Emergency Hospital Admissions…..does the admission route matter ?

Guest blog by Dr Iseult Roche

A&E direct hospital admissions have increased since 2002 and new research (published in the Journal of the Royal Society of Medicine) also shows emergency admissions via GP’s  have fallen in the same period of 2002-11. However, why this increase has happened is “unclear”.

This possibly gives another potential reason why there is an increased burden on A&E A&E imagedepartments; not only from an increased number of admissions, but also in the type of work staff and departments are expected to carry out and manage. A&E departments are supposed to deal with acute presentations only, but this is far from the case.

The research author, Thomas Cowling writes “A&E staff now have increased responsibility as gatekeepers for inpatient care and as care coordinators, which is not reflected in how A&E departments’ activity is measured or reimbursed.”

This is certainly true and places  A&E departments at risk in varying ways – from targets and finances, to staffing levels and duties, and most importantly optimum patient care.

Mr Cowling noted: “New models of urgent care services that employ GPs in or alongside A&E departments as gatekeepers to specialist urgent care ought to be evaluated before they are scaled up to avoid further ad hoc developments. This also applies to the current government’s pilot scheme of extended opening hours in general practice.”

Although the number of direct Speciality Admissions via GP referral had fallen during that time, it would be incorrect to consider one as being entirely responsible for the other.

There are many hypothetical reasons for these patterns and Doctors have suggested these:
- Firstly, during this time frame the total overall number of Emergency admissions have increased.
- Secondly, the general population are more health aware and self-refer if they have acute worries.Genetic testing
- Thirdly,  urgent tests cannot be obtained as speedily via a GP compared to A&E ; even basic blood tests take time and for some direct speciality referrals, such results are necessary (or at least useful) for a speedy and successful acceptance. In some cases GP’s may send a patient to A&E with a letter, rather than spend a lengthy period of time in discussion with a busy on-call registrar.

Other reasons suggested have included the advice given by 111 service (or its’ predecessor),  the negative attitude portrayed of GP’s in the media – so patients believe they will not get an urgent appointment and go to A&E rather than consult their GP – and also Speciality accepting protocols which may require admission via A&E rather than directly to the admitting team on-call.

old womanFor patients in care or nursing homes, there is a burden of responsibility placed on the staff and they may well resort all too quickly to sending patients to A&E rather than wait for a GP call-out (even if a GP consultation would be sufficient).

The potential reasons for the correlation are legion, but certainly it would be incorrect if the results were to be taken at a simplistic or face value.

Also, in reality, if a patient is acutely unwell and is actually admitted via A&E rather than GP, surely how they were admitted is less important, when compared to the fact they actually did need admitting. Although there are many patients who may present to A&E unnecessarily and a GP appointment would have prevented this (however that is a slightly different matter).

GP’s do an incredibly demanding job, balancing holistic long-term care with acute needs. Moral seems to be at a low point among GP’s and trainees. This is a time for health workers to stick together for the benefit of all, especially our patients.

Certainly the results pose questions about the current strategy in place to reduce pressure on Emergency departments and hospitals generally.

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Obesogenic nation – when will we have a strategy with teeth?

Today’s report on weight-loss surgery is another warning to government on the social, economic and personal costs of obesity. It shows that about 5% of those having surgery are aged 25 years or under and 40% of them were ‘super-obese’, in other words they had a BMI of 50 or more. This is a shocking statistic that reflects the failure of everyone around that individual to provide support through their childhood into their early adult years.

And whilst on average people have lost 60% of their excess weight a year after surgery, obesitythumbnailunless the root causes of over-eating are tackled, some will lose little weight whilst others around them will become obese. It is perfectly possible to have surgery and continue to eat high calorie foods and drink excess alcohol resulting in little weight loss, if the very reasons for over-eating have not been properly addressed. Whilst a psychological assessment is always made before surgery, many people need significant amounts of ongoing counselling support which currently is not provided.

