At times of immense pressure, how can health and care services work together to create capacity outside of hospitals? In this episode, we’re joined by Dr David Oliver, an expert in geriatric medicine, who reflects on different approaches, delayed discharges and the impact of dwindling places in care homes. Speaking as concerns mount over the Omicron variant, he sheds light on life at the frontline and the long-term problems the pandemic has cast under the spotlight.
- Pre-transfer clinical discussion and assessment
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Health on the Line
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Hello. We all know how incredibly tough this winter is proving for the health and care system. That's for some very specific reasons of which, of course covid and the covid backlog are the most important. But we've also seen the crisis cruelly expose problems that have built up for years. For example, the failures of workforce planning or the deep weaknesses of our care systems.
And in the crisis, we've also been reminded of the seeming intractability of issues that we have tried to address over and over again. Just about every hospital leader I speak to tells me they have many, sometimes hundreds of people, mainly older people in hospital who could be in community settings or at home, if only the support was available to them.
Today on Health on the Line, I'm speaking to a high profile and distinguished clinician and leader who has strong views on how we need to rethink, not just the solutions to issues like delayed discharge, but whether we're even asking the right questions.
I'm excited to be joined by David Oliver. David has been an NHS doctor for 33 years, and a consultant in geriatrics and general internal medicine for 24 years. He looked after acute covid wards for months on end during the pandemic peaks. And alongside David's busy clinical commitments as an acute hospital consultant, he's played a variety of other senior roles, giving broad experience in policy, professional leadership, medical management, academia, and medical journalism. David, I could go on for hours about your many achievements, but let's just start with how things are where you are in the health service. Everyone I speak to talks about immense pressures, but how do things feel in Berkshire?
Yes, I’m at Royal Berkshire Hospital, we're one of the biggest district general hospitals in the country, big catchment area. And I was on call yesterday till about nine o'clock at the front door in the acute medical unit, and have been on the wards all day today. It's busy and it gets busier every year. And our figures show that really only five years ago, we were getting about 350 people through our emergency department every 24 hours. We are up in the high four hundreds now. And of course, that follows through into medical admissions. We also have the same problems everywhere else has with delayed transfers, even though we've got some fantastic local community health services. And we have some quite tired staff who've gone through two years of covid medicine.
What I can report is that in terms of covid per se, we're nowhere near, at the moment, the kind of numbers I was seeing when I worked through last Christmas and new year, where a third of our beds had covid patients, our intensive care unit doubled. We're seeing a small trickle of covid cases coming in. So, it's more of the traditional so-called winter pressures at the front door, and exit block at the back door. But of course, all though I work in acute care, I know that my colleagues in elective care are facing a major catch-up backlog. The fallout from two years of covid medicine and we're facing the same problems everyone has about staffing gaps in some specialties and around social care shortages in particular.
So, when we try to analyse just this particular moment, David, and what's caused it, my sense is that it's a combination of the following things. First of all, it's the effect of ten years of austerity, which has left us with real problems in terms of workforce gaps in the workforce and also a depleted capital stock.
So, even though the money we're going to get next year and the year after is fine, it's not fine because of the fact that we built up those problems during the years of austerity. Then you've got covid, which as you say is fewer numbers now. But of course, there is a danger now with Omicron that it will rise. Then you've got the backlog of covid. And then you've got the fact that the way we organise our health service means that winter is always tough for us because we assume high occupancy rates. We have lower numbers of beds per citizen than most other developed countries.
Would that be your analysis of why things are so difficult, that combination of factors?
Fundamentally the covid pandemic has exposed some long-standing structural problems that those of us in the health policy world knew were there to begin with.
The lack of social care, provision and workforce, which has been compounded by Brexit and immigration rules. The failure to plan the workforce. The fact that England in particular has just about the lowest bed base per capita and lowest intensive care bed base per capita in OACD nations, and the ever-rising amounts of front door activity, which of course the hospital doesn't largely control, and the higher rates of exit block at the backdoor.
