Back in the summer of 2013, the Secretary of State for Health Jeremy Hunt announced a public consultation on a new plan to improve care for vulnerable older people. This appeared to be very much his personal mission – indeed he went on to say in a speech at The King’s Fund that vulnerable older people would be his ‘primary focus for the next 12 months’.
The key themes in the plan included improving care co-ordination for patients aged over 75 through ‘named accountable clinicians’, promoting healthy active ageing and wellbeing, and improving ‘information and choice’ backed by more transparent information and IT solutions. Some details around delivery were imprecise (for instance, how ‘accountability’ would work and how fit-for-purpose NHS IT systems would be). The use of the word ‘vulnerable’ with its connotations of dependency and abuse was also unfortunate.
The plan then disappeared from view. It re-emerged in winter 2013 renamed No one left alone. Early spring brought another renaming, this time as Pro-active primary care, with a clearer focus on case management for older people with complex needs. Just a week or so later, in April 2014, the plan was finally published as Transforming primary care.
To my surprise, the press coverage accompanying the launch focused on a small section of the plan concerning non-recurring pilot money to allow 1,000 group practices in England to stay open longer in evenings and at weekends – a marginal change more relevant to working adults than to frail older people. On closer inspection, it became clear that the plan had been packaged together with the announcement of 20 pilot schemes to improve access to GPs – funded by a £50 million Challenge Fund launched by the Prime Minister in October last year – which was heavily briefed to the media. So much for vulnerable older people being the ‘primary focus’.
What about the substance of the plan? Our recent report Making our health and care systems fit for an ageing population, and our work on care co-ordination and integration, have underlined the clear need to focus more on older people’s wellbeing, prevention, anticipatory care and more joined-up, person-centred services – in particular continuity of care with a single clinician. Some government policies have clearly helped this agenda – for example, the national dementia strategy, the Equality Act and the government’s concerted response to the Francis Inquiry.
Building on this, the plan includes two significant commitments – that everyone aged 75 and over will have a named GP and that 800,000 people with the most complex needs will receive more support through a Proactive Care Programme. Central to delivering these commitments are changes to the GP contract. This chiefly entails scrapping a range of Quality and Outcomes Framework incentives and re-allocating the money to support the Proactive Care Programme. Reference is again made to the £3.8 billion Better Care Fund (with a focus on integration to prevent hospital admissions, delayed transfers or care home placements) and to the integration pioneer sites. Though, as we know, the Better Care Fund is not new money and, if recent media speculation is to be believed, there are doubts about whether the sums behind the Better Care Fund add up and whether it has a realistic prospect of delivering on ambitions.
The section on ‘information, choice and control’ turns out to mean broadly expanding the use of the already dubious friends and family test to primary care, and publishing Care Quality Commission data. This is despite the fact that we know most older people simply want their own local practice to be responsive to their needs.
Clear evidence exists to show that some of the most frail older people in nursing and residential homes have little access to health care inputs and primary care. Yet the plan offers next to nothing on this, beyond urging GP surgeries to provide an ‘ex-directory number’. It stops far short of instituting contractual obligations to deliver services. Nor does the plan have much to say about the critical interfaces between primary and urgent/emergency care for older people – as if the two were not fundamentally interdependent.
I welcome any attempt to improve services for older people. However, it’s a shame that the Secretary of State’s obvious interest in improving care and co-ordination for frail older people appears to have been side-tracked and watered down. Perhaps more involvement of experienced hands-on clinicians, local service leaders and professional bodies from the outset might have made the proposed changes more deliverable on the ground.