We have talked for decades of the pressing need to ‘shift care from hospital to community’. Each year the warnings become more dire, headlines shouting that lack of action represents a threat to the sustainability of our highly valued NHS.

This talk of ‘shift’ influences each annual planning cycle, yet our hospital services face record levels of demand. This pressure is felt most acutely in our urgent and emergency services, of which older people are the biggest users.

Our system is composed of interlinked, yet autonomous, organisations, led by people who have responsibilities for one institution rather than the local health system. There is no denying the difficulty in shifting thinking to place, and people crossing organisational boundaries and responsibilities. Individual leaders across health, local government, housing and the voluntary sector all understand the importance of collaborative working, but can struggle to make it happen within the context of conflicting incentives, whether financial or regulatory.

The move towards developing sustainability and transformation plans (STPs) represents a positive shift to plan health and care services by place rather than around individual institutions. Despite these positive moves from the national bodies to shift our approach to planning care, it remains clear to everyone in the care system that the lid on the pressure cooker will soon come off. One area where this is particularly notable is in our care for older people. We know that a fundamental change to the way care for older people is designed and delivered is required. That is where the NHS Confederation’s Commission on Improving Urgent Care for Older People comes into play. The Commission’s report ‘Growing Old Together’, published in January 2016, represents a year’s work, examining the best evidence, and the best practical examples, of how we can improve the planning and delivery of urgent care for older people. It represents a view from experts right across the care system - commissioning, community, primary and acute sector leaders - alongside patients and carers, medical professionals and local authority representative, all with the aim of creating practical applications for people leading and working to deliver care for older people. 

Growing Old Together sets out eight key principles for revolutionising the way that urgent care for older people is delivered. These principles support a vision for joined-up care that involves social, physical and mental healthcare, where we support the needs of older people in their lives and in their communities, and by doing so, are able to deliver better outcomes and a more stable NHS.

The principles are as follows:

• Start with care driven by the person’s needs and goals
• A greater focus on proactive care
• Acknowledge current strains on the system and allow time to think
• Care co-ordination that offers older people a single point of contact to guide them through an often complex system
• Make greater use of multi-disciplinary teams
• Ensure workforce, training and care skills reflect the care needs of older people today
• Enable leadership to support staff to innovate and make a difference
• Measure the things that matter to people.​

The Commission’s expert panel strongly believes that by starting at a point where care is designed around a person’s needs and goals, rather than around organisational or system structures, other challenges can be better addressed, allowing local leaders the space to build relationships and sustainable solutions. The panel is clear that there is a critical role for hospitals in the provision of high quality care for older people, but emphasise the importance in ensuring that this is the right care, provided at the right time, to meet people’s health needs.

Our work has uncovered compelling evidence of impressive initiatives taking place across the country.  One of the common themes running through our site visits was the enthusiasm of frontline staff to identify and bring about improvements in patient care or experience. Very often it was the experience of one particular patient that prompted them to make changes that then impacted on a whole group of patients.

In Sheffield Teaching Hospitals NHS Foundation Trust, for example, teams caring for older people realised that the traditional method of assessing medically fit patients for discharge home could often lead to longer than necessary stays in hospital, and a higher level of home support than was actually required. The team decided to turn things on their head and trialled assessing patients in their own homes. The concept of discharge to assess (D2A) was born and the new way of working means that more than 7,000 patients have been assessed on discharge using the new active recovery service over the last year. Patient satisfaction has been high and the results show people have been discharged home when medically fit in an average of 1.1 days, compared with 5.5 days three years ago – a saving of more than 30,000 bed days, and delivering a higher quality of patient experience.

In Cornwall, Age UK staff members or trained volunteers fulfil a co-ordination role for older people identified as being at risk of hospital admission. As well as working with NHS staff on a care plan designed to keep people in their own homes, they look at the person’s social needs, and the goals that they identify as most important for them. This care involves aspects such as social activities, benefits advice and home help. Early evaluation shows a significant increase in wellbeing, a 31 per cent reduction in all hospital admissions, and a 26 per cent reduction in non-elective hospital admissions.

One of the fundamental lessons from our work, highlighted by these examples, is that radical change does not need to be complex: it is about starting with a person’s needs and organising their care around them. The result is a simpler, more straightforward way of delivering care. We are under no illusions that this is easy to say and difficult to deliver, but as we move to models of care which consider place over institution it seems particularly resonant.We know that necessity is the mother of invention. The challenge now is to make sure we have the spread of innovation at both scale and pace. Without this, that pressure-cooker lid looks increasingly likely to blow off, leaving staff, older people and their carers feeling the impact. Local excellence needs be celebrated, but more importantly it needs to be shared across the health and care sector so that everyone reaps the rewards.