The Long Term Plan for out of hospital care

NHS England’s lead for the Hospital to Home programme looks at how the NHS Long Term Plan has provided, for the first time, a realistic model to support older people with long term conditions or complex health needs at home and in their own community:

What a great programme BBC2’s Hospital is, shining a light on our amazing healthcare with dedicated staff working in challenging conditions.

So where do the people go to after their time in hospital?  We know that for many the need for health care doesn’t just stop. What about the people who need health and social care in their own homes or care home, receiving often complex care, to keep them well?

Sometimes it seems that the ‘H’ in NHS stands for ‘Hospital’. But we know that services in the community wrap around higher profile services and are as essential.

Now there is a significant step change. Importantly, as its very first chapter, the NHS Long Term Plan acknowledges the multiple challenges community health services and general practice face with insufficient staff and capacity to meet increasing complexity and rising patient need.

In recognition of this, an extra £4.5billion a year by 2023-24 will support a new service model, enhancing existing services enabling people to stay at home, with more options, better support and improved joined up care. That figure includes an extra £1billion on top of that announced by the Prime Minister in November last year.

People in England now live for far longer, but extra years of life are not always spent in good health. Older people are more likely to live with multiple long-term conditions and complexity, or live with frailty or dementia. Older people don’t always get the care they need in the right setting and at the right time.  Hospital interventions for many people with complex needs can experience extended lengths of hospital stay risking unwarranted and harmful healthcare outcomes.

Ironically as I write this blog my dad in his 80s has fallen out of bed onto the floor.

  • I’m insistent having been a district nurse that he doesn’t need to be admitted to hospital.
  • But I’m wondering what services there are in the local area for older people…

So, for those of you who haven’t had chance to delve into the long term plan, what does the model look like?

  • A new NHS offer of urgent community response and recovery support: investing in and enhancing existing rapid community response teams, to prevent unnecessary emergency hospital admissions and speed up discharges – importantly receiving services within two hours in a crisis and a two-day referral for reablement care, and to improve access via a single point of access for people requiring urgent care in the community.
  • Guaranteed NHS support for people living in care homes: supporting timely access to out of hours support and end of life care, including supporting care homes to have easier and secure access for sharing information about their residents using NHSmail.
  • Supporting people to age well: the NHS in England is leading the way identifying older people with moderate frailty at particular risk of deterioration, offering them proactive personalised care and support. In doing so delivering a core model for the future care of people with complex needs. This will be delivered by Primary care networks where general practices, community teams, social care hospitals and the voluntary sector work together to help their local population, including older people, to stay well, better manage their own conditions and live independently at home for longer.

Delivering these three services together offers prevention, crisis intervention, reablement, rehabilitation, end of life care and care for people living in care homes.

They must meet the needs of local communities and consequently if they are to the address inequalities in both access to services and in health care outcomes.

Partnership working with all major stakeholders including health, social care and the voluntary sector is key to the success of these models.

Other parts of the NHS Long Term Plan will enable the development of these services to improve outcomes for people as they age.

For example:

  • developing a sustainable and appropriately skilled workforce;
  • ensuring community staff have access to mobile digital services
  • personalised care budgets to support people to live in their own homes

We have a real opportunity to respond to the focus on community and primary care and work together delivering these services consistently, finding solutions together to make a real difference to our local populations.

And for those wondering what has happened to my dad, well thankfully the ambulance service has picked him up, comprehensively assessed him and advised on falls prevention. Great work happening day in, day out by our NHS.

And I’m looking forward to an improved offer for older people to help them live supported when they need it wherever they live in England over the next few years.

Kathryn Evans RGN, BNurs (Hons), MA, Queens Nurse Community Nurse Lead, Nursing and Midwifery Team, NHS England.

Kathryn Evans, RGN, BNurs (Hons), MA, Queens Nurse

Kath is the Deputy Director of Urgent Community Response for the Ageing Well Programme as part of the NHS Long Term Plan in NHS England and NHS Improvement.

Key areas of work include improving the outcomes and responsiveness of intermediate care to meet new national standards. She contributes to the greater work of the programme, which includes continuing the roll out of the Enhanced Health in Care Homes framework including, NHSmail into the independent social care sector and supporting community multidisciplinary teams in improving outcomes for people with frailty and multimorbidity.

Kath’s background includes working as a nurse with over 25 years’ experience in the NHS, in professional leadership, service development and operational management in the community. Kath has worked at a regional level in service improvement and assurance and delivery of CCG’s.

She has led on improving the reduction in Delayed Transfers of Care from hospital and was the Community Nurse lead for NHS England having a background as a District Nurse.

Kath is passionate about partnership working across health and social care and community services.

Follow her on Twitter: @kathevans2015</a

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One comment

  1. Mike Dickinson says:

    I would very much like to make contact with the relevant person about my Companys research and development of a housing concept that addresses the changing demands of occupants through their whole lifecycle. The concept allows maximum flexibility to change the house internal configuration to respond to needs including mobility, illness, dementia, provision for live in carer (family) whilst maintaining maximum independence. The concept is currently going through Patenting .
    I have personally experienced immobility, dementia of my mother in law at the same time having a father in law (both living at home) who had complex health needs and was almost unable to walk. These experiences and my long background in design and construction led to the Concept being developed over the last 3 years. I strongly believe it will be a contributor to ensuring people live in healthy houses for the majority of their life.

    I look forward to your response.
    Kindest regards
    Mike Dickinson