Ambulatory Care

Victoria Prentis Excerpts

Wednesday 27th April 2016 Westminster Hall

[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.