We need to think carefully about our models of healthcare and where possible we should look after people in their home, says Professor Alistair Burns.

The NHS in Cambridgeshire faces challenges which are common to the whole of the health and care system – acute hospitals and general practice are under pressure. Much of the rising need stems from older people with physical health problems which can culminate in a state of general frailty.

This can result in a higher level of clinical complexity, most usually with comorbid mental and physical health problems. For example, a third of the older patients in Cambridgeshire who receive specialist mental health care are also receiving community physical health care. Everyone accepts that our health service is largely designed to deal with people who have single health problems – but it is important to now look at the wider challenges that comorbidity brings and think holistically.

So what has happened in Cambridgeshire?

Some radical changes have been made to provide integrated physical and mental health care closer to people’s homes. Community and mental and physical health services for both older people and people with long term conditions are now provided by a single organisation – the Cambridgeshire and Peterborough NHS Foundation Trust. Until two years ago, the Trust was solely the mental health provider for the county – it now provides both mental health and physical health care.

This is a project at scale – the service looks after 50,000 patients at any one time and has 11,000 new referrals a month. The service includes minor injury units, inpatient physical rehabilitation, district nursing, occupational therapy, speech and language therapy, physiotherapy, podiatry and a range of specialist teams – inpatient and community mental health care with consultants in psychiatry, neurology and geriatric medicine. There are support workers and emergency response teams for both mental health and physical health crises.  We aim to treat people primarily at home and everything is available under one roof.

The Joint Emergency Team is modelled in part on a psychiatric crisis team and looks to treat physically unwell patients at home.  This team now receives up to 1,000 referrals a month and repeated audits have shown as many as three quarters of people seen would have been admitted to an acute hospital, were it not for the team. One profoundly depressed patient with diabetes was delighted to have her mental and physical health addressed holistically, not only recovering from depression but improving her blood sugars and losing weight.  ‘It’s great to be treated as a whole person, mind and body’.

The services unify a diverse range of teams so patients with complex and multiple physical and mental health problems now have an integrated team around them which can deal promptly with their clinical needs. Hospital care is not always better than care at home. For example, for each day an 80 year old person stays in an acute hospital bed, they lose muscle mass equivalent to a year of ageing. People generally prefer to stay in their own home rather than in hospital.  To quote one patient – “The best thing they have done is keep me out of hospital”.  We know that is what we would prefer for ourselves and our families.

From a system perspective, home care may be cheaper and allows acute trusts to focus on the very specialist interventions they do so well. The psychiatric teams have embraced physical health – consultant old age psychiatrists are looking again at falls and pressure areas and are able to dip in to the array of physical services now provided within their own organisation.

As the Kings Fund recently pointed out, psychiatry led the way in treating people at home and keeping them out of hospital. Psychiatrists, and in particular old age psychiatrists, are the new barefoot doctors.

We need to think carefully about our models of healthcare.  Where possible we should look after people in their home in an integrated way, and adapt our systems to meet current demands.

We also need to look at the way we train healthcare professionals.  We should match our skills to the population need and that might mean more generalists skilled in older people’s complex care.  The concept of ‘extensivists’ running ‘extensive care’ services for the older people living with frailty is appearing in different places across the country where multiple physical, mental and social needs are addressed holistically in the community.  These are the sort of healthcare professionals the NHS will increasingly need in the future.

• For healthcare professionals, if you are interested in looking differently at your service and want a challenge, let us know.
• For commissioners, Sustainability and Transformation Partnerships and emerging Integrated Care Systems, think about this as an innovative and holistic way of addressing growing complexity of health care and needs
• For educators, might this model deserve further scrutiny?

For more information on the Cambridgeshire and Peterborough service, please visit the Trust’s website or contact us using the details below.

Alistair Burns
National Clinical Director for Dementia and Older People’s Mental Health
Email: alistair.burns@manchester.ac.uk

NHS England and NHS Improvement

Ben Underwood
Consultant Old Age Psychiatrist, Clinical Director
Email: ben.underwood@cpft.nhs.uk

Tracy Dowling
Chief Executive, Cambridgeshire and Peterborough NHS Foundation Trust
Email: Tracy.Dowling@cpft.nhs.uk