previously treated with tamoxifen, following Mastectomy, suffered pathological fracture of humerus and showed raised blood calcium. Received four weekly intravenous pamidronate—at home. Maintained lifestyle, supported by nurse specialist.

  6.8  Many older people are admitted to hospital because of the perceived absence of one or more of these elements of service. This perception is a mistake. Barriers to use of home care arise primarily from organisational or budgetary boundaries in the statutory sector, particularly the health—social divide. Because we have never had such a boundary, the independent sector just get on and deliver "joint" home health and care services, as they have done for decades.

  Case study:

  A 44 year old mother of young children with Breast cancer. Received weekly Herceptin infusions via PICC for 30 weeks—at home. During the period she got a job and worked full time. Infusions switched to evenings to avoid disruption.

  6.9  At the high tech/high dependency end, a number of statutory and independent services have emerged. Here are some examples of initiatives involving care at home or "closer to home", of which we know:

    —  Supported hospital discharge;

    —  post MI cardiac rehabilitation;

    —  Intensive stroke rehabilitation;

    —  terminal/palliative care;

    —  Hospice at home;

    —  home care with a health/nursing element;

    —  generic health and social care workers;

    —  community mental health resettlement;

    —  severe learning disabilities resettlement;

    —  Admission avoidance;

    —  rapid response, (can be linked to NHS Direct, out of hours GPs or GP services in A&E);

    —  hospital at home;

    —  DVT management;

    —  IV therapy, (eg antibiotics);

    —  chemotherapy;

    —  transfusions;

    —  dialysis;

    —  total parenteral nutrition;

    —  COPD telemonitoring and therapy;

    —  chronic asthma telemonitoring;

    —  CHD telemonitoring and therapy;

    —  drug reaction telemonitoring;

    —  anti-coagulent monitoring;

    —  medication compliance monitoring;

    —  remote mental health/drug and alcohol counselling;

    —  wound care;

    —  Parkinson's and Multiple Sclerosis packages;

    —  continence management;

    —  home based respite care—especially children;

    —  home paediatric nursing;

    —  care for ventilator dependent disabled;

    —  short term in situ nursing support for care home residents;

    —  "smart house" systems;

7.  TELEMEDICINE AND TELEMONITORING

  7.1  The role of telemedicine and telemonitoring is the most exciting, growing, open ended element of what is becoming available. Combination of home healthcare and telemedicine hold the key to the really big improvements in capacity, flexibility and patient outcomes. It can impact on capacity to an extra-ordinary degree, as well as delivering safer, and better outcomes by enabling earlier intervention.

  7.2  Development of remote monitoring facilities, transmitting patients' vital signs from home (eg blood pressure, pulse, ECG, pulse oximetry, spirometry and weight) will continue to raise the baseline of dependency and range of conditions which home care packages can cover.

  7.3  A key benefit of tele-monitoring is 24 hour phone access to a nurse managers and specialist doctors, in possession of patient records. In contrast to advice lines such as NHS Direct, such operations are able to give specific, symptom and evidence based clinical advice to individual patients. We are aware that some pilot work is being done in NHS Direct to perform this kind of function but would highlight the availability of established services, which would enable faster implementation.

  7.4  As an indication, one existing telemonitoring centre can have capacity to manage 20 thousand patients at a time. Against this, the NHS plan target of 1,700 non residential places for intermediate care by 2004 looks blindingly unambitious.

  7.5  Other benefits include; more continuous symptom data, avoiding stress of clinical settings, automated analysis of routine data, reduced load on hospital accommodation and administration, less travel time for clinicians and ability to "see" more patients, less travel time and loss of income for the patient and any accompanying family members, easier second opinions, reduced geographic inequalities by spreading centralised specialist expertise, opportunities for teaching and collegiate support to isolated clinicians.

  Examples:

  7.5.a  Admission avoidance for exacerbations of chronic obstructive pulmonary disease (COPD)—medical assessment and triage at point of admission (eg in MAU or A&E) identify up to 80 per cent of presenting cases suitable for home care. Tailored treatment and care packages can include IV fluids, antibiotics nebulisers, peak flow measurements, home oxygen plus essential patient and carer education, collection of all drugs and home equipment and practical support such as escorting the patient home. COPD is the commonest cause of admission to hospital due to respiratory conditions, amounting to 1250 cases per year in some individual hospitals. Cost vary by dependency but, at the highest level, the monthly service would equate to two to three hospital bed days.

  7.5.b  Management of Congestive Heart Failure, a combination of daily ECG, weight, pulse oximetry and blood pressure monitoring can reduce length of stay and re-admissions. One American study showed a reduction from 74 per cent to 10.4 per cent and an Israeli study reported 80 per cent reduction. The cost is less than a single, weekly district nurse visit.

  7.5.c  Daily spirometry at home, (transmitted over the phone), can detect imminent asthma attacks and enable medication changes which prevent acute episodes entirely, which otherwise would have meant admission—not to mention serious distress and disruption for the patient. Cost of the monthly service is similar to a single outpatient visit.

