nhs Managers

1. Dr Jay Banerjee Consultant in Emergency Medicine University Hospitals of Leicester nhsManagers.net

2. Older people: urgent/emergency care • Over the next 20 years, the number of people aged 85 and over in the UK is set to increase by two-thirds, compared with a 10 per cent growth in the overall population. • ≥60 years account for 23% of attendances to the EDs and compared to the 21-59 age group, are more likely to arrive by ambulance, have more investigations done and despite similar booking in and assessment times, spend a longer time in the ED. • The admission rates for the over 60s is also higher compared to the 21-59 years age group and they account for 43% of all admissions to hospitals in England and Wales.

3. Hospital bed use

4. Annual costs: in £000’s/person with disease (UK, 2010) – burden of disease

5. National reports NHS • NHS must close the gap between the promise of care and compassion outlined in its Constitution and the injustice that many older people experience (Health Service Ombudsman, 2011) • 35% of inspected hospitals needed to improve, 25% did not meet 1 or 2 standards (Care Quality Commission, 2011) • patients’ privacy not being respected – for example, curtains and screens not being closed properly (CQC) • staff speaking to patients in a dismissive or disrespectful way (CQC) • how often should a patient be told that “because of being unable to use the toilet… she should wet the bed”? Is that OK as long as it is only 10 times a month or 20? (Patient Association, UK, 2011) • Francis report (February 2013) • Berwick report (August 2013)

6. Hospital outcomes • Negative outcomes in hospital including HAI, falls, delirium, pressure ulcers, diagnostic errors, missed diagnosis, adverse drug reactions, death • Negative outcomes post discharge including high readmission rates, functional decline, death, institutionalisation • Reports of poor care, invasion of privacy and dignity, lack of compassionate care

7. Increasing attendance to ED? • While a substantial research literature describes general patterns of ED use, there is much less research on ED use as a function of other health service use. Gaps in the research literature result in a limited understanding of the full scope of the issue and opportunities for practice and policy intervention (Gruneir et al. Emergency Department Use by Older Adults: A Literature Review on Trends, Appropriateness, and Consequences of Unmet Health Care Needs . Med Care Res Rev April 2011 68: 131-155, first published on September 9, 2010)

8. Purpose of Silver Book • Describes the issues relating to older people accessing urgent care in the first 24 hours irrespective of provider • Describes the competencies required to respond • Recommends urgent care standards for older people - first 24 hrs of an acute care episode

9. Membership • Age UK • Assoc. of Directors of Adult SS • British Geriatrics Society • Chartered Society of Physiotherapy • College of Emergency Medicine • College of Occupational Therapists • Community Hospitals Association • Emergency Nurse Consultants Assoc. • National Ambulance Service Med. Dir. • Society for Acute Medicine • Royal College of General Practitioners • Royal College of Nursing • Royal College of Physicians • Royal College of Psychiatrists

10. Silver Book: “Is” and “Isn’t” • This document is a best practice guideline, comprising recommendations based on a review of the literature and refers to evidence where available • It does not describe the commissioning and mode of delivery of the competencies, as these will vary according to local needs, resources and policies • The older person’s care needs may be delivered in the emergency room, the acute medical unit or a community setting depending on local service configuration.

11. Underpinning principles • Respect for the autonomy and dignity of the older person must underpin our approach and practice at all times. • A whole systems approach with integrated health and social care services strategically aligned within a joint regulatory and governance framework, delivered by interdisciplinary working with a patient centred approach provides the only means to achieve the best outcomes for frail older people with medical crises

12. Front load senior decision process including primary care, ED Consultants& Geriatricians Clear operational performance framework integrated with GP processes Ready access to specialist advice when needed - Redesign to decrease LOS with social & multidisciplinary input using a “pull” system - Effective Date of Discharge - Ambulatory care (macro level) for falls/LTC Improved integration with 1° & 2° responders via NHS Pathways Optimise emergency care: - Evidence based management - Multidisciplinary input from PT / OT & community matrons - Access to intermediate and social care - Front line geriatrician input - Effective information sharing with primary care/ secondary care/ community - Develop minimum data set • - Focus on Long Term Conditions (heart failure/frailty/dementia/ COPD) • - More effective responses to urgent care needs • - Advance care planning/end of Life care plans • - Targeted input into Care Homes • Access to integrated services through NHS Pathways (3DN) including health & social care Objective: A left shift of activity across the system as a function of time; yesterday’s urgent cases are today’s acute cases and tomorrow’s chronic cases. General Practice & GP OOH Inpatient wards Community Support 999 ED AMU

13. Whole system metrics • Proportion of urgent care encounters in primary care leading to a hospital attendance and separately hospital admission in people aged 65+/75+/85+ • ED attendance and re-attendance rate per 1000 population of 65+/75+/85+ • Emergency department conversion rate for people aged 65+/75+/85+ per 1000 population • Hospital readmission rates for people aged 65+/75+/85+ and ED re-attendance rate for same group • Rates of long term care use at 90 days post-discharge following ED attendance and discharge from hospital for people aged 65+/75+/85+ • Mortality rate per 1000 in the 65+/75+ and 85+ • Patient and carer satisfaction survey • Staff satisfaction survey

14. Comprehensive assessment

15. Standards – eg. • There must be an initial primary care response to an urgent request for help from an older person within 30 minutes • The presence of one or more frailty syndrome should trigger a more detailed comprehensive geriatric assessment, to start within 2 hours (14 hours overnight) either in the community, patient’s own home or as an in-patient, according to the patient’s needs

16. Recommendations • Generic – across all settings in first 24 hrs; including discharge planning • Specific – include • Primary care • Community hospitals • ED/UC/AMU • Mental health • Safeguarding • Major incident planning • Commissioning • Training and development for all staff groups

17. Staff competencies - generic • Communication including listening skills • Compassion, empathy and respect • Clinical reasoning and assessment skills • Time/patience and the ability to build a rapport • Awareness of community services • Risk assessment surrounding discharge planning • Multidisciplinary team working skills • Personal care training skills • Moving and handling skills • Basic life support skills • Ability to balance contrasting needs of a complex person

18. Delivery

19. Some practice points • Assessment of needs - individual/population • Develop system-wide competencies - to deliver CGA • Tailor services locally - resources, cost, availability • Consider workforce implications • Foster multi-disciplinary collaborative at micro, meso- and macro- level

20. Moving on…. • “Acting our way into a different way of thinking”……the Silver Book can serve as a useful guide