Albeit that we've stopped reporting official delayed transfers of care figures. They were always, as the national audit office reported a few years back, a bit of a fiction anyway. They underestimate the real numbers. But I think on top of all of that, you've got the effect of covid on the workforce, fatigue and morale and the big backlog on elective care.
And of course, with one or two exceptions in the UK, we don't separate elective from acute sites. And so, anything that happens in the acute bed base has implications for the catch-up work.
So, I think we'd probably share the analysis of where we are and I guess what we can do for the next few months. And it's of course, a much more acute view because you're there actually at the frontline, is hope that we can get through this. But I want to talk about some of these kinds of issues that have been exposed.
I want to start with one that you've just written about just in the last few days, I think, which is this question of delayed discharge. When a problem is so apparently intractable, in the end you have to start saying maybe we're not even asking the right questions and maybe the assumptions we're making are wrong about this.
So, what's your sense of how it is? We don't find ourselves in another 20 years with hospital leaders saying, well, of course, one of my big problems is I've got hundreds of people in hospital who don't need to be here.
Yes, so what I wrote about this week in the BMJ was about the kind of almost fetishisation of rapid discharge at all costs as the one metric by which we're judged. And the point being, that is largely driven by the fact that you've got A) a low bed base and B) many beds effectively taken out of commission by delays. And when I was in the Department of Health towards the tail end of the Labour government and in the first three years of the coalition, again, I was endlessly having to brief ministers about delay transfers and readmission. So, it is a perennial problem. It's very fashionable to go and quote bed audits from consultancy firms saying that whatever figure you like... a third, a quarter, of people in hospitals no longer need to be there.
And that's technically true if the capacity outside the hospital was actually available, but of course they hypothetically no longer need to be in hospital, the capacity to get them out doesn't exist. It's also quite fashionable to say that if hospitals sorted out their own internal procedures and flow and delays, then many of these problems wouldn't happen.
So, I think it is worth saying that we do have to put our own house in order. We have to make sure at the front door we have senior decision makers, well into the evening, seven days a week. We have a real focus on trying to assess people quickly, turn them around quickly. And work with community partners so they don't come in the first place, because a lot of socially vulnerable people who are sucked into hospital wards beyond the front door will get stuck. They will get stranded. But even if you have a relentless focus on daily, senior review, discharge planning, checking in about actions that you need to escalate, we only have around half the capacity in and out of hospital, intermediate care style services we need.
This has been shown in several rounds of the national audit of intermediate care. And it's been highlighted by the national audit office report on discharge. And then of course we've had sustained cuts to social care funding and provision since 2010. We have no more care home places now than we had a decade ago.
We've got a hundred thousand vacancies in the social care workforce. And so inevitably, however sharp we are within the hospital's internal flow, if people need post-acute rehabilitation, if they need long-term care, if they need personal care at home, then we have to provide that. And that's not in the hospitals gift.
And there's also often considerable stress for families and carers. Again, the politicians are very fond of saying that families should look after their own elders, but the vast majority of care in this country is given by unpaid family members and they are stressed because of the lack of support. So, these problems have been existent for years.
But the other thing is that the case mix in hospitals is not what it was when I started out. The core business now of acute hospitals is older people with multiple long-term conditions, with frailty, with dementia. So, there are just more people coming in with a kind of problems that require step down services outside hospital. And we have missed a trick repeatedly by failing to invest in those services.
And is there a danger as we now focus again on the elective backlog, that we're just going to persist with this, that everyone, even with the problem staring us in the face and the way that it is, the politicians, and to an extent the public say, well, no, the number one priority is the elective backlog. And that of course pulled money back into the acute sector. And we're back at square one.
Well, I think you're as aware, probably more aware of the real politic and the comms challenge than I am really, and I think the answer is during the New Labour years, wait time targets and access were made a big political priority because the public really were bothered by them. And that's understandable. But we've ended up embedding access to GPs and wait times, both in urgent and elective care in hospitals, as things that are measured and reported on and the system leaders are judged on.
