For anybody lying in a hospital bed, there are two linked questions likely to dominate their thoughts during long days spent on the wards: “When will I get better?” and “When can I go home?”
But the recent reality for many elderly and frail patients is that the gap between getting better and going home has often been more like a gulf.
WATCH & READ MORE >>> Could less care be better care if it keeps people independent?
The problem became so severe that the government ordered local authorities and NHS trusts to come up with ways of reducing the number of unnecessary days spent in hospital.
And Eric Musson was amongst the first wave of patients in Lancashire to experience a new hospital discharge policy designed to do just that.
If the 87-year-old had undergone his hip replacement operation twelve months earlier, his ability to cope once he left hospital would almost certainly have been assessed while he was still there. That would have meant bedside visits from a variety of social care staff, which may have taken several days to arrange.
However, as soon as Eric was medically fit to leave hospital, he was - in the politest possible sense - shown the exit.
The priority for the new Home First scheme is, as the name suggests, to get patients back through their own front doors - and only then worry about what might be needed to help keep them there.
For Eric, that meant he was welcomed home not only by his wife - but also the social care professionals from Lancashire County Council who would previously have visited him on his ward. The service pledges to have a specialist assessor on the discharged patient’s doorstep within half an hour of them returning.
“When you first come home, you really don’t know what on earth to do and so it was very nice to have them waiting for me,” Eric explains.
“I’d had physio in hospital, but I had to be sure I could get up and down the stairs and in and out of bed.”
Assessing whether he was able to navigate these necessities - as well as the equally vital capacity to make a cup of tea - was physiotherapist, Natalie Robinson. She says there is no substitute for somebody’s own surroundings when they are trying to demonstrate what they can do for themselves.
“It improves their confidence, because they suddenly realise, ‘Oh, I can manage that after all’,” Natalie says. “Whereas in hospital, it might have been thought that they needed social care just because they were so anxious about [coping].”
However, many patients will still need practical help and not just reassurance. Assistance items - like the high stool Eric requested to help him use the bathroom sink - are delivered on the same day that they are ordered by the county council’s new integrated care team.
Meanwhile, assessors are able to secure whatever level of care they think is necessary to help people settle back in to home life safely.
During the first couple of weeks, that could be anything from “crisis support” - round-the-clock assistance for periods of up to 72 hours - to hour-long daily visits. Throughout that time, physios like Natalie work with patients to regain any mobility lost while they were in hospital or as a result their medical condition.
After three days of being back home, patients are visited by an occupational therapist, whose job it is to ensure their needs are being met - but also to return them to the level of fitness and self-sufficiency which they previously enjoyed. And that means setting different goals for different patients.
“If they were independent in the kitchen or on the stairs, that is what we’re aiming to get back to,” therapist Carla Wright explains. “Or it could be independent outdoor mobility, like getting into town or doing their own shopping - it depends what the patient needs.”
As for Eric, one of the few pleasures he has yet to rediscover is the taste for a pint. But in the meantime, he is content with the moniker of “model patient” conferred on him by his wife of 57 years.
Within a few days of returning home - and with the help of physio Natalie - he had already made it a few yards down the street.
“I’m not going to go completely barmy and start running, but I’ve been on much longer walks over the last few days and I’m hoping to be able to play golf again,” Eric says.
“My consultant told me I just need to get on with things - and now I feel I can.”
For the Home First team - job done.
REMOVING A STIGMA OR RUNNING A RISK?
The man in charge of East Lancashire's integrated care team - and the day-to-day operation of the new hospital discharge policy - always believed that there would be benefits to getting patients back home as soon as they were medically fit.
But Alex Townsend was shocked when he discovered that they were not just limited to the physical or even the financial.
“When I asked for feedback from patients, I realised how much the term ‘bed-blocking’ has been [affecting people]. They’ve seen it on the news and they actually feel guilty for being ill - and we should never be in a position where just because you’re older and in hospital, you feel bad for it,” Alex says.
The phrase ‘bed-blocking’ was first coined during the 1980s and has since been used to describe three decades of a deepening crisis which has seen growing numbers of elderly patients trapped in hospital beds, because of delays in securing care for them once they are discharged.
