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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