Dr Peter Levin

Published 20/06/20

The Embrace Care Project is beginning to look like a political stunt. Cornwall's frail older folk deserve better.  

 In the midst of the stress and turmoil caused by the Covid-19 pandemic, work on integrating Cornwall’s health and social care system goes on. Little has been heard of the Embrace Care project since before Christmas, so it’s time to take a closer look at it.

The context to the project was set by NHS England, which wants to see better use made of hospital beds. It also expects all hospitals with a major emergency department to provide an acute frailty service and carry out a clinical frailty assessment of a patient within 30 minutes of their arrival.

The Embrace Care project in Cornwall was set up in May 2019 ‘to focus on improving the outcomes for older people’. It was run by a team from consultants Newton Europe, who asked what happened when patients were admitted at a hospital’s ‘front door’.

The team reviewed the cases of 54 patients over 65 years old, in a workshop with participants drawn from a range of hospital and care roles. For each patient, participants were asked: ‘Should this person have been admitted?’ They concluded that more than half of the most frail patients were admitted inappropriately, whereas not a single one of the least frail was.

Of course, the most frail are most likely to have complex needs, such as multiple long-term conditions and mental health vulnerability, so it’s bound to be more difficult and time-consuming to reach a confident diagnosis for them, especially for junior doctors working on their own. Keeping patients in for observation will always be the safest thing to do.

The Royal Cornwall Hospitals Trust says on its website that it provides a frailty assessment service in the Emergency Department and Medical Admissions Unit:

Our Consultants and multidisciplinary teams provide specialist frailty care on wards at all our main acute hospitals and at community hospitals. There is a special acute older people’s ward at Royal Cornwall Hospital ... where we see our frailest acute patients.

How well does this work? In 2019 Treliske was inspected by the Care Quality Commission. Its report, published in February, says of the service:

People could not always access [it] when they needed it and did not always receive the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not always in line with national standards.

So here was a situation which Newton Europe’s bright sparks could have investigated, aiming to improve access and waiting times for frail patients, as has been achieved elsewhere. But they didn’t.

Last November a short report, Embrace – An Introduction to the Design Phase, appeared. This proposed ‘a new way of working’, with Community Teams.

The Community Team would provide support for an older person so they wouldn’t have to go into hospital following a fall or other mishap. It would identify their needs, such as adaptations to their home and therapy to improve mobility. It would help inpatients to return home, and ensure that appropriate care was organized. And it would establish contact with their GP and their carers, and with local organizations who might be able to help re-establish them in their community. There would also be a local bed-based rehabilitation centre, to which the Community Team could refer patients.

While we might applaud these proposals, there is nothing at all in them to help someone who’s just had a fall and needs a smooth pathway to a hospital bed.

So where did the community team ideas come from? None of the Newton Europe work generated a question to which community teams are the obvious answer. 

They are, however, an obvious answer to a political question. The proposal for community teams looks like a bid from Cornwall Council, which would run them, to take control of the health and social care system. It doesn’t follow from the Embrace Care project. The Newton Europe team appears to be being used, under the pretext of solving a technical problem, to achieve a political objective.