Ambulatory Care

Wednesday 27th April 2016 Westminster Hall

11:04

[John Howell (Henley) (Con)]

I beg to move,

That this House has considered the use of ambulatory care.

I will start by referring to the NHS England publication that prompted me to call for the debate. NHS England has recently published a multi-agency quick guide and supporting information to support local health and social care systems to reduce the time that people spend in hospital. It acknowledges that people’s physical and mental ability and independence can decline in a hospital bed. For people aged 80 and over, 10 days in hospital equates to 10 years of muscle wasting. The report therefore recommends that people should seek to make decisions about their long-term care outside hospital and preferably in their own home or in a bed where their true long-term needs are understood.

The report was prepared not by the Government, but by the emergency care improvement programme of NHS England. It adds to the overwhelming clinical evidence that this approach is by far the best way of proceeding. The report goes on to say that care at home enables people to live independently and well in their preferred environment for longer. It contains checklists of questions for patients and commissioners to achieve that situation.

I am immensely encouraged by that, as it is on that basis that the number of beds has been worked out at Townlands hospital in Henley and the answer of up to 14 initially has been reached. Those beds are to be associated with the hospital, but in the care home at the side of the hospital. It is reassuring to know that we are at the forefront of current thinking and action. This approach is supported by organisations such as the Alzheimer’s Society and clinicians throughout the NHS. It is the right way to proceed and in the best interests of the whole community.

Before I continue, I should probably say what ambulatory care is, besides what I have just described. Ambulatory care is medical care provided on an out-patient basis. It includes diagnosis, observation, consultation, treatment, intervention and rehabilitation services. This care can include advanced medical technology and procedures, the costs of which should not be underestimated. Under this new care model, outlined in the NHS five year forward view, GP group practices would expand and include nurses, community health services and, in particular, social workers. Those practices would shift the majority of out-patient consultations and ambulatory care to out-of-hospital settings.

Let us consider the effects of hospitalisation. For many older persons, hospitalisation results in functional decline despite cure or repair of the condition that took them into hospital in the first place. Hospitalisation can result in complications unrelated to the problem that caused admission or to its specific treatment, for reasons that are explainable and avoidable. Age is often associated with a number of functional changes—which I am sure you and I, Mr Owen, have no experience of at this stage in our lives—including reductions in muscle strength and aerobic capacity; diminished pulmonary ventilation; altered sensory confidence, appetite and thirst; and a tendency towards urinary incontinence, which I am not saying any of us suffer from.

Hospitalisation and bed rest superimpose factors such as enforced immobilisation, reduction of plasma volume, accelerated bone loss, increased closing volumes and sensory deprivation. Any of those factors may thrust vulnerable older persons into a state of irreversible functional decline, so hospitalisation is a major risk for them. I am talking particularly about the very old. For many, hospitalisation is followed by an often irreversible decline in functional status and a change in quality and style of life.

A recent US study showed that of 60 functionally independent individuals aged 75 or older who were admitted to hospital from their home for acute illness, 75% were no longer independent on discharge. That included 15% who were discharged to nursing homes.

[Victoria Prentis (Banbury) (Con)]

By intervening, I am not of course in any way suggesting that my hon. Friend needs to take the weight off his feet after that sad list of symptoms. He is rightly concentrating on the needs and degeneration of older people who go into hospital, but does he agree that ambulatory care is also important for younger people? In our local general hospital, the Horton, there is a marvellous new children’s out-patient service, which is used by both his constituents and mine. Does he agree that that is a centrally important part of the offer of that hospital, which provides acute in-patient care as well as the out-patient care on the side?

[John Howell]

I thank my hon. Friend for allowing me to have a rest and to make the most of that time—as I get older, I need that. I do agree with her; she makes a very valid point. I am concentrating on older people because traditionally that is where the population who have used the hospital in Henley have come from. I think that in the past year only one was under 55. But as I said, my hon. Friend makes a very valid point.

In many cases, the decline that people experience cannot be attributed to the progression of the acute problem for which they were hospitalised in the first place. An example is pneumonia. Even if the disease is cured in a few days or, indeed, if a hip fracture repair is technically perfect and uncomplicated, the patient may never return to the same functional status as they had before they went into hospital.

According to the US study, between 30% and 60% of patients with hip fractures are discharged from the hospital to nursing homes; 20% to 30% of those persons are still residing in nursing homes one year later. Only 20% of one large group of patients returned to their pre-operative functional level after a hip fracture repair.

