Stafford Hospital Working Group
13 December2012
Record of Meeting
1.Welcome and Introductions
Jeremy Lefroy(JL)(Chair)welcomed everyone and thanked them for coming. During the meeting he introduced the following:
- Professor Paul Kingston(PK)from Staffordshire University
- Roger Thayne(RT) (ex Head of Staffordshire Ambulance Service)
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2.Proposed Meeting Outline
- PKtopresent information on research he has been engaged in at Staffordshire University concerning the health care of older people.
Questions and comments from the floor to follow.
- RTto share his views of ambulance provision in the West Midlands as at the present time.
Questionsand comments from the floor to follow.
- Final section of the meeting to offer an opportunity for open floor questions and discussion, particularly in the light of this week’s announcements from Monitor and plans for the next three months.
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3. Presentation by Prof. Paul Kingsleyon RAID (Rapid Assessment and Interface Discharge) model
PK thanked the meeting for the opportunity to present some of the research in which he had been engaged at Staffordshire University and the resulting RAID model.
Background
The present challenge to acute hospitals is the increasing number of patients admitted over the age of 65 – on any day this will be two-thirds of the total number of patients. Of these two-thirds, half will have dementia. Only one in three will have received a diagnosis of this. In addition, there will be a number with delirium which looks like to dementia but is different, primarily because of its acute rather than gradual onset. Many of this ‘older persons’ population will have depression as well. Some are suffering from all three conditions.
Any mental health condition delays discharge. Although figures have been around for 25 years, in the last 5 years there has been greater interest and understanding of the impact of the input, throughput and output progression of acute care.
In acute hospitals, training received by most nurses, physiotherapists and other health clinicians include only rudimentary training in mental health issues. Most newly qualified staff have never managed dementia, delirium or depression and are therefore not well equipped for the treatment of patients presenting with these conditions.
Research Task
With a colleague from Birmingham, George Tadros, PK was tasked to come up with a new model for acute hospitals in Birmingham to manage the dilemma of the increased numbers of elderly patients presenting with mental health issues in acute hospitals. Traditionally, this has been managed by ‘liaison psychiatry’. This means that an on-call psychiatristattends the acute hospital two or three days a week. Acute hospitals are frantically trying to manage situations for which they are not trained. Liaison psychiatry is not generally effective, although it is acknowledged that there are isolatedexamples of where it has worked well.
The task was to design a new model of care for Birmingham City Hospital – an acute hospital with 650 beds and a high ethnic population. Funding of £1.2m was allocated for the new service. The result was the creation of a new mental health team to work in the hospital 24/7, replacing the traditional ‘liaison psychiatry’ model. As part of the investment, £100,000 was allocated for an evaluation of the impact of that service.
Evaluation
The evaluation focused on three areas: discharge, re-admission and quality of care as reported by patients and staff.
The research team was confident that the evaluation showed the new model was having a major impact on assisting clinicians and was better than the existing service. On average patients were being discharged three days earlier than previously.
CCGs and Trusts were concerned about bias and therefore the statistics were sent for scrutiny to the London School of Economics who confirmed the findings of the research team’s evaluation but said that savings had been underestimated. The estimated savings of £4m per year was seen to be an underestimate because consideration had not been given to the fact that, on average, prior to the new model, 60% of the elderly patients who went into Birmingham City Hospital never went home but transferred to care homes, nursing homes or sheltered accommodation. In the new model the number not returning home dropped to 40%, increasing the annual saving to between £4m and £5m. For every £1 invested in the original £1.2 investment, there was an anticipated return of at least £4.
The Model
It is not unusual for a person over the age of 65 to have a fall at a weekend and the following scenario is not uncommon. Firstly, a GP is called. The patient, who may already be feeling shocked and confused,is sent to A&E and where s/he becomes further confused. A&E is reluctant to send the person home because of this confusion. The person, therefore, is transferred to the Mental Assessment Unit where s/he becomes more confused. TheMental Assessment Unit is unwilling to send the person home in this confused state. The patient is therefore transferred to a ward for what could be several weeks.
The argument is that the patient should never get as far asthe Mental Health Unit. In 40% of cases it has been shown that it is possible to transfer the person back home. What is needed is support in an acute episode of confusion. It is important to make sure the progression stops and the patient is discharged as fast as possible.
This can be done by making sure the clinician managing the situation is attached to a psychiatric nurse, psychologist or psychiatrist, with physical and psychological management working together.
Hospital doctors on their own are likely to take the‘safe’ option and keep a patient in. Whilst this is understandable, presenting less risk of a further injury, it arguablypresents a greater risk to mental health and of a long stay in hospital. The research findings show that it is possible to reduce half of admissions if A&E is linked to the mental health service.
