Integrated care can’t come soon enough – just ask the lady next door!
I need look no further than my neighbour’s doorstep for a graphic illustration of why integrated care is essential to get the right care equipment to the right place at the right time. Let’s call her Angela to protect her privacy. It all began when this elderly lady, deemed medically overweight and with restricted mobility, was assessed as needing a stairlift, but this still was not installed 18 months later. This delay was to prove a crucial turning point in Angela’s care needs.
Meanwhile, her husband, let’s call him Graham, who is in his seventies, had to ‘push’ his heavy partner upstairs night and day when she needed the toilet or to go to bed. Unfortunately Graham suffered a heart attack and was hospitalised before the stairlift came to his aid.
With her husband in hospital, Angela attempted to climb the stairs with only her daughter to help. This was unsuccessful and Angela’s daughter called an ambulance to help. It took two ambulance crews to get Angela down the stairs safely. Following this, Angela was confined to the ground floor, suffering the indignity of a commode and other equipment in the living room and needing carers to bathe her. Her health deteriorated, and she herself was hospitalised. When Angela was in hospital she developed quite serious pressure ulcers and as a result was in hospital for approximately 6 months. When she was ready to be discharged the essential stairlift still had not arrived – even though 18 months had elapsed since it was granted. As a result, her home was deemed unsuitable: apparently there were also difficulties acquiring ‘heavy-duty’ equipment, and there were also disputes between health and social care about funding.
At this point, one has to think how the situation might have developed had the stairlift been promptly installed in Angela’s home.
The stairlift never arrived and eventually Angela had to be rehoused in a bungalow which required the fitting of a range of special equipment, as well as grabs rails etc. Carers came in daily to bathe her and attend to her needs. Her bad luck took another turn when the wrong mattress was supplied (not the specialised bariatric mattress she needed) and her pressure ulcers got worse. As a result, she was re-admitted to hospital for a further 4 months of care.
Confined and depressed
I recently visited Angela and Graham to find that she is now confined to just one room and suffers from depression that she attributes to having had to give up the home they had lived in for almost 30 years, together with the care she experienced in recent months. These days she needs comprehensive support: she regularly has home visits from the GP, needs carers on a daily basis and has regular visits from community nursing staff and occupational therapists.
She told me that her confinement to one room is partly because her ‘heavy-duty’ equipment doesn’t fit through the doors and widening the doors is ‘not seen as a priority’. She said that she is also only able to get out of bed when the carers or clinical staff turn up, adding that sometimes no-one comes. She said some carers come and they don’t know how to use the equipment properly and when this happens she has to remain in bed; “It’s so depressing”.
It is only when we take a step back and consider disability equipment in the wider context that we see how important it is in supporting our entire care system – perhaps the same correlation as arms in war! In Angela’s case, consider the damage done (not to mention the extra resultant burden on the health and care systems!) by the failure to supply the stairlift and by the wrong equipment being provided in error. A careful initial assessment, and proactive planning, may also have identified that a stairlift, even if it had arrived, was only going to be a short term solution and that Angela would be better in a bungalow. This may have allowed a seamless transition for Angela and may have prevented many of the unnecessary consequences – such as two hospital stays.
Disability equipment, its availability and timely provision are essential to the government’s aims around integration, prevention and re-ablement.
The questions we should ask
There are too many issues in Angela’s case to analyse in great detail. To learn from it, especially in the light of the new ‘integration’ agenda, and with the newly identified 14 Integration pioneer areas, we need to ask ourselves the following questions:
- Was the health and wellbeing of Angela and Graham considered when decisions were made and who should have been ultimately responsible for this? Will any one group be responsible for ensuring that the overall health and wellbeing of people is covered – for example, Health and Wellbeing Boards?
- How could this situation have been prevented from escalating out of control and what robust plans are there in the current system to avoid this happening again?
- What unnecessary costs and secondary episodes of care could have been avoided in this case and how can we prevent cases like this from happening again and again? Is there a case for funding ‘invest to save’ services?
- How could the care have been more connected or joined up and what agencies and systems need to be speaking to one another? Will the current integration plans address this?
- Do cases like this fall outside, or between the gaps of the current regulatory regime because of the interface with multiple services? Is this a commissioning issue or a provider issue? If it’s a commissioning issue would it be picked up? Would this case be covered in assessment of social care, CCG, housing or hospital care? What chief inspector (or inspectors) at CQC will be looking at issues like Angela’s case – social care, hospitals, general practice?
- Would the use of a personal budget have helped in this particular case?
- In light of the big focus on the quality and safety of care in acute settings over recent months and the various reviews (e.g. Francis, Berwick), what plans are in place for addressing quality and safety in the community where equipment is concerned?
National approach needed
Having personally managed equipment services in the past and worked at various levels, I believe that this case is an all too common occurrence. If we addressed issues like this on a national scale, consider the improved clinical and financial outcomes we would have!
With approximately 12 million pieces of equipment provided each year in the UK to approximately 4 million people by statutory services, should there not be a greater focus on the strategy, deployment and use of that equipment, with the right systems and processes, including safeguards, in place for delivering a truly effective service? Should we be investing more time and money in these services – is that not what early intervention and prevention is supposed to be about?
You never know, it might help the lady next door!
Brian Donnelly, CEO of CECOPS