Keeping John out of hospital with a two-hour crisis response

Dr Shelagh O’Riordan is Chair of the BGS Community Geriatrics SIG and a Consultant Community Geriatrician at, Kent Community Health NHS Foundation Trust. She Tweets as @jupiterhouse1

Last week I was called by the ambulance team who were at the house of John, who had advanced dementia, had not been eating and drinking well for about a month and had fallen today. His wife had called the GP surgery and was advised to call 999. John wasn’t injured but he wasn’t well. He had a temperature and was drowsy. I talked to the paramedic and John’s wife, and we agreed to a visit by an advanced clinical practitioner within two hours. When I said her husband didn’t have to go to hospital and we would talk about what was most important to them both, she was tearful and so relieved.

John was assessed at home, where he received antibiotics and treatment for constipation and pressure-relieving equipment was ordered. Support was arranged for personal care and an anticipatory care plan was agreed that John wouldn’t go to hospital for anything bar a major broken bone and that, when the time came, he would want to die peacefully at home.

There are so many people living with frailty and multimorbidity who are just like John. By providing real alternatives to hospital admission, we can really offer patient-focussed care. The recently published Urgent Community Response guidance builds on ambitions set out in the NHS Long Term Plan, stating that by 31 March 2022 all Integrated Care Systems (ICSs) in England must ensure delivery of the national community two-hour crisis response standard.

Two-hour crisis response is available to all adults, not just older people, but it is likely that a large proportion of those receiving this service will be older. This standard aims to improve patient outcomes by meeting their urgent care needs at home or usual place of residence. By providing crisis care within the community, people will be able to stay at home receiving the care they might have got in hospital and maybe even sooner.

One of the key elements of the urgent community response is that it should be a key option for people who live in care homes and for the staff looking after them. The recent BGS report, Ambitions for Change, states that providing healthcare in the care home should be the default, and care home residents often have the most to lose by hospital admission. Having an alternative offer to hospital admission for care home residents will be a real improvement.

Many BGS members will have been involved in services to provide crisis response in the community for many years while others may be struggling to get started with this. The guidance published recently by NHS England provides details on what ICSs will be required to provide come March next year. BGS members fed into the drafting of this document to ensure that it provides the best guidance for those implementing crisis response services across the country and we hope that you find this guidance helpful.

It’s important to note that there isn’t a one size fits all answer to this – several different models exist to provide crisis response to older people in our communities and it is important to find the model that best suits your locality. To help with this, the BGS has published Right Time, Right Place which outlines some of the models currently in use and provides some tips for getting started.

We all have patients like John who have ended up in hospital, even though this isn’t the best place for them. We can provide better care for them in their homes or care homes – this provides better outcomes for patients, costs less in the long run than hospital care and supports a quicker recovery. As more localities start to implement crisis response services, it will be important for BGS members to share experiences and learnings so that older people have access to high-quality urgent community response, regardless of where in England they live.