  7.6  Telemonitoring offers safer, more confident discharge, for example following MI or stroke, offering patient support, improved rehabilitation programme compliance and early identification of deterioration. For cardiac events, telemonitoring can reduce the critical "pain to needle" time from three hours to 45 minutes, with the centre giving paramedics immediate diagnosis to help decisions on thrombolysis. Success with at risk patients has led to services are being trialled with ambulance services.

  R7.1  We recommend that the DoH should ask those working on developing National Service Frameworks for priority conditions to give particular attention to the benefits of continuous telemonitoring of at risk patients and groups.

  7.7  In mental health, telemonitoring offers the opportunity for normalisation of surroundings and treatment. It is important to remember that people with mental health problems will have the usual range of physical complaints but that usual treatment regimes may be disruptive and disturbing and that usual treatment settings may not be equipped to offer necessary specialist support.

  7.8  Monitoring of physical condition at home can help to identify adverse drug reactions earlier, without disrupting the patient's routine or environment. The greater specialisation of those reading the data—for example with cardiac nurses and cardiologists interpreting ECG's, is more reliable.

  7.9  There is already significant evidence of the value for those with early stages of dementia, through using technology solutions to prompt or remind people of daily routine tasks. This can take the form of passive systems which note, for example, whether someone has used the fridge and reminds them to eat, or which control a preloaded medication system to avoid multiple dosages. The development of such "smart house" systems is tremendous, at present and there seems to be a method of monitoring almost anything.

  7.10  Systems can also be more active, for example through voice or video linking for psychiatric consultations. For rural areas, this has obvious attractions. A study in Scotland looked at neuro-psychological assessment for people with history of alcohol abuse. The sessions tended to be a few minutes longer, the results were similar and both patients and clinicians were happy with the process.

  7.11  But telemedicine need not be super high tech. There is good evidence that nurse based emotional support and behavioural interventions by the very simple medium of the telephone can significantly improve clinical outcomes in antidepressant drug treatment. Interestingly, a study of this initiative noted no additional improvement, when patients also got peer support.

  7.12  For most diagnosis or symptom surveillance which relies on frequent observations over an extended period, these can be delivered without blocking a hospital bed, in more normal conditions for the patient and at far lower cost. This can be combined with home healthcare staff services for rapid response or can be integrated into clusters of high risk candidates such as in nursing homes or sheltered housing.

8.  VESTED INTERESTS AND "MIND SET" BARRIERS

  8.1  A continuing barrier to wider use of home care for intermediate or acute care is a mind set, among the population at large and among health professionals, that if there is something wrong with you, which cannot be fixed by a three minute GP consultation, the proper thing to do is to go into hospital.

  8.2  This prejudice often overrides patients' real preference and clinicians' objective judgement on actual patient need. It is your right to have your stay in hospital. The NHS, in most people's minds, consists of hospitals. For that matter, most people see the independent sector also as hospitals—plus the insurance funding to get into them. Both impressions are false.

  8.3  If the problem is long term, the presumption used to be that a care home was the only or "normal" solution. That prejudice is being broken down but still persists, in the media and, apparently, among some Ministers and other policy makers.

  8.4  It is outrageous that the public debate on options for intermediate care (as well as long term care), has been hijacked by the Care Home providers. If you read the press or listen to debate in the House, you could think that use of care homes was the only proposal in the intermediate care initiative, just as they come across as the only service involved in new standards for care.

  R8.1  UKHCA recommend the introduction of a new presumption—perhaps a Patient's Charter Standard—that all health and care services, acute or long term, will be delivered while the patient remains in their normal place of residence, unless one of the following factors applies:

    —  The patient is likely to need urgent access to non-portable equipment; But much equipment is now completely portable.

    —  The patient is likely to need regular or urgent physical access to specialist staff. When you consider who really deals with patients, for most of their stay, and the actual contact time involved, this may not be as big an issue as it seems.

    —  The patient's residence is unsuitable/unadaptable; Some are—but given incidence of hospital acquired infections, we should not be too sanctimonious.

    —  The patient would be a danger to themselves or others, without constant supervision. This is a balance already being worked on, even in dementia and mental health.

    —  Home based care would cost too much. This is the real issue of judgement.

  8.5  Genuine Best Value must consider relative cost against issues such as quality of life. The relative merits and costs of care homes and long stay hospitals against home care are a case in point. It has not been helpful that some early initiatives (eg Peterborough hospital at home) did not give adequate attention to cost of provision.

  8.6  Many health interventions can now happen partly or completely at home. With improving technology, historically high costs are falling rapidly. Many can now save large amounts of money and give better clinical outcome.

  8.7  Many patients are not in need of proximity to doctors or complex equipment but are manageable by basic nursing, within the professional competence of individual general nurses, therapists and appropriately trained care assistants. Using home health care therefore increases capacity, without heavy capital outlay and with low management and medical staffing overhead. This means, whether we are talking about "winter" pressures or re-ablement or intermediate care or just better services, home health care should be the first choice and the centre of planning for the future.