The terminology has recently been replaced with the less personally-degrading ‘delayed transfers of care’ or DTOC - but the basic problem persists.
So why should it be inherently more speedy for a patient to be assessed in their own home rather than a hospital bed?
Alex points to additional investment in the new scheme, but also “a change of culture” amongst council and NHS staff - including the need to work together to ensure that people are not left stranded after being discharged.
But in the race to find a solution, is Lancashire taking a risk with some of its most vulnerable residents?
According to Alex, it is impossible to eliminate risk, but it is important to worry only about those which are real.
“When people were assessed in a hospital environment, there were slippy floors and lots of people around - and so it didn’t give us an accurate picture,” Alex explains. “So we’d find we would be commissioning social care for people on a higher level just in case they weren’t going to be safe.”
Under the new system, the focus is on personal choice and giving the patient what they want.
“We’re autonomous individuals, we take risks when we step outside the front door of a morning. Just because you’re getting older doesn’t mean you can’t take risks - we try to mitigate and manage them,” Alex adds.
But he admits that the new ‘give it a go’ philosophy will not always work out - and residential care may still be the destination for those patients with the greatest needs.
“One of the principles of Home First is that anybody who is admitted to hospital gets to see their own home again. But we have the ability to [refer] them into a residential care home if it’s really not going well for them and that’s what they want for themselves.”
“WE CAN’T THANK THEM ENOUGH”
Social worker Jonathon Leonard assesses residents in their homes, but also works on hospital wards - and says it is obvious where patients prefer to be.
“There is a big difference in people’s faces once they are settled at home - they feel a bit calmer and less stressed,” he says.
“You do get anxiety from the families, because they’re sometimes not too sure [about the Home First policy]. After all, people have usually gone into hospital in traumatic circumstances.”
But he adds that the flexibility in the new service means patients can be confident in getting the right level of care at any given time.
“They can increase it if it isn’t enough - and then people usually go on to the reablement service which helps them to move on further”
For Anne Musson, wife of hip replacement patient Eric, it was a “seamless” experience.
“Let’s suppose we had come back home and there was nobody here - we wouldn’t have known what he is allowed to do or should be attempting to do. Having the staff here gave us strength and confidence,” the 79-year-old says.
“Having [physiotherapist] Natalie close by Eric’s side as he took his first steps outdoors, just saying, “You’re fine” - that encouragement and calm demeanour made all the difference.
“I applaud the team for their determination that it was going to work. We can’t thank them enough,” she adds.
ALL ABOUT THE MONEY?
The Home First scheme has been funded by existing money which was pooled between the traditionally separate budgets of local authorities and NHS trusts - but also by some of Lancashire’s share of the extra £2bn announced by the government for social care in 2017, known as the Improved Better Care Fund.
That money - totalling £46m - was a one-off cash injection and although other, smaller, grants have been made available since, future funding for the programme seems set to depend on a new blueprint for social care due to be published by Whitehall next year.
But such is the enthusiasm for the scheme in Lancashire, its future might not be wholly dependent on additional cash to support it.
“If the money dried up it would be difficult to deliver, but we would have to look at what we could do differently to be able to continue this service,” Sue Lott, Lancashire County Council’s Head of Service for Adult Care, says.
“It’s delivering better outcomes for people and helping free up hospital beds - so we need to look as a system at what the biggest priorities are and where the money needs to go.
“It’s about the money moving around the system to follow the person.”
The service has been gradually rolled out to different parts of the county and, over the last twelve months, total hospital discharge delays (DTOC) have reduced by almost a third. The improvement helped Lancashire hit government targets in 2018 which were branded “impossible” by the region’s health and wellbeing board last year.
But Home First may not be a panacea - after repeated reductions, DTOC rates have gradually increased across the county since the summer.
FACTS AND STATS
3,000 - number of LCC residents whose care needs have been assessed at home instead of in hospital
4 percent - hospital readmission rate for Home First patients in areas which first piloted the scheme
4,709 - number of unnecessary days spent in hospital by LCC residents (October 2017)
3,412 - number of unnecessary days spent in hospital by LCC residents (October 2018)
28 percent - year-on-year reduction