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Margot James MP: How to keep older people out of A & E - and also improve their care

Screen shot 2013-05-24 at 23.21.38Margot James MP is PPS to Lord Green, Minister for Trade and Investment, Chairman of the All Party Parliamentary Group on Trade & Investment and the MP for Stourbridge. Follow Margot on Twitter.

Attendance at A&E has increased by 50 per cent in the past decade, hospitals face ever-greater pressure on this department, and knock-on effects across their services. During the Easter recess, I did some research and met two NHS Trust CEOs, the Chair of my local Dudley Clinical Commissioning Group, the regional director of NHS Direct and the CEO of the West Midlands Ambulance Trust. They confirmed that many cancellations of elective procedures were directly caused by unusually high numbers of urgent cases coming through A&E. So it is imperative that we understand the issues driving this surge in attendance.
The Health Secretary was quite right to identify the GP contract agreed in 2004, which led to a steep decline in GP out of hours commitment, as a factor causing increased pressure on A&E. Some 90 per cent of GP practices do not now provide out of hours services in the evenings or at weekends, and there has been an extra four million people each year using A&E since the GP contract changed. The inadequacy of the out of hours service was mentioned by everyone I spoke to in the NHS. We had a good service in this area before 2004, and it has not been fit for purpose since; Dr Laurence Buckman’s outburst recently does not change this fact.

However recent criticism of the new NHS 111 service is also justified. There is a reasonable perception that because call handling staff are not clinically qualified, unlike its predecessor NHS Direct, they refer more patients to A&E. I am persuaded however, by NHS Direct, that all call handlers are supported by experienced nurses, and in the fullness of time it is anticipated that the new system will reduce A&E visits and make better use of qualified nurse time. The hospital view, however, is that the treatment algorithms used by NHS 111 differ from those previously used by NHS Direct in ways that are likely to conclude with more referrals to A&E; this assertion needs proper scrutiny.

The growing number of over 60 five year olds is a strong factor in increased demand for A&E. Between 2005 and 2010, this population grew by 8 per cent - or 730,000 people. It is the very elderly who are disproportionately difficult to discharge that result in high cost admissions and that group - the over eighty five year olds - grew by 27 per cent during the same period. Additionally, there are vastly more technical and medical interventions available for this age group than existed even twenty years ago, with consequent additional costs.

Except in cases where there is a very clear need for clinical care that simply cannot be provided in the community, older people should be kept out of hospital.  I have seen and heard of too many older people who, following a hospital stay, may have had the specific ailment treated, but have deteriorated in other ways as a direct result of the shock of hospitalisation.

Older people are in hospital in large numbers because we have such a mixed picture of community support in Britain. In my borough of Dudley, for example, Russells Hall Hospital has experienced extreme pressures on its A&E department without any problems regarding the discharge of patients. Conversely, in Birmingham, the Moseley Hall Hospital and West Health Rehabilitation service rarely have any beds for the hard-pressed Queen Elizabeth Hospital to refer patients to for step down care. Yet they have wards closed all the time because, I am told, they cannot staff the wards, so must keep them closed, which is unacceptable.

There is nothing new about some of the solutions to these problems. Stronger community services should be both preventing more hospital admissions and A&E visits than at present and many services that are currently rooted in hospitals should be provided in the community.

My local area boasts a ‘Virtual Ward Team’, consisting of a community-based nurse team which assess people with long term medical conditions and their risk of a hospital admission. Patients are managed in a partnership between their GP practice and the nurse team to prevent situations occurring which would have resulted in presentation at A&E and/or a hospital admission prior to the team being established.
Dudley also delivers more services for people with long term medical conditions such as diabetes in the community, thanks to strong local commissioning. This system could certainly be extended to ease pressure on A&E. There is also immense opportunity with technology at home and specialist nursing in the community. We should consider looking to the private and voluntary sector for ideas that will enable the NHS to manage demand in times of ever tightening budgets.
The Government has made good progress in strengthening the NHS since it was elected, managing to both protect the health budget and get better value from what is spent via reduced waiting times in some categories, reduced infections, more professionals and fewer managers and a virtual end to mixed sex wards. However, increased pressure on A&E could jeopardise that progress, so I am pleased that Jeremy Hunt will unveil a holistic plan for the care of frail older people in the autumn, a plan that should include a significant transfer of NHS resources from hospitals to the community together with an improvement to the out of hours service.


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