Wednesday, 19 December 2012

Hospitals specialising in community healthcare are key to future of the NHS

Hospitals specialising in community healthcare are key to future of the NHS: Prevention and rehabilitation need to be more widespread if the NHS is to cope with the costs of ageing, say healthcare leaders

It's 11 o'clock on Thursday morning and six men and women in their 60s and 70s are doing a gentle exercise class in the gym of Edgware community hospital in north London. They take it in turns to do step-ups on to a low board, jog up and down lightly on a mini-trampoline and lift small hand-held weights in what looks like a slow-motion circuit training session. These patients cannot manage a more vigorous workout as they all have serious breathing trouble. They suffer from chronic obstructive pulmonary disease (COPD), the generic name for serious and debilitating lung problems such as emphysema and chronic bronchitis. It is also one of the long-term health conditions that, like diabetes, arthritis and high blood pressure, pose a major challenge for the NHS because growing numbers of patients have at least one of these long-term conditions – 15 million in England alone.
After some cool-down exercises sitting in their chairs, the patients have a cup of tea or coffee and a biscuit and listen while lead physio Bunmi Adebajo explains how they can preserve vital energy by, for example, buying pre-chopped vegetables rather than cutting them up themselves. "I have to take life easy," says one of the patients, JC Shah, a 79-year-old ex-teacher, who also has a heart problem. He carries a blue inhaler everywhere in case he needs a few blasts of the drug to open up his lungs, does the deep-breathing exercises Adebajo has taught the class, and can only go for walks with his wife by his side in case he becomes breathless and passes out. Shah enjoys the camaraderie of the twice-weekly sessions at the hospital and says he finds the exercises and advice beneficial.
It is also convenient. He lives only a few miles away. Until 2009, patients like Shah from suburban north London had to travel further afield, to Watford general hospital. But the COPD services are now closer to home in what used to be a district general hospital, complete with an A&E unit. It now provides only clinics and day surgery, and no acute services. Its few overnight beds are for frail elderly people undergoing rehabilitation after a fall or stroke, not for emergencies. The COPD sessions are provided by Central London Community Healthcare NHS trust (CLCH). It is one of just 21 NHS trusts in England which specialise in community-based healthcare. Given the increasing pressure from ministers, health charities and think-tanks, such as the King's Fund, to move services out of hospitals, this should be a growing area of NHS activity, but in contrast to the score of community healthcare trusts, there are 166 acute hospital trusts.
CLCH employs 3,200 people, of whom 2,600 are community-based healthcare staff such as district nurses, occupational therapists and physiotherapists. It works in four London boroughs – Westminster, Kensington and Chelsea, Hammersmith and Fulham, and Barnet – with a population of about 1 million. Staff work out of 160 locally situated sites and in many cases in people's homes. They have contact with about 150,000 patients a year, 60% in clinics and the other 40% in patients' own homes. "We are a slightly hidden part of the NHS," says James Reilly, the trust's chief executive. "We don't operate out of one hospital, we don't have big large buildings and we aren't one big single institution."
In last week's National Audit Office analysis of the NHS's quest to make £20bn of efficiency savings by 2015, it said: "There is broad consensus that changing how health services are provided is key to a financially sustainable NHS. Such changes will include integrating care and expanding community-based care." But it added that only limited "service transformation" had yet been achieved.
CLCH is already delivering care in the way that many healthcare leaders say will have to become much more common if the service is to cope with the double burden of ageing and long-term conditions, while simultaneously seeing no significant increase in its budget. "We perpetuate the myth that the NHS is about buildings," says Reilly. "But we need to get the right care to the right patients in the right place at the right time, and increasingly that's not in hospital."
The NHS will increasingly have to be focused on providing preventative or rehabilitative treatments to keep people out of hospital, he adds. The COPD service, for instance, aims to help patients manage their condition and avoid suffering such difficulty breathing that they have to go into hospital. CLCH's community and specialist nurses also treat people with diabetes, who would otherwise end up in St Mary's hospital in west London under a deal with Imperial College Healthcare NHS trust, which runs the hosptial. Over the last four years, almost 2,000 diabetics have been referred for community treatment and have avoided hospital.
CLCH staff also help rehabilitate patients recovering from a stroke or fall and provide children's services, such as advice to new parents and assessments of babies' health. Other services include physiotherapy, occupational therapy, podiatry and speech and language therapy. In a collaboration with the Royal Free London NHS foundation trust and Barnet council, CLCH also helps to reduce patients' length of stay in hospital by ensuring they are well enough supported when they do get home and can cope there. Nurses or therapists visit up to four times a day for up to five days after discharge.
Research shows that MPs support these moves. An overwhelming majority of 99 MPs of different parties endorsed the principle of community-based care for children's and young people's day-to-day care (99%), care for older people (92%) and treatment of long-term conditions such as diabetes and heart disease (76%). These views were roughly the same across all the political parties. Three out of four of the MPs thought more priority should be given to community healthcare rather than acute hospitals, although only 17% said it should receive a significantly greater priority. Conservative MPs were the most supportive of acute hospitals.
Despite support for the principle of moving towards more community care, the research by political research agency Dod's on CLCH's behalf, found that MPs are also understandably anxious about the impact that could have on their local hospital. "The electorate often think it's healthcare on the cheap and are very resistant to the downsizing or closure of big acute units," said one Tory. "Results are too long term for governments with their eyes on the polls," added a Lib Dem, while a Labour MP said: "It's just not as headline-grabbing as cancer or heart disease targets."
Reilly is undeterred. "This part of NHS care is still very much embryonic. But it's going to be vital. We're going to need it more and more. Policymakers and the NHS need to give it more attention," he says. Chris Ham, chief executive of the King's Fund, says that "service transformation … is really hard to do politically, practically and financially." With research showing that 30-40% of patients do not need to be in hospital, this has to be the NHS's future path, Ham says. "It's a journey the NHS must make – it's urgent that it does so."
But he points out that it is a journey that must be made in conjunction with social care, whose budgets are under severe pressure. "That means the resources aren't there to fund the level of social care we need if we are seriously going to shift more care into the community", he warns. The Guardian

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