And I just don't think that social care or community health services are as high in the public consciousness. There's only about 860,000 people in receipt of social care, adult social care for instance. Most people don't come into contact with a social care service. They don't know much about it. And I think that's why it's been easier to marginalise and put it on the back burner.
And you only have to look at the recent allocation of funding in the Building Back Better. I think I'm right in saying it was about £34 billion over three years, of which only £5.4 billion was going to social care. Because I think we know that the public are more concerned about access to their GP and access to acute hospital care and the more kind of telegenic and newsworthy.
So, for instance, the fact that district nursing workforce has been decimated over the past ten years or the health visiting workforce. The fact that we don't have sufficient capacity in community health services, I just don't think it plays big in news values and therefore not in political priorities, but if I was kind of a benevolent dictator and I could do one thing to solve the problems in both the acute care system and to an extent for primary care, it's that investment in those things like hospital at home or intermediate care rehabilitation, or care planning outside hospital. And of course, about a third of adults in acute hospitals right now are in effect in the last 12 months of their life, we still have a situation where hospice is largely funded via charity and are without the mainstream of NHS funding.
So, I just think at every point where we've put extra investments into the service, it's been hoovered up into acute bedded care and not sufficient in to other primary or community health services.
No, I completely agree. My experience of policy teaches me, David, that if you want to solve a complex problem, you have to dress it simultaneously in a number of ways. It's very difficult to use one lever to solve a complex problem.
And so, if we look at some of the elements that would be needed to solve this, the first is, and I do think there's been change here. One of the things I was delighted about and proud of when I joined the Confederation, was that the Confederation set up the Health for Care Alliance, which is an explicit attempt to bring together health organisations who say collectively social care matters as much as health.
And in as much as we as health bodies lobby for more money for health, we will equally argue that we need greater investment in social care. And you may have heard me, and also Chris Hopson from NHS Providers recently, talking about the winter crisis saying if there was any spare cash, don't give it to the health service, use it to get dowry payments or top-ups to social care staff to try to address the shortages there. So, I think there's been a shift in recognition now and a willingness of people in the health system to recognise that their fate is inextricably tied up with the social system.
David Oliver: No, I think that's right. I was the vice president of the Royal College of Physicians until 2019, and we were a member of the NHS Confed-led Health for Care Alliance, and I think you're absolutely right. There has been a sea change where quite openly healthcare people, including acute hospital people, are saying that has to be a priority at the moment and not just investment in social care but to reinvest in public health and prevention policy and population health and wellbeing. I think it's a move in the right direction, albeit that we've so far repeatedly ducked at government level, meaningful, sustainable solutions to social care funding and provision. Bear in mind, if you look at the Health Foundation analysis, we face something like a 7 billion gap just to restore social care to levels of provision we had in 2010, let alone to expand access because the criteria for accessing social care at all are quite restrictive. But I think it's really good to see, and I'm hoping that the integrated care systems do go beyond paper talk and lead to some more meaningful look across a population about where the resource should be.
Of course, in the end, although we do have a very low hospital bed base and I don't want to advocate closing wards, the brave thing is for hospitals to say, well, if we do have X percentage of beds occupied by people who don't need to be there, perhaps we need to take some of that resource and put it into prevention and community services.
Well, that takes me then to the second aspect to this. So, one is political about solidarity, about recognition that we're in the same boat together, combining our kind of political strengths to argue for greater investment in social care.
But the second is integration of services. And indeed, just this afternoon, I was at a conversation in Whitehall about the integration white paper. I think a big part of that is going to be integration measures. Do you think that having system leaders in place leaders being held to account for integration measures would be something that would make a difference?