Our recent report Careless eating costs lives highlights the obesogenic environment in which we now live and that action at all levels – from the personal to government – is urgently needed.

Added to this, rising levels of malnutrition indicate that we are not eating as we should.

The Health and Social Care Information Centre (HSCIC) in August, show the number of people admitted to English and Welsh hospitals rose dramatically – from 5,469 to 6,520 – in the past year alone. There was 19-percent increase in the number of UK citizens hospitalized for malnutrition over the past twelve months[1]. Over the last five years there was a 71 per cent increase in hospital admissions where malnutrition was a primary or secondary diagnosis, from 3,900 admissions in 2009-10 to 6,690 admissions in 2013-14.

Above all we have to get serious about prevention of obesity in the first place. A national strategy on nutrition, a mandatory Responsibility Deal, local government plans, concerted action in schools and less snacking by you and me are all required. We don’t have enough surgeons for all those eligible for weight-loss surgery anyway, and as the good doctor has always said, prevention is better than cure – for the individual, society and the economy.

[1] http://www.hscic.gov.uk/catalogue/PUB14568

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Making it personal – restoring trust and confidence in health and care services for older people

Guest blog by Sara McKee, Evermore Founder & Director of Market Innovation

I recently took part in a 2020health debate exploring how
we can restore trust ansara_mckeed confidence in health and care services for older people. It’s a big issue and rather than tackling the whole system, I’ll focus on housing and support – an area that can cause heartache and heart break for older people and their families.

The UK residential care market is fragmented. The big players like BUPA, Four Seasons, HC1, Care UK & Anchor account for less than 10%. The remainder are small, independent providers with one or two homes, where they know customers and team members well.

In my experience it’s the bureaucratic practices of the big organisations that strip the personal relationship out of the care, which then leads to the failures that dominate the headlines. Although we shouldn’t forget that there is great care, love and companionship happening everyday across the country.

The focus on process over relationships impacts the way larger organisation are run and the care people receive. For example, there is a hierarchy of roles that are all task-based in a traditional residential care home setting. Consequently there could be up to 100 staff to cover all daily activities in an average 60-bed care home. They’re busy ticking boxes not getting to know their customers in a meaningful and impactful way, which is demoralising for staff and a poor experience for residents.

Why is it like this? When we look after our parents, we don’t do it on a task basis, nor do we have forms to fill in. Instead, we do everything we can to meet their needs and ensure they live a happy and meaningful life. Like Nike, we just do it.

It’s this personal approach that needs to be taken when it comes to creating an environment where older people can flourish. It’s time to cut the bureaucracy so staff have the autonomy to spend more time doing what’s best for the customers and spend less time doing paper work.

Let’s also focus on the individual and stop this paternalistic approach of doing things to and for them, rather than with them, In the existing model users of residential care are treated as recipients of services, and often their power to make decisions and contribute is taken away.

People must be given the opportunity to continue living their life in the way they want, albeit with help available if they need it. If they want to muck in to make dinner, do the ironing, or help with the household budget then let them. These are things people dread giving up as it symbolises a loss of independence, so why take them away? This extends to their health and care – provide older people with the information, tools and support to navigate the system rather than making decisions for them.

It’s really quite simple. It’s time to provide older people with what they want – an environment that allows them to live well, happy and secure but with a safety net. And an environment that is just like a normal family home, instead of an institution. That means no nurses stations, staff notices on walls, or sterile restaurants serving food cooked in industrial kitchens.

We’ll only change older people’s perceptions and build their trust in the sector by changing the way we do things!   At Evermore, we’re going to focus on getting rid of the bureaucracy and the institutionalisation that has removed the personal aspect of care to the detriment of customers and staff. We’ll celebrate small households where family settings are created and customers truly cherished, focusing on what’s important: living happy for longer.

Are you with us?

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Simon has the vision: we have to deliver. Why saving the NHS is down to everyone of us.