Many hospitalised patients have difficulty implementing their habitual strategies to avoid incontinence. The environment is unfamiliar. The path to the toilet may not be clear. The high bed may be intimidating. The bed rail becomes an absolute barrier, and the various “tethers”, such as intravenous lines, nasal oxygen lines and catheters, become restraining harnesses. About 40% to 50% of hospitalised persons over the age of 65 are incontinent within a few days of hospitalisation. A high percentage of hospitalised older persons discharged to nursing homes never return to their homes or community. In one study, 55% of persons over the age of 65 who entered nursing homes remained for more than a year. Many of the others were discharged to other hospitals or long-term care facilities, or simply died. The outcome for many hospitalised elders is loss of home and, ultimately, loss of place.

It is most important that relationships among physicians, nurses and other health professionals reflect the interdisciplinary nature of the whole of this process. In particular, I am a great enthusiast for the integration of the NHS with social care. That needs to move ahead very quickly to give the clinicians the responsibility for commissioning the social care that is required. Maintaining wellness and independence in the community prevents conditions deteriorating and therefore results in better health outcomes. Emergency hospital admissions are distressing.

[Jim Shannon (Strangford) (DUP)]

I thank the hon. Gentleman for bringing this very important issue to Westminster Hall for consideration. Over the past five years in Northern Ireland, category A ambulance call-outs have increased by 30.9%. It is a devolved matter, but it does indicate a greater dependence on and need for ambulance responses. Does the hon. Gentleman have any thoughts about the best way to ensure that the ambulance service and ambulance staff can do better for elderly people?

[John Howell]

The hon. Gentleman makes a valid point. The costs need to be offset. This is a balancing exercise within the NHS. Costs that are saved by stopping people going into hospital can be spent on the treatments and services they require to get them better. That is a far better way of working.

Emergency hospital admissions are distressing. Better management that keeps people well and out of hospital should lead to a better patient experience. The King’s Fund estimates that emergency admissions for ambulatory care-sensitive conditions could be reduced by between 8% and 18% simply by tackling variations in care and spreading existing good practice. That would result in savings of between £96 million and £238 million, which, as part of the overall management of the NHS budget, could be allocated against the provision of the often quite expensive services that provide the necessary medical investigations on the spot.

A doctor in my constituency, Dr Andrew Burnett of the Sonning Common practice, said:

“Very few of my patients want to be admitted to hospital.”

Most people, if they need to be treated or, indeed, if they are nearing the end of their life, would like that experience to be located at home. I think that probably applies to us all.

There is a particular problem in relation to dementia. I spoke to the Alzheimer’s Society, which said that people are often admitted with an acute physical illness on top of their dementia, and the combination of the two can cause their confusion to become worse. They are then taken out of familiar surroundings and placed on a hospital ward with lots of strange people, noises and smells. That can be terrifying for them and they rapidly deteriorate. The advice from the Alzheimer’s Society is to try to keep people out of hospital for as long as possible. That is why we, and the Oxfordshire medical facilities, are striving hard to develop systems to enable people with physical illnesses to be managed out of hospital.

That is one of the rationales for the new Townlands hospital in Henley, where the clinical commissioning group, along with Oxford University hospitals, Oxford Health and, indeed, the county council, are members of the ambulatory emergency care network, through which organisations can learn from one another to develop robust pathways. Some good case studies are involved in that, but time prevents me from going through them at the moment. I draw the Minister’s attention to those if he needs some examples of how ambulatory care actually works.

Another clinician, Pete McGrane of the CCG, has said:

“Patients who were recently hospitalized are not only recovering from their acute illness; they also experience a period of generalized risk for a range of adverse health events.”

There have been cases in my constituency where the health of elderly people has deteriorated following discharge, or even in hospital, due to other conditions. The relatives have sought to blame the health service for poor care. After following up on those cases, the complaints investigation has shown that it is not poor care that has exacerbated the patients’ distress and symptoms; it is a direct consequence of hospitalisation.

I went to see a hospital in Welwyn Garden City, which has no beds inside. Instead, it has beds in an adjoining care home at the side of the hospital. The place was absolutely heaving with people. I met a gentleman there called Dave. I do not have his surname, nor have I asked his permission to use his name, so we will just keep it as Dave. He could not speak highly enough of the treatment he got. He called in every day for treatment and then got on with his life at home. It revolutionised the treatment he received, which, doctors had confirmed, would otherwise have required a debilitating 56 days of medication, staying in hospital. His experience of hospital stays had shown up their disadvantages, and he pointed out that people were so much more likely to improve, as he had, and to feel better, as he did, if they could stay at home. He was clearly a great enthusiast for this type of service.

