Trying to care for older people says Professor Mayur Lakhani, is like playing cricket with a broken bat.
Imagine playing cricket and going out to open the innings with a broken bat. As a practising GP, that’s what it feels like at present in trying to deliver good, timely care for older people.
One of the reasons is that there is an absence of a strong national vision for older people.
Another more practical barrier is that community health services; district nurses, matrons, therapists, intermediate care teams (and health visitors, school nurses, midwives for that matter), are not joined up with GP services.
This means that community health services and GP practices can be blissfully ignorant of what each are doing on a day to day basis except when there is a crisis. And when there is a crisis, hospital admission becomes the default option. But hospital is not always the answer.
Teamwork is essential in this field. But current working is characterised by ‘turf wars’ so that care is delivered according to who your employer is rather than the need of the patient.
Take this example: An older person, a housebound nonagenarian receives his flu jab at home from a community nurse. But his spouse, who is also a frail older person is declined a flu jab because she is not on the ‘case-load’ of the community services. She is thus unimmunized and later develops a chest infection.
We are blessed by the quality of individual community health services staff. And we must celebrate good team working that is found in end of life care, delivered by district nurses. But we need more working like this.
Despite protestations by GPs, including by the RCGP in its Roadmap, new roles have been created that are semi-detached from GPs.
The result? Community staff have been progressively disconnected from GP practices resulting in fragmented care, and confusion.
Currently community health services are best described as being in ‘neutral gear’. We need responsiveness and urgency from CHS services. But GPs’ influence on CHS is dilute and indirect.
Why are community health services part of acute trusts or mental health trusts?
Surely greater alignment with CCGs and therefore general practice would be a more natural alliance with community health service budgets being devolved to federations of practices via the CCGs – just imagine the power of that.
Reform is needed. The status quo is unsustainable to deal with an ageing population with complex needs and comorbidity. The highest overall consultation rates occur in the age band 85 to 89 years: an average of 14.0 consultations per person-year. The exceptional potential of the GP consultation enables systematic care but GPs need strong teams to tackle the problems that old people face.
Assessment should be person focused and not disease focused. This can be achieved through commissioning community older people’s teams that include specialists and generalists. Teams are needed that can respond rapidly and make diagnoses. Teams that meet regularly, take pains to communicate effectively and plan together. Teams can be at practice, practice cluster or locality level according to local need.
Worldwide, the strategy is clear -all health care systems need to reduce the dominance of hospitals and reshape towards a more primary care, family doctor orientated service. Here GP commissioning can be a force for good.
The conventional wisdom has been to focus on tackling the acute sector. This is a must, but clinical commissioning groups would be well advised to spearhead bold improvements to community services, including mental health.
In this way we can achieve better care for older people and improve support for Britain’s hardworking GPs. Fortunately the signs are positive that community health services are willing to enter into positive dialogue with clinical commissioning groups.
In this way we can achieve the glittering prize of integration of care. The principle is simple: Make the GP practice the basic unit of care and the fount of team based care.
Professor Mayur Lakhani is chair of the National Council of Palliative Care, former chair of the RCGP and a GP in Sileby, Leicestershire. This article is written in a personal capacity.