Joining up the NHS
When Simon Ward came out of hospital, his wife Sujen was armed with a long list of numbers for the services who could help them. Social services, occupational health, district nursing. The list went on.
She rang and she rang and nobody called back. If she got through, appointments were made but not kept.
It is not an unusual story for people with chronic, long-term conditions. As Care and Support Minister Norman Lamb says, too many people fall through the cracks.
So, his ambition is to have health and social care fully joined up. The aim is to have a fully integrated system by 2018, with different projects in every part of the country by 2015.
New pioneer areas will be selected shortly to evaluate how these systems would work, and a team of panels, including experts from abroad, will evaluate each area to ensure their approaches do work in practice.
It is an obvious idea in many ways. If a patient has a variety of needs and requires the help of different services then it only seems sensible that they get around the table and talk.
But the way the health and social care systems have grown up has meant they often work in isolation, which means the patient or their carer has to fight to have everything co-ordinated. And often they never do win that battle, which means the patient ending up, time and again, in hospital.
It can also mean they stay too long in hospital – bed-blocking – because there is nobody overseeing their care when they return home.
In Mr Ward’s case, he has Parkinson’s disease, prostate cancer and memory loss. Added to this are undiagnosed pains in his legs which cause him enormous discomfort.
He was constantly being taken to accident and emergency and admitted. But in February he fell under the auspices of a pilot being run jointly by three London councils: Westminster, Hammersmith and Fulham, and Chelsea and Westminster.
The Community Independent Service has been testing what they call reablement packages. It is a six-week package in which all the needs – social care and health and physical care – are assessed. Mrs Ward had to make one phone call and everything fell into place.
Sitting in a central office are the necessary staff so they know the patient, they have the case notes there, and they can more easily discuss who needs to go to the patient at what time and what his needs will be when they get there.
Mrs Ward says she had been exhausted, physically and mentally. Her husband never sleeps through the night, he needs help being turned and is sometimes incontinent. If he forgets to take his medication, he can seize up, and it is often difficult to control his pain.
Yet since the reablement package was put in place, he has not been readmitted to hospital. The six weeks is up so now they have carers coming into the house to help, but should he have to return to hospital, his name would be flagged up and new assessments would be made.
There are a variety of ways of dealing with integrated care. In the same part of London, another integrated care model is being tried to help diabetic patients. The north west London care pathway is being watched with interest because it is an attempt to draw absolutely everyone involved in care together from the GP, to the hospital consultants, mental health, the physical therapies, social services, district nursing. Advising them has been Age UK and Diabetes UK.
The government is insistent that it will not, at this stage, be prescriptive about what type of integrated care local authorities should choose. But they want to see both a reduction in readmissions and the end to unnecessary bed blocking.
And there is a compelling financial case. Delayed discharges from hospital cost the NHS in England £370m a year. Cutting readmissions through A&E can save £132m.
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