Simon Stevens was on the @BBCR4 8.10am interview this morning, answering questions posted on twitter #AskNHSEngland about the new NHS Five Year Plan. It was a shame really as the tweets really skewed the discussion, and the important questions of where the money would come from (at least another £8Bn requested), the demographic challenge (the current labour intensive approach is unsustainable practically and financially), public redress where services don’t improve /are poor, and the role for each of us in ensuring a sustainable NHS were left unanswered.

There is a telling sentence at the end of summary of the NHS Five Year Plan published today. It reads “there are viable options for sustaining and improving the NHS over the next five years, provided that the NHS does its part, allied with the support of government, and of our other partners, both national and local.” It is a call to arms to all of us. The Five Year Forward View (FYFV) sets out aspirations and ideas for ensuring a sustainable NHS which will require action from everyone of us if it is to succeed.

2020health is delighted that so much of what we have published in the past few years is echoed in this Plan including:

  • In our ‘Going with the flow’ report we said there was a need to designate large, specialist hospitals, colour coded blue, as well as their being a role for small, local hospitals colour coded red. The Plan outlines the need to find viable models for smaller hospitals as well as strategic planning for specialist centres (FYFV pg 22).
  • In our same report we promoted much greater involvement of individuals and community organisations in health and social care – as we also did in our reflections on nursing – this is echoed throughout the FYFV.
  • In our ‘Careless eating costs lives’ report we detailed requirements to tackle obesity, many of which would help with other conditions too. The FYFV is determined or though not detailed on supporting action to deal with public health risks (FYFV pg 10).
  • The Plan recognises the vital part that technology has to play; our latest initiative, the ‘Health Tech and You’ Awards is at the forefront of showcasing to the public what is available to help us look after ourselves better, and our reports on the VHA’s use of technology, Electronic Patient records and Healthcare Without Walls have all detailed the art of the possible across healthcare.

The NHS FYFV particularly looks to employers and local authorities to play their part:

  • Getting serious about revolutionising prevention by incentivising healthier behaviours, giving local authorities more power on public health, targeted prevention strategies and employment support and workplace health.
  • Empowering patients through providing information, voluntary sector partnerships to help with condition management and expanding choice.
  • Engaging communities through supporting carers, promoting volunteering, voluntary sector partnerships and with the NHS as an exemplar local employer.

These are all noble aspirations, however much is required of local and national government to deliver the plan, and there are still some key components missing.

  1. Whilst the Plan talks about workforce training, we need to horizon scan for the impact of technology which is democratising health in a transformational way. The public will have far more information about themselves, their conditions and their management. The role of professionals will change radically and they need to be ready for that.
  2. Serious recognition that much of our health is determined by factors outside of the NHS: education, environment, housing, transport We know this is an NHS plan, but it doesn’t operate in isolation and can’t make improvements in the public’s health alone. Whilst it does reference the role of Local Authorities, this requires more of the coordinated approach that is already being talked about for health and social care.
  3. On the public’s health the Plan boldly states that: “So for all of these major health risks – including tobacco, alcohol, junk food and excess sugar – we will actively support comprehensive, hard-hitting and broad-based national action to include clear information and labelling, targeted personal support and wider changes to distribution, marketing, pricing, and product formulation. We will also use the substantial combined purchasing power of the NHS to reinforce these measures.” We know it is outside of their powers, but this FYFV should have been an urgent call to government to act now. Without immediate, determined action on problems such as obesity, much of this plan could fail to deliver a sustainable service.
  4. There is huge variation in the way the NHS adopts new technology and medicines and it often doesn’t provide the best, but just the best that can be afforded. If we allow patients to pay for the latest and best in class, then their cost will come down faster and they will be available to everyone more quickly. It is simply not fair to prevent people from choosing to spend some of their own money on a novel technology. The Plan does acknowledge the postcode lottery already in existence, but patients will increasingly look for themselves as to the best treatment available and what power will they have to ensure they receive it?