I think notionally it's a good idea. I would just caution people to look at the devolved nations, which when they devolved scrapped internal markets and purchase providers splits and do have something more akin to what we're planning here with regional health boards. They still, to a greater or less extent, faced the same wicked problems NHS England does about over full hospitals and delay transfers and rising demand and workforce gaps.
So, whatever you do with structures will only take you so far if you don't have the staff or you don't have the capacity. But I'm a clinician first and foremost, who's dabbled a bit in the policy world and it's frustrating, the endless fixation on redrawing organograms and lines of accountability.
So, I think you're right. If we have a meaningful set of performance indicators that the whole system can be measured against and move away from sectional interests of each organisation, I think that has to be the way to go. And I'd rather see that than endless rearranging of deck chairs.
I mean I'm 56 and a couple of months. I'd quite like it if, before I retire, we don't see any more big bang reorganisations because let's face it, it's the same clinicians and the same NHS managers and it's a distraction, isn't it?
Yes. And I guess coming into the NHS from the outside, I'm generally incredibly impressed by the people that I meet, but yet, sometimes I hear things and I think it's hard to see how something like that can persist. It does reflect badly.
So, I was talking to a leader the other day who's doing great work around kind of hospital at home or virtual wards. Now he said, the reason he'd been able to do it was because those patients remained, as it were under the consultant. It was the consultant who continued to be responsible for their care. And that's why he'd been able to do it. But, in the end that really ought to be part of community provision. And he said that when he'd been trying to engage his community trust and this, they said, well no we don't have the resources to do that. And we wouldn't want our patients as it were, who were the responsibility of acute sector consultants. So, I can't say I fully understood all the kind of ins and outs of it, but there are those moments when you look at the health service and think my goodness, surely we can kind of bang heads together here. And if we are going to expand the notions of hospital at home, which we surely do and you said that earlier, we are going to have to find ways of getting the acute sector and the community sector to work effectively together, aren’t we?
We are. And actually, for listeners there's a very good British geriatric society resource that's called Right Place, Right Time, that sets out all the different models of care outside hospital, either to prevent admission or to expedite discharge. And that's got good links to some of the evidence around this.
I know it's a truism and I know it sounds platitudinous, but if you put the patient first and not the organisational accountabilities first, there are people who, if we had better advanced care planning to support them to live well with their long-term conditions, might not run into crisis in the first place. And if they are running into a crisis, we can put some supports in before they end up defaulting into hospital. All day long yesterday, I was seeing people like that who'd been running into trouble over days or weeks. And then the second thing is when they do run into crisis with acute illness or injury, we need to have some alternative ways of assessing them at the hospital front door, in their own home or in community facilities, including in care homes, by the way, because many people come in from care homes.
And the annoying thing is all those models exist. They're all quite well evaluated. There are some great works examples around the country, but we don't do enough of it for enough people enough of the time to make a difference at that system level. The people who make it into those services will do very well.
But we know for instance, with hospital at home, from clinical trials and reviews, that the outcomes are just as good, if not a bit better than hospital and people are less likely to land in a nursing home six months after having hospital at home. So, it works and people like it, we're not doing enough of it, but I'm sure that a lot of the reason we've not invested is because the organisational accountabilities drive certain behaviours. And we talk a lot of platitudinous mission statements about person-centred care, but often what we do in effect is organisational-centred care.
Is part of the issue here, David, that we just need to recognise more explicitly, that people want very different things out of the health service. That we have these two doorways, primary care and ED, and the way the system works is people are thrust towards each of these two doorways. But yet, what most people want from the health service, most of the time is simply a diagnosis and to be triaged if they've got a problem and that's a very different need. When it comes to that, you don't really want wrap around this or anyone to worry about your life in general or anything else. You just want to know whether you've got a problem and to be referred to somebody if you do. That's very different from the kind of people that you are spending most of your time dealing with, who've got long-term conditions for whom, the issue is partly about health, but it's also about their broader quality of life and around the kind of support they've got, because they're going to be living with their illness. And that's different again from dementia, which although has a basis as a disease, there is no effective medical intervention right now. So you're talking about managing that and I've seen good examples of doing things differently in terms of dementia.
