The Long Term Plan for out of hospital care

NHS England’s lead for the Hospital to Home programme looks at how the NHS Long Term Plan has provided, for the first time, a realistic model to support older people with long term conditions or complex health needs at home and in their own community:

What a great programme BBC2’s Hospital is, shining a light on our amazing healthcare with dedicated staff working in challenging conditions.

So where do the people go to after their time in hospital?  We know that for many the need for health care doesn’t just stop. What about the people who need health and social care in their own homes or care home, receiving often complex care, to keep them well?

Sometimes it seems that the ‘H’ in NHS stands for ‘Hospital’. But we know that services in the community wrap around higher profile services and are as essential.

Now there is a significant step change. Importantly, as its very first chapter, the NHS long term plan acknowledges the multiple challenges community health services and general practice face with insufficient staff and capacity to meet increasing complexity and rising patient need.

In recognition of this, an extra £4.5billion a year by 2023-24 will support a new service model, enhancing existing services enabling people to stay at home, with more options, better support and improved joined up care. That figure includes an extra £1billion on top of that announced by the Prime Minister in November last year.

People in England now live for far longer, but extra years of life are not always spent in good health. Older people are more likely to live with multiple long-term conditions and complexity, or live with frailty or dementia. Older people don’t always get the care they need in the right setting and at the right time.  Hospital interventions for many people with complex needs can experience extended lengths of hospital stay risking unwarranted and harmful healthcare outcomes.

Ironically as I write this blog my dad in his 80s has fallen out of bed onto the floor.

  • I’m insistent having been a district nurse that he doesn’t need to be admitted to hospital.
  • But I’m wondering what services there are in the local area for older people…

So, for those of you who haven’t had chance to delve into the long term plan, what does the model look like?

  • A new NHS offer of urgent community response and recovery support: investing in and enhancing existing rapid community response teams, to prevent unnecessary emergency hospital admissions and speed up discharges – importantly receiving services within two hours in a crisis and a two-day referral for reablement care, and to improve access via a single point of access for people requiring urgent care in the community.
  • Guaranteed NHS support for people living in care homes: supporting timely access to out of hours support and end of life care, including supporting care homes to have easier and secure access for sharing information about their residents using NHSmail.
  • Supporting people to age well: the NHS in England is leading the way identifying older people with moderate frailty at particular risk of deterioration, offering them proactive personalised care and support. In doing so delivering a core model for the future care of people with complex needs. This will be delivered by Primary care networks where general practices, community teams, social care hospitals and the voluntary sector work together to help their local population, including older people, to stay well, better manage their own conditions and live independently at home for longer.

Delivering these three services together offers prevention, crisis intervention, reablement, rehabilitation, end of life care and care for people living in care homes.

They must meet the needs of local communities and consequently if they are to the address inequalities in both access to services and in health care outcomes.

Partnership working with all major stakeholders including health, social care and the voluntary sector is key to the success of these models.

Other parts of the NHS Long Term Plan will enable the development of these services to improve outcomes for people as they age.

For example:

  • developing a sustainable and appropriately skilled workforce;
  • ensuring community staff have access to mobile digital services
  • personalised care budgets to support people to live in their own homes

We have a real opportunity to respond to the focus on community and primary care and work together delivering these services consistently, finding solutions together to make a real difference to our local populations.

And for those wondering what has happened to my dad, well thankfully the ambulance service has picked him up, comprehensively assessed him and advised on falls prevention. Great work happening day in, day out by our NHS.

And I’m looking forward to an improved offer for older people to help them live supported when they need it wherever they live in England over the next few years.

Kathryn evans

Kathryn Evans, Head of Planning Delivery and programme lead for the Hospital to Home (H2H) programme.

Kathryn is a nurse with over 25 years’ experience of working in the NHS, both in Essex, Yorkshire and Humber and nationally. She has worked in a variety of roles. These have included being a District Nurse and then moving into professional leadership and service development.

Kathryn is an experienced operational manager. During her career she has managed a variety of community services from District Nursing and Community Matrons, GP practice, intermediate care wards and a Hospice.

She has worked at a regional level in service improvement and also in an assurance and delivery.

Nationally Kathryn has worked in the Nursing Directorate for NHS England, under the leadership of Professor Jane Cummings, Chief Nursing Officer for England as Community Nurse Lead.

She is now Head of Planning Delivery in the Hospital to Home team fostering collaborative relationships with key partners.

Kathryn is passionate about community nursing, and community services.