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Charting a sea of uncertainty for patients with complex needs – Dr Martin McShane

Dr Martin McShane, NHS England’s Director for Improving the Quality of Life for People with Long Term Conditions, calls for radical change to the way we care for after an ageing population:

Sometimes you can’t see the wood for the trees. Over the last two decades I have experienced the impact and consequences of the changes in ageing and the eruption of complex care, as a clinician and commissioner. We can do more and more for people who are living longer and longer.

The context has changed but has our model of care? I would say it has – in a direction which has compounded, rather than addressed, the problem. In particular I would say it has for the medical profession.

The generalist in the community and the specialist in the hospital have moved further and further apart. General practice has maintained its base, its key role in dealing with the chaos at the frontier land of health care. Meanwhile specialists have become more and more specialised (ask an orthopaedic surgeon which joint they specialise in!).

As the medical tectonic plates have drifted apart they have created a sea of uncertainty for patients with complex needs who are adrift in the community and increasingly wash up on the shore of the hospital.

The emergence of this ‘care gap’ needs to be addressed and whilst that has been recognised it has avoided challenging the medical profession to think and act differently.

Evercare, community matrons, virtual wards have all been models aimed at bringing care to people with complex needs who are at risk of poor quality of life and emergency admissions to hospital.  The problem is that the medical input for this group has not been clearly defined, supported or delivered.

It has been assumed other professions, nursing, AHP and the third sector can help keep this group afloat. Yet this is exactly the group that needs their comorbidities managed in a way NICE have yet to articulate.

They need anticipatory care from a multidisciplinary team which includes a medic with skills that straddle the care gap.  These are people who require time, frequent review, active care plans and medical input yet it is assumed this can be delivered from a General Practice which has seen a massive increase in workload and a relative decrease in investment.

We need to be radical and recognise that new models of care are needed that bring care into the system that is truly dedicated to meeting the challenge of complex care in the community and that the medical profession embrace.

One such model might be to establish Complex Care Practices. Registered lists with a multidisciplinary team where the doctor has less than 500 people, but only people with the most complex care needs. It could have a capitated budget drawing on the ineffective way resources are currently used for this group in the community and acute sector as well as the parsimonious amount invested in general practice.

It is time to think and act differently because doing what we have always done and expecting a different outcome….

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7 comments

  1. Ellie Gordon says:

    I wanted to add to the comments below to say that i totally agree that there is a need to change the way we provide for people with Long Term Conditions. As a nurse with over 19 years of experience, and more recently as a commissioner of NHS Continuing Healthcare, i am constantly looking to find new and innovative ways to ensure care needs are met. However this proves challenging when there does not always appear to be an appetite for whole system thinking.
    If you want support in this from an enthusiastic mental health nurse and commisioner – do let me know!

  2. Tim Sanders says:

    This makes a lot of sense, but two concerns about separating off “Complex Care Practices”:
    – shouldn’t it be “everybody’s business” ? There are bad cultural things that can happen when people with higher needs have a separate pathway – the “hand off” and “shunting” that happens finds its way into the experience of the patient and carer.

    – the cohort of people with complex needs has a fairly high ‘turnover’ – I bet mortality rate would be 25-30% each year, being replaced by new people developing such needs all the time. Managing handovers across a boundary between mainstream and complex care practices, with this level of “churn”, could take up a lot of time and effort, as well as leaving people falling into the gap where there’s disagreement about who’s “complex”.

    Some alternative approaches:
    – developing new post-qualification training to manage complexity and co-morbidities. There are promising new courses like Bradford Dementia Group’s Diploma to become a GP with special interest in dementia; but we might need to go beyond such single-condition-focussed courses.
    – bringing more specialists into primary care, like the Gnosall / Staffordshire model for dementia.
    – networks of care with more liaison roles; geriatricians who know all about complex needs coming out into the community. So the people with complex needs stay with the mainstream GP practice, but the support and expertise comes to them.

  3. Karen Taylor says:

    Strongly agree with the assessment above – so lets get on and do it – what’s stopping us – NHSE has the resources and levers to support this to happen and to happen now not to wait to trial, pilot or otherwise delay. It can’t possibly cost more than the disjointed and ineffective way of providing care currently. And yes, agree with the point on unpaid and poorly supported carers, below, who indeed bear the brunt too often at the expense of their own health. They should be active participants in the MDT. While most GPs do the best they can, they are often ill equipped to mange the complexities of patients with high acuity and complex comorbidities – but could do so much more with regular access to and support from specialists. Better still lets vertically integrate healthcare so all participants in the care pathway have a vested interest in and accountability for, outcomes.

  4. Agree with looking at changing demands over time, adapting services and experimenting with new models. Disagree with complex care practices because I fear they would destroy continuity built up over years, by classifying and removing patients from existing lists. New complex structures and funding needed, affecting existing GPs – by losing their highest demand patients, they would have to take a cut in their average capitation. Not sure they’ll vote for that.

  5. I note you have not mentioned or considered the role of unpaid carers, usually family members who in fact bear the brunt of the responsibility and day to day management of people with complex care needs. If you would like to talk, please contact us at the UK’s largest carers charity, Carers Trust.

    • Anonymous says:

      It’s absolutely the case that, if trained, paid professionals with annual leave entitlements and an eight-hour day are struggling with complex needs, then family carers with none of those things are really struggling.

      I’m sure Martin McShane gets this; he visited us in Leeds in August 2013, and referred to his development as a clinician from seeing “the patient” in isolation, to “the patient and family”, to “the patient, the family and the community”.

      To be fair, I think this is a short blog post about a clinical model, and reads well for what it is. Getting it right for patients will usually get it right for carers – I’d say that these are often the situations where a carer might be relieved of some of the difficulties of caring by the provision of health and social care, only to find that it’s replaced by a nightmare of unco-ordinated, uncommunicative and fragmented provision.

      I think this was a blog post

  6. Mike Kangira says:

    I really found this article very interesting and yes i strongly agree with Dr McShane’s views . I presently work within a supported Living Service with 5 adults who have very very complex needs . On many occasions when they attend appointments with GP’s , there is clear evidence that the GP’s feel very challanged with these 5 client’s needs even when they attend A & E at the local Hospital in the county . It is indeed high time NHS /Government looks into this area otherwise this client group’s needs are not being fully met . Dr McShane’s model of complex care Practices will go a very long way in meeting this client group’s needs .