But I guess my question is, do we in the health service just need to find ways of being able to recognise that what people want is different and that therefore we need to be directing them more to services that match their need?
Yes, I think that's right. The reason there's such a focus on people with multiple long-term conditions, including dementia and frailty, and especially older people and health inequalities. Because the multi-morbidity and frailty can happen in your forties and fifties, and in deprived council wards aging happens earlier, is because that group of people consume an awful lot of hospital bed occupancy, an awful lot of GP time, an awful lot of resource. And a lot of the people are in the receipt of social care.
So you can't solve any of the problems in the health service without addressing the needs of that group of people. But that group who do need some proactive care planning and some wraparound services, and some carer support, are a very different constituency, as you say, from maybe younger fitter people, living with one long-term condition or have short-lived self-limiting illness or injury or need elective care. I'm personally, a defendant supporter of a state funded, state provided, NHS model. But I do worry that increasingly with generational shift, you'll have people who are used to the convenience of travel booking sites and Amazon who won't want the more monolithic offer.
And I think there is something about doing things differently for the different constituencies. But sometimes the political solutions are not based on what the real issues are. And if you look at what's happening with overcrowding and pressure on beds, it is not minor walk-in, low-triage category people.
They may be responsible for lots of the additional pressure at the front door, but it's people who need beds. And there's nowhere to admit them to, that's the issue. But I think you're right. We have to redesign the offer based on what different groups of people want from the service.
And I think part of this is about access. I chatted a few days ago to folk in the Bristol dementia service, and having been around somebody who's gone through dementia, what I just found... I mean I think they're pretty well resourced and they'd recognise they are well resourced. And so there's an issue about how realistic is to want to replicate what they do, but they just said one thing. And I thought why my goodness, as a carer, that would have been transformative. And what they said was once you are referred to the dementia service, you're in our service for life. And I compare that to, I think, what most people's experiences, if they are living with somebody, caring for someone with dementia, which is that you trug along and things start to deteriorate and you get to your first crisis, which is the diagnosis, and then you get the diagnosis. And then generally you're told, well you've got the diagnosis go away and do your best to see how you cope. And then you hit another crisis, which is you can no longer cope. And so you get some kind of social care provision and the person gets a place in a day centre or something. And then you stay at that level until you hit another crisis, which is the point at which you might need a care home. And this kind of staccato process of getting to a point and then being left alone, and then getting to another point and being left alone, and each point feeling that you've got to kind of struggle and go through the same process.
And then when you listen to a service say, as soon as you get a diagnosis in this service, we're with you for life and we will support you on the journey. I just thought my goodness, that must be a completely different experience. And I also feel the same way about mental health. That some of the best mental health provision I've seen is open. Anyone can come in. People don't necessarily need to see a clinician. They just need to be with other people. They need to be in a supportive environment, talking to other people who share their problems, maybe the best thing to do. But so much about the NHS is about controlling access. And I wonder whether sometimes that's not even counterproductive, that actually if we opened up access, we might find that actually we reduced demand.
No, I think that's right. If you take the example of outpatients, which have been slightly neglected in the policy world, unless it's two-week cancer ways, we're often bringing people up mechanistically for routine six month follow-ups. When actually in a lot of cases, what they probably want is a one-stop clinic, where they get all their little initial investigations, and then from that point on, the flexibility to contact someone in the clinic when they want a bit of advice or reassurance or to be seen. And at the moment, we're probably using a lot of slots dragging people up for routine follow-ups that don't have any particular value. And as you say, other things like peer support, social prescribing etc. have utility. But access probably has been the defining issue in terms of political priorities for quite some time, hasn't it?
One of the people I've heard speak quite a few times since I got the job is Charlotte Augst, who runs National Voices. And she's brilliant. And one of the things I heard her say that I thought was very powerful was that we don't get as much as we should out of the interactions we have with patients.
