To receive a presentation a presentation from Professor Sue Procter from City University, the Panel’s independent expert adviser, on:
· General principles and policy issues
· Evidence of what works best.
Minutes:
The Panel received a presentation from Professor Sue Procter, from the City University, on key issues relating to high intensity users and interventions that have undertaken.
High intensity users tended to have one or more long term conditions (LTCs) plus complex social circumstances and/or additional mental health problems including anxiety and depression. Not all patients with one or more LTCs became high intensity service users. Those that did tended to make additional demands on A&E and out of hours services, including hospital admissions, and/or suffered from LTCs that had traditionally been managed by the NHS in isolation from social services (e.g. COPD, diabetes, heart failure).
High intensity users could be managed as part of a strategic response to LTCs, but tended to require additional demand management strategies such as;
· Anxiety management
· Out of hours and fluctuating support from social services in response to exacerbations of their condition
· Help to address complex social circumstances
· Containment strategies in order to prevent the patient bypassing planned care system
The Chronic Care Model identified the essential elements of a health care system that encouraged high quality chronic disease care. Strategic responses to high intensity were typically based on these. These elements were:
· Community resources and policies
· Health care organisation prioritising chronic care
· Self-management support
· Delivery system design
· Decision support for to ensure integration of protocols and guidelines
· Clinical information such as
Ø Reminder systems to support compliance
Ø Feedback to health professionals providing information on chronic illness measures such as hypertension or lipid levels
Ø Registries for planning individual patient care and conducting population based care.
The role of the Community Matron was an important part of many strategies. Community Matrons typically took responsibility for about 50 older people with high levels needs and worked collaboratively with all professionals and care givers. They worked in partnership with GPs and members of the primary health care team. They worked with the patient to develop a personal care plan, kept in touch and regularly monitored the patient’s condition. They performed a range of useful functions such as:
· Initiating action as required
· Updating medical records
· Mobilising multi-agency resources as required
· Educating care givers into when to alert services
· Generating additional support as required
· Maintaining responsibility for patient even if they are admitted to hospital
· Preparing relatives and patients for health outcomes
· Evaluating care packages with GP.
In respect of telemedicine, there was very little UK evidence so far. Its implementation was still beset by technical problems. It required a well maintained system of response and worked best when linked to telecare and call alarm systems. An evaluation undertaken in NE London indicated that telemedicine aided communication between patients and health care professionals and could lead to the resolution of seemingly intractable problems. However, it was not universally acceptable to all very high intensity users. In addition, patients and families already experiencing high levels of stress may not welcome additional stress when technical problems are experienced with telemedicine.
On the whole, UK information systems were not joined up and this seemed to be the case in Haringey. Essential information such as District Nursing notes tended to be manual rather than electronic and therefore could not be interrogated. Existing information systems such as GP registers did not enable identification of current or potential VHIU. The PARR formula was a response to current deficiencies in routine data collection. The accuracy of its predictions was variable.
The single point of access was a way of providing a single point of information about the patient. It was designed to prevent the duplication that could occur when patients used multiple access points, such as A&E and out of hours GP services. It also enabled identification of the total population living with an LTC in order to plan services. A problem with current NHS information systems was that they gave information on episodes of care or incidence of a single disease not people.
In respect of the effectiveness of community matrons and case management, there was little evidence of it leading to a reduction in hospital admissions. However, other evidence showed that the approach was effective and that patients were benefiting from it by being alive and well, still living at home and avoiding hospital. Many trust boards were also pleased with local evidence showing that community matrons more than covered their costs in emergency admissions saved. It was also clear that they improved quality of life. There was always likely to be sufficient demand to fill hospital beds so significant savings were unlikely to be made. In addition, many studies were based on the US experience, which was not comparable to the UK due to structural differences.
One particular initiative that had been undertaken was the “virtual ward”. This involved a network of virtual wards caring for the top 0.3% of a PCT’s registered population ranked according to predicted risk of emergency hospital admission in the following year. Each ward had a capacity to care for 100 patients and was linked permanently with a group of GP practices. The clinical work of a virtual ward was led by a community matron. There was also a ward clerk and the telephone number for him/her the ward clerk was the sole point of contact for the entire virtual ward. Patients were cared for at different intensities according to need: of the 100 patients, 5 were reviewed daily, 35 weekly and 60 monthly. When a patient fell below the top 100 for the virtual ward’s catchment area, discharge was considered. In the first two years following discharge the GP practice conducted quarterly rather than annual reviews.
Professor Procter briefly outlined the main principles of the report by Lord Darzi entitled “Healthcare for London – A Framework for Action”. The report was based on the following principles of care:
· Fairness – equally available to all, taking full account of personal circumstances and diversity
· Personalised – tailored to the needs and wants of each individual, especially the most vulnerable and those in greatest need, providing access to services at the time and place of their choice
· Effective – focused on delivering outcomes for patients that are among the best in the world
· Safe – as safe as it possibly can be, giving patients and the public the confidence they need in the care they receive.
The Panel thanked Professor Procter for her presentation.