Care in the future: functions and form

Since the publication of this blog Dr Martin McShane has left NHS England.

NHS England’s Director for Patients with Long Term Conditions, Dr Martin McShane, is among the speakers at the Future of the NHS Conference 2015 being held in Manchester. Here he examines how care must change to cope with a growing and ageing population:

Let’s consider some facts…

Before the age of 40, currently, the population in England uses one million emergency bed days. Beyond the age of 85 the population uses seven million emergency bed days per year.  In fact, approaching 50 per cent of all emergency bed days are used by the population above the age of 75.

A recent report from the Health Foundation and Nuffield Trust pointed out there are 325,000 older people n care homes. For the purposes of comparison, there are 134,000 General and Acute beds in the NHS.

  • 50 per cent of residents are estimated not to get the support they deserve from the NHS
  • Residents have a 40-50 per cent higher rate of emergency admission than the general population over 75
  • 42 per cent of admissions are in the last six months of life

The emergence of multi-morbidity is significant, with at least 16 per cent of the population experiencing a multiplicity of conditions requiring long term management and taking up a third of all GP consultations.

The NHS and social care are victims of the success achieved in the last few decades of extending life expectancy and being able to do more and more for a variety of conditions that cannot be cured but can be managed.

There has been a shift in the complexity of care required which our traditional care models are struggling to cope with. If we are to cope and create a sustainable health and care service we need to think about the functions such a care system will need to deliver.

People have said they value continuity of care. It has been proposed that this needs three functions:

  1. Informational continuity – the information about the individual is with them wherever they are.
  2. Management continuity – policy and incentives to support collaborative professional working.
  3. Relational continuity – there is a trusted adviser the individual can work with to help them navigate the complexity of the system.

If this is to happen it redefines the role of the specialist beyond just providing a service to individuals to having an important role in supporting services to a population.

This means a specialist having a triple role:

  1. Providing a specialist service.
  2. Providing support to generalists managing the population in the community.
  3. Providing continuous capability training for generalists in the community.

The enablers for this are linked to the triple components of continuity of care:

  1. Informational continuity:  the use of electronic care records and plans is a game changer – we have seen that with the electronic palliative care record, which means that less than 20 per cent of people die in hospital compared with a national average of 50 per cent.  However, there is also the need for population continuity of information: by linking data we can track the value of interventions applied and could also support quality improvement as a driving force for improving care.
  2. Management continuity: policy and incentives need to be shaped to support professional collaboration.  Good examples are the year of care tariff, budgets over three to five years, measures and metrics that link inputs with outcomes (IAPT is an excellent example of this – it measures access but also recovery) and information that supports quality improvement – any data published less frequently than quarterly is inadequate.
  3. Relational continuity – if we are to bridge the gap between generalists and specialists then we also need to have relational continuity between professionals – for advice and counsel in decision making.

Finally we need to move to a model which puts the individual’s goals central to their care.  The first question professionals should ask an individual is, ‘what matters most to you?’ This should establish the goals the individual seeks to enhance their quality of life (and death).

Many of those goals will be biomedical but some will require adapting the evidence base, especially in cases of multi-morbidity – returning to Sackett’s original definition of evidence based medicine as being ‘the use of evidence to inform the consultation and decision making’.

We need to create a system which fits the individual rather than a system the individual has to fit.

This is why we have promoted a framework, to ‘enhance the quality of life for people with long term conditions’, which seeks to create a system that addresses the needs of an individual no matter what their condition:

  1. Patient and carer empowerment
  2. Professional collaboration
  3. Best practice (clinical and organisational)
  4. Commissioning that supports the above to happen.

The visual representation of this framework is the ‘House of Care’.

The ‘functions’ of a system which addresses the challenges posed by LTCs naturally leads to a debate about ‘form’. Why do we have organisational separation between generalists and specialists – is it always necessary? Are there more varied organisational forms that would better support the challenges ahead?

The Five Year Forward View specifically addresses these questions and has created an opportunity for professionals, clinicians and managers, to step forward and work with the people they serve to find new ways of delivering what is needed now and for the future.

The solution is out there – we need to make it happen.

Dr Martin McShane was previously National Clinical Director for Long Term Conditions, since the publication of these blogs he has left NHS England.

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