So she said, for example, lots of people on waiting lists, don't even know why they're on the waiting list. They don't know whether on the waiting list for a diagnosis or for a treatment, that remarkably high numbers of people with long-term conditions haven't been given, or at least, don't understand the basic advice about how they should be managing their condition, managing their lives.
So her point was, if every interaction we had with the health service actually gave us all the information that it could give us and empowered us, we'd be much more productive. But somehow the interactions with the health services aren't. We're not using that point of contact as well as we should. Do you recognise that?
I think that's right, but I think from the perspective of a busy clinician, it’s become very transactional because of the workload pressure. So, if you're the GP and you're trying to crack on through 50, 60 contacts a day and all the administration, or if you're an A&E doctor, the relentless pressure of next, next, next. So, I've got to get around 28 people in the ward in four hours of a morning, so you're constantly thinking about not just the person in front of you, but the next people. But where I see this working well that you've described, when I have patients who are on the books of say the Parkinson's disease nurse practitioner, or the palliative care nurse specialist, or the heart failure nurse, they have real confidence in those people because they have a therapeutic relationship with them and they swear by what they say and they're always pleased to see them. Because people in those kinds of roles are not just dishing out the drugs, they are helping people navigate the system. They're helping people understand what to do when there's a crisis, help access other supports with their lives. And I think certainly for people living with long-term medical problems, we need more of that care planning in that person that coordinates alongside people.
But I think from the perspective of health professional, your time is limited and you've always got your eye on the clock and you're under tremendous pressure to get people seen, make decisions, find beds as early in the day as possible if you're in my kind of job. Time is precious. And the key to time, yes, you can take some of the admin tasks outside of our job so we can work a bit smarter. But most of all, the existential threat facing the service is the workforce crisis. And we've still yet to see a meaningful workforce plan. And some of that's training more people, but some of it's treating them better and giving them more flexibility and supports. They don't want to retire or leave the service or scale down their hours. If we don't crack that problem, we won't have the time to provide the more bespoke type of information you're talking about.
Yes, it feels as though we're kind of caught in a kind of high-intensity/low-productivity trap, which is that people are working incredibly hard and in doing so, being required to work in ways which aren't as fulfilling as they should be for the people who do the work, which is on the reasons why people walk away, but probably in the not high productivity. I remember research years and years ago about the fact that if GPs spend twice as long in a consultation with a patient, that patient is half as likely to come back again in the near future. We've got to somehow move to a different lower intensity, higher productivity equilibrium, haven't we?
I think the GPs know that. And it's the same as a hospital doctor. There's a lot of talk in clinical circles about moral distress and moral injury, which is when you, perfectly well aware, that because of the system you're working in, you can't give people a quality of care that you'd like to be able to do, or that you could be proud of, or that you'd be happy for a member of your own family to have. And constantly working in an environment where you know you're not giving the standard of care you'd like, and also where you're always on the cusp of missing something, mistakes or errors, is not a satisfying position to be in.
And I think we'd all agree we'd like to be able to give people more time. Some of that is about reducing unnecessary admin burden. Some of it's about filling the workforce gaps. Some of it's about reducing demand through some of the ways we've discussed through better focus on prevention, upstream care. And the whole time I've been involved in that kind of health policy world, there's been loads of rhetoric about, we need to move towards a wellness service and prevention and public health, but actually the policy direction has been the diametric opposite.
We've slashed local government and public health funding. We've consistently failed to enact meaningful policy around inequality, or food and drink and alcohol pricing. We've cut addiction services. So if we really want to focus on prevention and wellbeing, so we can therefore reduce burden and also give people the chance to work at the top of their clinical pay grade, giving more time to patients, we've got to put our money where our mouth is, and we haven't at the moment.
David, that's a strong point to end on. Thank you so much for giving me your time.
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