  8.8  Creation of a "Home First" standard would underline policy commitment towards modernisation and development of services, closer to home. By requiring specific objective justification for admission, it would help to shift public and professional prejudices away from assumption that hospital inpatient treatment or long-term institutional care is the "norm" for treatment.

  8.9  Health workers—GPs, hospital emergency or ambulance services—often perceive that personal and practical support at home is not available on a sufficiently rapid response basis from social services. This is largely true, since most local authorities are geared to long term commitments. Access involves lengthy processes of needs assessment, eligibility decisions, means testing and senior level authorisation.

  8.10  Where there is a health element to the care needed, health workers and social care workers alike assume that only health trusts are in a position to deliver that element and so hospital admission is assumed to be the only option, either for emergencies or where NHS trusts have not developed sophisticated home based services.

  8.11  Services of these types are already widely available in the independent sector and are now being developed by the statutory sector, although structural issues often present challenges for them.

  Examples:

  An independent company was invited to provide a service giving IV antibiotics at home. It released beds from people with no real need of them, avoids further acquired infections, makes the patients happier etc. It works well. They discovered that the local district nursing service had previously set up a similar service but that it had failed because treatment had to be given four times a day and the district nurses only did a maximum of three visits a day.

  By contrast, the same company attended an exploratory joint commissioning meeting, at which they discussed emergency response. By the same evening they were supporting the first patient at home, who would otherwise have been admitted to hospital.

  8.12  Hospital consultants have often formed a barrier to home based services. They can perceive a loss of control over patients, which usually does not reflect the extent of their actual involvement in care delivery. It sometimes appears that consultants derive personal prestige from the numbers of patients under their control.

  8.13  There are legal and clinical issues over who holds medical responsibility for patients cared for at home. Solutions to this vary. Some services provide their own medical oversight. In others, the patient's GP accepts that the responsibility which they normally have is not compromised. In others the hospital consultant will retain responsibility. The key is appropriate protocols for hospital admission/re-admission. Or for doctor call out, where appropriate fees may also be an issue.

  8.14  Risk aversion is a major cause of resistance to new ways of working. This has been exacerbated by the absence of proper regulation of the home care sector and, in the clinical arena, by absence of well-documented evidence of outcomes. Good evidence is now starting to become available. Extracts from an example appear at Appendices 2 and 3.

  8.15  There is a structural difficulty that acute hospitals have a financial dis-incentive against discharging patients to home, where they have to fund service, even if those services are less expensive than the hospital bed which they replace. This creates tension with professional objectives of maximising service provision.

  8.16  Funding of a hospital tends to be based on its existence, at a given size or establishment, rather than, for example, on volume of successful outcomes. They are paid to have patients in their own beds. They are not (financially) penalised for numbers waiting to be admitted. They are not (financially) rewarded for increasing their capacity by using early discharge or admission avoidance schemes.

  8.17  If a hospital funds a patient to be discharged early, another patient will take their place immediately; The capacity of the "end-to-end" service is increased; Costs increase (though by a smaller proportion); Income does not increase and budgets run into deficit.

  R8.2  We recommend that specific funding should be available for acute hospitals to utilise early discharge services. This should be based on individual patient outcome and should make provision for clawback on readmission.

9.  INTEGRATION WITH EMERGENCY HEALTHCARE, PRIMARY CARE AND NHS DIRECT

  9.1  Greater integration of emergency healthcare and primary care—particularly out of hours—with rapid response home care would yield substantial benefit.

  9.2  Up to 40 per cent of patients presenting at A&E would more appropriately be seen by a General Practitioner. Schemes are now being implemented to address this, often in collaboration with GP out of hours services. Routine nurse triage is given the additional option to refer the patient to an on-site GP, who will often be able to deal with the problem immediately and many patients will be able to return home unsupported.

  9.3  A proportion of these patients, however, while not in need of hospital treatment or observation, would not be able to cope, at home, without support. At present these patients are likely to be admitted or may be held in A&E for extended periods, until routine services are able to respond. A rapid response service would enable such patients to return home immediately. If an appropriately skilled and equipped rapid response service is used, it will also be possible to avoid hospital admission of some patients whose needs include nursing tasks or extended observation.

  9.4  Similarly, patients accessing out-of-hours GP services (co-ops, deputising and primary care centres) may be inappropriately admitted, for lack of relatively low level inputs. Appropriate direct links to (and the capacity to commission services from) rapid response services would enable these services to avoid referring patients for hospital admission. Once again, trials of schemes which respond in this way are in existence, through the Out of Hours Exemplar programme.

  9.5  It seems probable that, if GPs make use of such services, out-of-hours, there will be a demand for them to access rapid response home care for their patients at other times, as well. Concerns that GPs may commission such services inappropriately could be addressed through time limiting, agreement on eligibility criteria and by requiring certification that they would otherwise have referred the patient to hospital.

  9.6  There may be scope for NHS Direct to advise patients to access rapid response care, though problems may arise over payment, for effective "self-referral", where the only care required is "personal/social".

  R9.1  UKHCA recommend greater use of GP services in A&E, direct links for all GPs, (especially out of hours services) to rapid response services and appropriate protocols to directly refer/commission.


 
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Prepared 29 July 2002