In Henley, there is one issue, above all, which I have already touched on and want to emphasise. It was helped by some papers that were forwarded to me by the Health Foundation, which said that it is undertaking

“a joint research programme…monitoring how the quality of health and social care is changing over time.”

I have been very concerned by the way in which we move forward with the integration of social care and health in the county to ensure that it delivers the sort of services that are required in the full context of the patient.

I am pleased and proud that I have helped to deliver a 21st century medical facility for the people not just of Henley, but of the whole of southern Oxfordshire, and that that incorporates ambulatory care. It is clearly the way forward and it is a way forward that I am sure will work.

11:04

[The Parliamentary Under-Secretary of State for Health (Ben Gummer)]

I thank my hon. Friends the Member for Henley (John Howell) and for Banbury (Victoria Prentis), both of whom have spoken with great expertise about the place that ambulatory care has within a developing and modernising national health service. I cannot better the description that my hon. Friend the Member for Henley gave of the purpose of ambulatory care and the place it holds in his constituency, which I will turn to at the end of my speech.

For the benefit of the House and the record, I will add some examples of what ambulatory care entails for patients around the country. There is a clinical decision unit in the Royal Free hospital that provides an alternative to admission to an emergency department for patients who may benefit from an extended observation period. The James Cook University hospital has an ambulatory emergency care unit that handles nearly a quarter of all emergency admissions and manages a whole range of medical emergencies, including cardiac failure, cellulitis, diabetes and low-risk gastrointestinal bleeds.

The university hospital of Leicester has a frailty unit, which supports patients who are over 70 and need treatment for conditions such as delirium, dementia and fractures. The rapid assessment and treatment unit at Queen’s hospital in Romford has greatly reduced the time between a patient being assessed and a care plan being implemented. Those examples are in addition to the example that my hon. Friend the Member for Henley gave of Townlands in Henley.

Where ambulatory units are collocated with an emergency department, patients arriving at A&E by ambulance or as walk-ins are triaged according to clinical need and directed to the unit for treatment or tests, effectively bypassing the main emergency department. Patients identified as needing specialist treatment, tests or monitoring at the hospital, but who do not need to stay overnight, can also be referred to ambulatory units by a general practitioner. Patients with long-term conditions can be booked in for regular treatments such as dialysis.

Ambulatory care units can also focus on returning patients to their homes after treatment as quickly and safely as possible, as my hon. Friend outlined. As a result, patients are more likely to have good health outcomes because they avoid unnecessary overnight stays. He outlined beautifully the principle behind ensuring that people do not stay in bed any longer than they need to. The statistics on that developing area of academic study are stark, and he put them plainly to the House for its attention, but at their core they encompass something rather encouraging for many, although not all, patients. The best principle is to keep on going. We have all seen that with our elderly relatives: the minute one stops prematurely or unnecessarily, one precipitates a decline in condition, rather than an improvement.

Ambulatory care is an exciting and important approach to providing patient care, just as my hon. Friend outlined, and it will be central to the development of the national health service in the years to come. It has not come about by accident. It is based on good science and academic study. We in the Department are led by the Royal College of Physicians’ acute care toolkit and NHS England’s “Safer, faster, better”, which is based on the royal college’s advice.

While ambulatory care units may vary between trusts, both the royal college and NHS England have provided guidance on what a good unit looks like, so the underlying principles that all units are built on are the same. The principles fall into three main categories. First, the units must be patient-focused, meeting the needs of patients through timely treatment and discharge, and bringing together secondary and primary care services to avoid admission where beneficial. Secondly, effective clinical decision making is key, ensuring not only that patients in ambulatory units receive the high standards of care we expect from the NHS, but that the patients who would benefit from an ambulatory setting are identified early and directed to the service. Finally, ambulatory care needs to form a coherent part of the hospital-wide health system and structure to improve the patient’s journey flow through the hospital. Gaining support from other parts of the system, including clinical commissioning groups, as in my hon. Friend’s constituency, and primary care more generally is key to ensuring that the potential benefits are realised.

Ambulatory care units work well as independent units within acute trusts, but they work best when they are part of an integrated system. That is why I am pleased to see that there is an ambulatory emergency care network, which allows trusts to share best practice and to understand how to improve their services further. The Royal College of Physicians estimates that more than 30% of patients admitted for medical, as opposed to surgical, reasons could be treated in an ambulatory setting. By treating and discharging patients on the same day, emergency admissions are reduced, leaving hospital beds available for those patients who need them the most. There is therefore an advantage not only to the patient but to the system as a whole, because we are freeing up capacity for people who really do need the beds.