Elsewhere the report doesn’t pull its punches. It tells politicians to stop meddling:

“In particular, the tendency over many decades for government repeatedly to tinker with the number and functions of the health authority / primary care trust / clinical commissioning group tier of the NHS needs to stop.”

Whilst this is true for national NHS structures, this Plan does actually need local politicians to step up and intervene more to enable the prevention strategies of which this report gives exemplars. And the case still has to be made for intervention – Nigel Farage’s popularity is not independent of his propensity to drink and smoke in front of the cameras. Rebellious freedom appeals to us all in different ways. And that brings us back to the money. The NHS was not set up to prevent, but to treat. Local Authorities are in the early days of getting their heads around health and wellbeing with their Public Health colleagues. With more cuts to LA budgets on the horizon, improving public health could be pie-in-the-sky without at least transitional funding being found. We wait for the politicians to respond – but in the meantime we can begin to ask ourselves how we can Be The Change – for the good of our families, neighbour’s and country’s health.

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Extraordinary confessions, a rare strike and a plan

It’s busy in health news today. There’s the NHS strike over pay -  the BBC’s Norman Smith has just reported (at 7.40am) that “Health sec Jeremy Hunt says will sit down and negotiate with NHS unions if they agree to reform pay increments”. This reflects the fact that about half NHS have been getting pay rises through annual incremental increases, although those at the top of their pay bands have not had any increase, and a 1% pay rise for everyone can’t be agreed whilst the automatic pay increases for some remain in place.

What the government need to get across are the choices. On a fixed budget you can’t have pay rises and more staff and still-very-generous pensions, without tax rises. It would  be an interesting question to pose to the public: would you rather pay more tax so NHS staff have a pay rise, or so there are more nurses and doctors on the ward?

The other inconvenient truth for politicians is that we are living in a digital age which is disrupting old ways of working, massively changing the workforce we need and in which many will see their wages in real terms fall. A difficult political message to communicate.

The Tory Party’s admission that reorganising the NHS in the way they did was a big mistake – see exclusive from Chris Smyth, Alice Thompson and Rachel Sylvester in the Times – is not news to anyone who works in it, but quite EXTRAORDINARY to come out now. Tories have been saying it privately for a long time, but this confession is amazing. Maybe this admission wasn’t supposed to leak, maybe this is the start of a new ‘frankness’ with the public over political mistakes, maybe the powers at Tory Towers think they have time to win back support on the NHS between now and the election if they come clean… then again, maybe not. Whilst we welcome the apology (is it quite that yet?), it puts Jeremy Hunt in an incredibly difficult position. His bosses would do well to get their message clear and consistent from now on – is there a strategy?

The good news is that 2020health meanwhile has an action plan out to tackle Obesity: obesitythumbnailCareless eating costs lives was published yesterday and is available here. We hope all the Political Parties will take a look as, quite honestly, this is a far greater threat to our future and prosperity than ebola.

Recommendations from the report include:

* Introduce tax incentives for larger businesses to make wellbeing provision (such as access to occupational health, nutritionist, gym facilities) available to smaller local businesses.

* Introduce licensing for fast food outlets to control the location and numbers of

outlets in a local community.

* Recognising the positive response to the Responsibility Deal Government should

require all companies to follow the excellent example of participants. The

Responsibility Deal to turn into a legislative framework which is phased in over the

next 5-10 years.

* Practical cookery skills and clear food education to be a compulsory part of the

school curriculum for pupils up to the end of key stage 3 (age 14).

* Clear disclosure of calories per items on restaurant and cafe menus which adhere

to a defined standard for font size, formatting, contrast and layout of menus.

* The ban on advertising of unhealthy foods aimed at children should be extended to

day-time TV, from 7am to 9pm.

