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BGS submission in response to the Health Select Inquiry on planning for winter pressure on A&E Departments

On 4 August, the BGS responded to the Health Select Inquiry on planning for winter pressures on A&E Departments.

The BGS calls for recognition that there are limits to the steps that hospitals themselves can take to lessen winter pressure on A&E departments, and that instead the underlying structural issues must be addressed.  Investment in fully integrated health and care services through the Five Year Forward View is essential.

This needs to be supported by a national strategic direction for people living with frailty, dementia, complex needs and multiple long-term conditions, which ensures access to comprehensive geriatric assessment, personalised care plans for treatment and long-term follow-up for all older people with frailty, dementia, complex and multiple long-term conditions, including for those coming towards the end of their life.

Summary of underlying issues (download full submission in pdf format):

There is no one single issue that explains why the NHS continues to struggle each winter to cope with the immense but predictable pressure placed on A&E departments.  Instead our experience of working with older people, very often with moderate or severe frailty, shows us that it is the combined effects of the ways in which social and health care systems are structured, resourced and delivered that result in unsustainable levels of pressure on A&E departments at certain points during the winter.  We believe that sufficient resourcing and implementation of the NHS Five Year Forward View will help to address these issues.  Our submission focuses on the following issues:

  • delays in transfers of care from acute hospital settings to community-based and home settings
  • insufficient capacity in intermediate care teams
  • delays in assessments of continuing care needs for older people
  • a reduction in social care funding
  • significant numbers of people over the age of 75 coming directly to A&E
  • workforce issues

An increase in the number of delayed transfers of care from an acute hospital setting.  The recently published National Audit Office report  on discharging older people from hospital estimates in the past two years to 1.15 million bed days were lost due to delayed transfer of care, and that delayed transfers rose by almost a third (31%) between 2013 and 2015.  There is inevitably a knock-on effect on A&E departments as patients who are assessed as needing admission are delayed in moving to wards if beds are not available. This means they must remain in the emergency department and be cared for there.  The following information helps to explain this increase:

  • 2.7 million hospital bed days are occupied by older patients no longer in need of acute treatment  
  • 50% of older patients attending A&E departments go on to be admitted to acute wards 
  • the UK has fewer acute hospital beds per person than the majority of other countries in Europe and the number has declined significantly since 2000 (3 per 1,000 people in 2013 compared to 4.1 per 1000 in 2000) .  
  • around 5% of admissions for people over 65 result in stays of more than 21 days; however, this 5% accounts for 41% of all occupied beds.  

Lack of capacity in intermediate care.   The National Audit of Intermediate Care (NAIC) shows that when people have access to intermediate care the vast majority (92%) either maintain or improve their level of dependency on care.  However it also shows that waiting times to access intermediate care have increased significantly in the last three years as a result of a capacity gap, and that one third of the people waiting for intermediate care support are waiting in an acute bed.  Aside from the costs incurred as a consequence of these delays, this again has an impact on A&E departments and is one of the key factors adding to winter pressures. Another relevant factor is that delays in accessing intermediate care result in poorer outcomes, as frail older people in hospital (especially those suffering from dementia) tend to lose independence with every passing day.  

Insufficient investment in social care.  As with delays in hospital discharge, and access to intermediate care, the overall reduction in social care services has a direct knock-on effect on A&E departments.  The King’s Fund briefing, Deficits in the NHS 2016 provides an up to date analysis which shows that despite transfers of NHS budget to social care it has not kept pace with the increase in demand, and the fall in social care spending between 2010-15 has led to two issues: i.people being unable to access the care they need leading to poorer health outcomes and an increased likelihood of presenting at A&E, and ii. people remaining on an acute hospital ward for longer than necessary, again with an impact on A&E departments, and most critically a negative impact on the health of older people with frailty which deteriorates with every additional day spent on an acute ward. For an older person with frailty the loss of skeletal muscle strength resulting from a hospital stay can make the difference being able to rise independently from a chair or bed and being dependent.