Increasing the numbers of patients seen in ambulatory care also has the potential to reduce waits for patients in A&E, which in turn decreases pressure on wards and increases bed availability, providing benefits to patients in other parts of the system. A whole number of benefits therefore come from ambulatory care. My hon. Friend mentioned the urgent and emergency care review and the place that ambulatory care has in that. I turn quickly to his experience of it at Townlands, where some features are particularly impressive. The first is the way in which the service has been brought together in the rapid access care unit—I imagine it is called a RACU, but I am sure the people of Henley pronounce it with a soft C. I found the integration of that with the Orders of St John Care Trust next door exciting.

It is clear that the clinical commissioning group in my hon. Friend’s constituency has been thoughtful about commissioning the care needed, involving other providers of care and using beds only when absolutely necessary. It is an ambulatory care setting without beds, but if beds are needed, it has 11 beds on a three-year contract, purchased from the trust next door, and if that number needs to increase still further, it can procure such beds through the CCG’s usual spot purchasing arrangements. For people who are admitted to an ambulatory setting, beds are available if needed for step-up care—or for step-down care for people coming from the John Radcliffe or from other acute trusts that serve my hon. Friend’s constituency.

Ambulatory care allows for a far more subtle approach to people needing care. As my hon. Friend outlined, it provides much better patient outcomes, is better for the health system as a whole and is much more flexible, ensuring that resources go precisely where they are needed. That opens out a much wider point, which he alluded to elegantly—I will say it rather more vulgarly than he did—namely the serious question of how we frame community services in the future. In parts of the country, we have a far older model of community service provision based on large bed capacity in community hospitals, which are much loved by their local communities, often funded in part by the local communities and in almost every instance founded by the local communities. We know, however, that in many cases they are not providing the best care for patients. It will often be a difficult transition to a better standard of care for patients, providing them with better outcomes and releasing resources for better outcomes for all patients across the health system.

By bringing the experience of Townlands hospital to the House’s attention, my hon. Friend has shown that we can be thoughtful and direct with constituents about the implications of change, and can explain carefully how improvements that might be challenging on the face of it, because it might seem that a benefit is being lost, can produce a whole series of additional benefits that enable better patient outcomes and a better distribution of resources within the system. He has allowed the House to understand how the benefits could be more widely spread across the NHS.

I turn finally to NHS England’s plans for ambulatory care. My hon. Friend will know about the vanguard sites in place across the country. Many of them involve the use of ambulatory care systems. There are many different kinds of ambulatory care settings involved in the vanguard sites, but the principle remains broadly the same: to try to identify those areas and experiences that replicate the positive experience that he, with the co-operation of his clinical commissioning group and primary care and acute trusts, has brought to Henley, and to ensure that that is tested on a system-wide basis. We can then roll that out across the rest of the country. We have 50 vanguard sites involved in one way or another in community care settings across the country, and I hope that that will inform a far wider transformation by the end of the five year forward view period, which concludes at the end of the Parliament.

[Mr Andrew Smith (Oxford East) (Lab)]

I am sorry to come in at the end of the debate, but I was delayed by traffic. I congratulate my colleague from Oxfordshire, the hon. Member for Henley (John Howell), on securing this important debate. Does the Minister agree that in the roll-out it is important that the ability, training and qualification of home careworkers is raised, so that they can complement the changes in services?

[Ben Gummer]

The right hon. Gentleman makes an interesting and subtle point. That is absolutely the case, and that is partly why, as part of the workforce review that I instigated, we are looking at apprenticeship and nursing associate models that will help to upskill nurses and care practitioners in not just acute but community settings. The result will be an ability to provide a far better, more holistic service to patients when they turn up at an ambulatory care setting, or indeed at the John Radcliffe, or, hopefully, when they are looked after at home before that happens, and when they return from either of those places. All that taken together provides a far better service to constituents.

I welcome the approach that Members have taken in this little but important debate. If we are positive about these changes and have a will to explain them to constituents, they will quickly understand why this system is better for them. Those Members who wish to pursue a cruder campaigning method that looks purely at the number of beds provided in any one setting, based on the model inherited from 1948 rather than one relevant to 2018, will be doing their constituents a disservice. In being brave and direct with his constituents and in explaining clearly the benefits that he has endeavoured to get, my hon. Friend the Member for Henley has delivered a far better service for the people of Henley than the one they had last year. It will continue to improve throughout the course of the Parliament.

Question put and agreed to.

11:29

Sitting suspended.