The new study in Birmingham screened 750 people over the age of 65, testing for dementia, delirium and depression. Of 450 patients admitted to the Mental Assessment Unit, 26 had a diagnosis for one of these conditions. Of the 450 screened, 226 were diagnosed according to the screening tool!
Dementia CQUIN (Commissioning for QUality and INnovation)
Dementia CQUIN is a way of trying to increase the diagnostic rate by asking questions as soon as people are admitted. This is clearly starting to work but concern arises over the availability of ongoing support, given that there is no indication of community care increasing proportionately.
The RAID model is now being rolled out across the country, funded by CCGs. It is established in all five hospitals in Birmingham and enquiries are being received from hospitals in other parts of the country. To date, no enquirieshave been received from Stafford. Some hospitals are developing ‘mini’ versions and the UHNS has developed a rudimentary model. It is becoming generally accepted that 24/7 mental health care is needed in acute hospitals and it would seem that the whole of England is trying to address the issue of mental health in the over 65s in acute hospitals.
Questions and comments from the floor(Q = Question; C = Comment)
Q:When you started this work was it from the Stafford base of Staffordshire University?
PK: It was tested outin Birmingham. The research team was based in Stafford.
Q: If you were based in Stafford why didn’t you conduct the research at Stafford Hospital?
PK: Because Stafford didn’t fund it. We were approached to carry out the research by Birmingham City Hospital.
C: Not all over-65s have dementia, delirium or depression. Many remain fit and in good mental health. This is the good news of the NHS!
Q:Did it ever occur to your team to offer help at Stafford Hospital?
PK: Training at Stafford Hospital has been offered on numerous occasions but we have never been asked to talk about the RAID research.
Q:You are so close to Stafford Hospital. Is there not a danger of ‘silo thinking’ – everyone doing their own thing in isolation from others?
PK: I would be surprised if Stafford hospital’s senior management team was not familiar with the term RAID.
C: At a recent presentation in Stafford centre, the Dementia team from Stafford Hospital outlined their model for dementia care. It was very impressive and sounds similar to the model you have produced. With CCGs funding RAID, it is surprising that Stafford Hospital wasn’t approached to see what was happening there and to look at working together.
PK:The CCG in Birmingham decided to fund the model two-and-a-half years ago. I am not able to explain that.
LH-T:There is a very good Dementia team in Stafford which has not been scrutinisedunder the research conditions you have described. There is a team of psychiatric nurses assessing patients as soon as they come in. I would be delighted to talk to you, to evaluate the scheme. It is a shame that we couldn’t have worked together.
PK: The main challenge, given the magnitude of the numbers of people suffering dementia, delirium and/or depression, is that the model has to be embedded in 24/7 operation in orderto work. Wolverhampton has set up a dementia-friendly scheme but this offers one ward with 14 beds. This won’t solve the problem faced byacute hospitals. It is a really difficult area to manage. It is interesting to note mental health management in Europe. This is embedded within acute hospitals, not separated.
JL: It is great that we have something from StaffordshireUniversity being used around the country.
C.In Europe there is no aftercare. Care in the community does not exist.
PK: Physical and mental health care cannot continue to be separated.
C: You said nurses aren’t trained in mental health care?
PK:Any nursing curriculum I have seen has includedonly rudimentary training in mental health care.
Q:Would it be true to say the RAID model is in its formative stages?
PK:No, the model is now fully evaluated and established in all five hospitals in Birmingham.
Q: So is it now in NICE guidelines?
PK:No, but it is recommended.
Q:Has this been presented to the Stafford Commissioning Group?
PK: I have spoken to the chair on 2 or 3 occasions. The group knows about it but don’t know whether they want to commission it or not.
Q: What questions would it be appropriate to ask of Stafford CCG? It is difficult to know what they are funding and what they are not.
PK: Relevant questions would be: What plans do they have to support individuals and patients screened for dementia in acute hospital care? Who will support them in large numbers?What are their plans to manage mental health in acute hospitals?
Q:A concern is screening patients without provision in place for ongoing support. How do you think it will work - as the community stands - to take on all these extra integrated plans? Can it be done? We need to get to grips with the reality of the situation.
PK: I am not optimistic. We have woken up too late to the challenge of an ageing population. We are constantly trying to catch up. All the initiatives are excellent but the worry remains as to where the community support will come from beyond the diagnosis.
JL: Have you any ideas beyond what you are studying at the moment?