Primary care.  80% of people over the age of 75 who are admitted to hospital have not been referred by their GP.  This includes people whose condition is treatable by a GP.  Instead there has been a significant increase in the number of people coming directly to A&E departments.   This places additional, often preventable, pressure on A&E.

Workforce issues.  There is a need for more geriatricians and specialists in older people’s health care.  The Royal College of Physicians most recent data shows that “geriatric and acute medicine has consistently had the largest number of posts being advertised, but they also consistently have the largest number of posts that cannot be filled” .  We also know that the current workforce crisis in GP and community nursing will take time to address.  Government’s plans in the GP Forward View  for increased investment in primary care between now and 2021 and a planned expansion of workforce capacity are welcome but need to be accelerated, and the recruitment and retention crisis in Emergency Medicine needs urgent action.    Our view is that the challenges that A&E departments face cannot be addressed without addressing current workforce issues.

Summary of measures that can be taken (download full submission in pdf format):

  • Do more to help avoid patients being admitted from nursing homes to hospital
  • Accelerate delivery of fully integrated care for older people
  • Give better support to patients with dementia who are admitted to hospital without an acute reason
  • Develop a national strategic direction for older people living with frailty,dementia, complex needs and multiple long-term conditions

In detail:  

Do more to help avoid patients being admitted from nursing homes to hospital.  Care home residents aged over 75 are three times more likely to be admitted as emergencies than over 75s in the general population.   We also know that one third of nursing and care home residents admitted acutely to hospital die during that admission, and that they are often close to the end of life when they are admitted.   Pressure on A&E departments can be lessened by ensuring that proactive care planning and better access to health care in care and nursing homes is in place.  A part of the solution lies in supporting and empowering staff across all care sectors in developing competencies in the management of older patients, and in ensuring that there is sufficient geriatrician and specialist nurse practitioners workforce to enable them to work with care homes to make attendance at A&E and subsequent admission a last resort. NICE guidelines support this approach    

Accelerate delivery of fully integrated care for older people, most especially those older people at risk of deterioration or unplanned hospital visits.  This is a shared vision which needs embedding.  The NHS 5 Year Forward View supported by Sustainability and Transformation Plans offers a real opportunity to make this happen. We welcome the Committee’s recent Inquiry and report on the impact of the 2015 Spending Review on health and social care, and believe that its recommendation to “ensure that the Sustainability and Transformation Fund is used for its intended purpose of pump priming the transformation of health and social care at scale and pace”  is key to being able to avoid crises in A&E departments.  Sustained investment in integrating health and social care services, and close monitoring of progress will also be required if the delivery of fully integrated services that better meet the needs of patients is to be achieved.  We also welcomed the recently published CQC report, Building Bridges, Breaking Barriers: Integrated care for older people  which showed that older people often have multiple care plans that are not being routinely linked, and that where initiatives to enable integration have been successful they have often been short-term with only partial or temporary funding.  

Give better support to patients with dementia who are admitted to hospital without an acute reason.  As many as 40% of admissions are for people over 75 and 1 in 4 beds in acute hospitals are occupied by someone with dementia who often have no acute reason for admission.  

Develop a national strategic direction for older people living with frailty, dementia, complex needs and multiple long-term conditions.  We call for better access to comprehensive geriatric assessment, personalised care plans for treatment and long-term follow-up for all older people with frailty, dementia, complex and multiple long-term conditions.  These can only be provided consistently and effectively through ensuring that staffing is at a level which is adequate for delivery of that care and follow-up.

Conclusion

The range and combination of issues affecting A&E departments is currently resulting in a lack of the resilience that is necessary for coping with seasonal increases in pressure of demand.

There is strong evidence to show that better care for frail older people can reduce demand on health and social care services and therefore improve the capacity of A&E departments when faced with seasonal pressures.  

We would be very happy to discuss this with the Committee and to attend an oral evidence session if called on to do so.

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