* A review needs to be undertaken of the economic and societal impacts of a

hypothecated tax on a range of food and drink contents at levels which are

deemed harmful to health.

* Increase awareness, coordination and reach of the Government’s ‘Healthy Start’ Voucher scheme. Extend voucher scheme to incentivise those who become active partners in their health by quitting smoking, reducing weight, walking a set number of steps etc.

* Establish a cross departmental permanent government task force on obesity. This

supports similar recommendations made by other health organisations.

* All new policies to be reviewed and assessed against an ‘obesity test’.

* Improved screening and normalisation of discussion about diet and weight at

medical appointments.

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‘Hot’ topic – Sexual Health Week

NatikaHHalil53Guest blog by Natika Halil,  FPA’s Director of Health and Wellbeing

Emergency contraception has been a hot topic since its inception over 40 years ago. Frequently the subject of sensationalist reports, it is the only method that can be used to prevent pregnancy after contraceptive failure or unprotected sex, and has benefited millions of women around the world by preventing pregnancies they know they would not want.

We have chosen emergency contraception for our Sexual Health Week theme this year because of the endless myths and misconceptions we hear about how it works and what the options are. The phrase that will spring to mind for many people is “the morning after pill”. It’s understandable that this has slipped into everyday use – but in truth it is really unhelpful and misleading, and we believe it helps propagate a couple of myths that could act as barriers to women getting the help they need when they need it.

For starterFPA-sexual-health-week-2014-poster-tightss there are three different methods of emergency contraception, and only two of them are pills. Further, none of the methods have to be used within 24 hours, or by the “morning after” to be effective. In fact one of the pills (ellaOne) and the emergency IUD (also known as the coil) can be used up to five days after unprotected sex, and the other pill Levonelle can be used up to three days after.

These are basic facts that – be it through lack of sex and relationships education or insufficient information from health professionals – unfortunately are not known by vast swathes of women, and indeed men, across the UK.

We surveyed more than 2,000 sexually active women* and found some glaring gaps in their knowledge and understanding. Across the UK almost two-thirds of women (62%) wrongly believed, or weren’t sure, that emergency contraception has to be used within 24 hours of unprotected sex to be effective.

More than one-third (36%) wrongly thought that you have to have a prescription to get any method of emergency contraception, or weren’t sure, and 63% thought repeat use of emergency hormonal contraception – the two pills available – can make you infertile, or didn’t know.

FPA-sexual-health-week-2014-poster-bagAnother stubborn myth is that emergency contraception is like having an abortion – in fact one prevents a pregnancy and one ends a pregnancy, and it is very clear in medical guidance and the law that they are different. Yet one half of women surveyed thought this was true, or weren’t sure.

While these results were shocking, in truth they probably weren’t surprising. Just 17% of the women had learnt about emergency contraception at school, and only one in six said they thought health professionals provide enough information about the different methods of emergency contraception that are available.

Where does that leave women to get their information from? The internet? Friends and family? Stubborn myths that seem to recycle for each new generation? We know there are many sources of less than trustworthy information out there, and unfortunately misinformation about emergency contraception can also be used as a tool by those with a less than pro-choice attitude.

During Sexual Health Week we are doing all we can to raise women’s awareness of what their options are, and give them evidence-based facts on which to base their decisions. We’re also talking directly to health professionals because the role is absolutely central to this. We’ve sent out more than 3,000 briefing packs to professionals who provide emergency contraception, and we want them to bear in mind the findings of our research as they go about their daily work, because it shows that there is more we can all do to tackle stigma and end ignorance.

For more information about Sexual Health Week, visit http://www.fpa.org.uk/shw1

*Survey of 2,509 UK women aged 16 to 54, of which 2,131 have ever been sexually active. All figures, unless otherwise stated, are from YouGov Plc. Fieldwork was undertaken between 22 and 25 July 2014. The survey was carried out online. The figures have been weighted and are representative of all UK adults (aged 18+).