PK: There is nofurther research on this at the moment, except in terms of safeguarding where care goes wrong. There is a need to rethink the whole thing. The current nursing model won’t work. Technology will help in the future. Research is currently being undertaken on sensors that will monitor people’s activity in their own homes:It is not the whole answer but it might be a useful part of a package of support.
Q: In the past there were hospitals for elderly people to be admitted where it was known they would not get better. Fernleigh was one such hospital in Stafford. Such hospitals offered a peaceful end to life. However, the decision was made to close such hospitals. Care in the community is patchy. As a society surely we have an ethical duty of care for the people of this country. Financial implications always seem to take priority. Surely we need to address the ‘human kindness’ side of things.
JL: This has been a useful discussion and pertinent because, as published in earlier minutes, statistics show a continuing significant rise in an ageing population.
C: And yet we are talking about closing hospitals. Cannock is a centre of excellence for rheumatology and yet it is in danger of closure.
JL: That is why we are having these working groups.
Q: RAID appears to offer an excellent model but what happens after discharge? There is no provision in the community for after care.
C: This is not just about care in the community but about quality of life too. Some care may be wonderful. Much is insufficient. Care in the community often simply means getting a person up (often too early) and helping them to bed (often too early). Where is the quality of life in that?
C: We should appreciate that a model such as has been described, if it works well,would support the hospital. It is clearly, however, not a straightforward issue.
PK: Politicians will not be able to solve this. The issue has implications for us all. How much are we prepared to pay for the service we want? Would we be prepared to pay more taxes? We may have to invest more than we’d bargained for. Until now we have relied on the NHS with a small proportion from the 3rd sector. With these resources shrinking, where will the necessary funding come from?
JL thankedPK for coming and reiterated that the government must urgently tackle where future fundingwill come from.
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4. Presentation by Roger Thayne
JL introduced RTand invited him tospeak on the challenges faced by the Ambulance Service now and the current situation in the WestMidlands.
RTdescribed his reputation in the NHS as being one of a ‘maverick’ but his desire always was to save lives.
A999 call meant there was an emergencyand his remit was not to judge what was an emergency but to get to it as quickly as possible and to do what needed to be done.The most important thing was to get the patient to where s/he needed to be for the most effective care. If, for example, an intensive care unit was needed, a patient should not be taken to a hospital where there wasn’t one.
As head of Staffordshire’s Ambulance Service RT had tried to use the money it had to provide a good service and to gear the service up to saving lives. Prior to last year the government had no knowledge of whether these outcomes were being achieved as no statistics were collected. The last Secretary of Health had begun to do this.
If there is an emergency, an ambulance takes a patient to where s/he needs to go to receive treatment. There are 50,000 more patients taken to hospitals in Staffordshire now than used to be the case. The best hospital in the Midlands for surviving cardiac arrests is Stafford. The figure is halved inUHNS, and considerably more reduced in Burton.
What is important is that patients are taken to the right hospital for their particular needs.
If a person has a heart attack s/he needs an immediate thrombalysis.A more recent treatment is angioplastyand this is also needed immediately - within an hour. Such treatment is difficult in rural areas and the patient needs to be taken to UHNS or Wolverhampton. European standards require treatment within 90 minutes. For a triple A aortic rupture, vascular surgery is also needed very quickly.RTA victims are taken to UHNS because it is a trauma centre.For abdominal surgery, patients are taken to UHNS or Birmingham. Patients with these conditions have never been taken to Stafford. The ambulance service must take patients where they need to go.
Patients do not have to stay at the hospital to which they have been taken for treatment. Many conditions could be much better managed at home. Wards are not quiet, neither do they offer much privacy or appetising food. Such factors can be very important to recovery.
It is important to note that an ambulance canoften get to a patient quicker than a hospital shock team. Also a lot can be done on the end of a phone – telemedicine. What is important is putting the patient’s needs first and, as far as a successful ambulance service is concerned, if it is gearedup to what the patient needs and organised to be in the right place at the right time, there are few complaints,
RT lamented the constraints he felt the NHS had placed on him ‘getting on with what he was there to do’ by ‘too many meetings and paperwork etc.’ Any medical service is there to save life and treat injury or illness. He had always kept himself aware on a daily basis of statistical evidence of effectiveness. How many cardiac arrests? How did we do? And he was also always ready to admit to mistakes.
RT felt that the NHS had ‘taken our hospitals away from us’ and that it was ‘time we got our health service back’.
Questions and comments from the floor
Q: We have had the best ambulance service in the world. Would you say the service today in Staffordshire is ofthe same standard?
RT: Statistics show that today’s ambulance servicecosts 50% more, and the number of lives saved has been halved. No change is expected.