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‘Counting the Cost’ – Meningitis Awareness Week (15 – 21 September)

Guest Blog by Chris Head, Chief Executive, Meningitis Research Foundation

Meningitis kills and seriously disables more young children in the UK and Ireland than any other disease. Young adults are the second highest at risk group but people of all age groups can be affected as 17,500 members of Meningitis Research Foundation can testify. Globally meningitis kills an estimated 1,000 people every single day.

We estimate 3,400 people are affected by meningitis and septicaemia in the UK and Ireland every year. One in ten dies and a quarter of all survivors are left with life altering disabilities ranging from deafness and brain damage to amputations.

And our Counting the Cost study concluded the lifetime financial cost to society of someone seriously disabled by just one form of the disease, MenB, is up to £4.5m – and that’s not including any litigation costs which may also be paid.

It’s our charity’s annual Meningitis Awareness Week (15 – 21 September) and 215 families have signed up to share their stories in the media.  You can also read many more personal stories in our Book of Experience online www.meningitis.org

Robbie's new legs 2014Robbie Jones, who celebrates his 8th birthday during Meningitis Awareness Week,  and his mum Jill are among those sharing their story. He was just 21 months old when he contracted meningitis – losing both his legs and all his fingertips.  Since then he has grown in and out of numerous legs. His latest pair features his favourite football club – Manchester United. He is also learning to swim, and the joy that the freedom water brings him is clear to see. Jill says: “ We had heard about meningitis but never thought it would happen to our family and had never seen the effects it could have on survivors.”

But awareness is not enough. We believe the first line of protection is vaccination and everyone should be immunised with all available meningitis vaccines. To this aim we have invested £17.5m in 140 international and UK based meningitis research projects to support finding solutions for this devastating disease.

We have been marking our 25th anniversary this year and in that time we have seen meningitis and septicaemia cases halve.  Improved protection has played a major role; vaccines for Hib, MenC and 13 strains of pneumococcal meningitis and septicaemia are all now freely available and an EU licensed vaccine for MenB is available privately and has been recommended for use in babies in the UK by the Joint Committee on Vaccination and Immunisation (JCVI).

However the question of whether adolescents will be included has yet to be decided. The UK Government has agreed to commission a very large study to show whether vaccinating teenagers could prevent the spread of the illness.  This indirect protection for the whole population has been key to the success of MenC and other meningitis vaccines which is why we are urging the Government to ensure this study happens without delay.

And research into the effectiveness of the MenC vaccine is why the UK Government is currently running a MenC booster campaign for those starting university this year. Vaccine protection was proved to wane over time and with MenC cases spreading rapidly through halls of residence, the Government decided to act with a catch-up campaign for students up to age 25 and all those who have never been vaccinated for MenC. The booster campaign augments the dose now given to teenage children at 14 years of age and will run yearly until 2017.

This charity has been supporting the MenC booster campaign by freely distributing posters and symptoms cards to universities, colleges and secondary schools.   It’s is just part of our year-round symptom awareness raising work.

We encourage everyone to recognise the symptoms and act fast to save lives. Other initiatives include a Meningitis Baby Watch card distributed to around one third of all new parents by local health authorities, officially endorsed guidelines for medical professionals, handy sized symptoms cards, informative leaflets and a symptoms video presented by our Patron, the popular TV GP, Dr Hilary Jones. Our symptoms information online receives over 1m visits a year.

But we cannot be complacent. Great strides have been made but that doesn’t mean meningitis has gone away.   We believe protection is the ultimate answer to meningitis.  We welcome the JCVI’s recommendation for a MenB vaccine at 2,4 and 12 months and we will play an active role in making parents and carers aware,  but we want to see an adolescent catch-up programmes for older children and Government commitment to prevent rarer forms of meningitis too.

It’s been a roller coaster ride for 25 years but there is still a lot more to do.

For symptoms information and much more, visit www.meningitis.org

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