Clinical leadership is urgently needed to improve the care older people receive. Steve Feast explains
Twenty years ago, most clinicians considered people in their 60s and 70s as elderly – in the twilight of their healthy lifespan with limited expectations of their future. Cottage hospitals still cared and catered for many elderly people in large mixed sex wards offering limited opportunities for recreation or stimulation. Older people saw out their last years while receiving dedicated but limited care.
This paradigm has already shifted enormously – elderly now means people in their 80s or 90s or even older – and care has become a much more dynamic process centred on keeping people independent and at home.
‘Clinical leaders need to become representatives and advocates of a growing older people’s social movement’
The determined and successful advocacy movement that represents older people is rightly changing and stretching people’s expectations of public services. Individual budgets and better information helps people navigate to the care they need in their last years. At the same time, long term care has moved from the province of the hospital to the home or the residential and nursing home sectors, bringing with it more of a focus on recreation and opportunities for social interaction. The emerging evidence base is that good social interactions and connectedness linked to moderate physical activity are the best ways to reduce risks of dementia and plan for healthy ageing.
Clinical leaders need to engage with this change, moving from being individual clinical advisers to become representatives and advocates of a growing older people’s social movement. To adopt and champion new service models using our own authority and leadership roles across health and care services to co-design solutions with potential users. Clinical and care options are most effective when they are based around the needs of those most likely to use them – this includes the needs of carers and relatives. Involving older people in the design and delivery of buildings, the services they house and the care pathways within them is an essential next step in the changing world of later life care.
A personal experience
My own personal experience is that there is a long way to go before we see tangible benefits from adopting a joint approach. Following a referral by a GP, I recently took my mother to a large hospital to see a specialist. Her mobility is not great but not bad enough to qualify for a disabled car pass. There was no public transport link from where she lives. I, like many other relatives, took the day off to provide transport. When I picked my mother up she was confident and expectant of the day ahead. Fifteen minutes after arrival at the hospital, we found a parking space. Being a proud and independent person, my mother insisted on paying the fee – a charge I calculate as just about 10 per cent of her disposable weekly income.
A slow 20 minute walk brought us to the front of the hospital. Once in the foyer, the signs overhead told us the direction to head in, but gave no idea of the distance involved. There were no wheelchairs in sight so we again elected to walk. This took another 20 minutes. By this point, my mother was exhausted and was beginning to lose the verve with which the day had begun.
The clinic staff were friendly but also clearly oblivious to the fact that people in the waiting area may have been quite shocked they were openly discussing their private lives and the capability of the medical staff we were waiting to see. It felt a long way from the respect and dignity agenda. Where were the socially and culturally competent services that I believe will best help older people feel empowered rather than more anxious? My mother was addressed by her first name and treated in a generally child like but friendly and open manner - and she responded in similar style, as did the other patients, creating an atmosphere more akin to a kindergarten than a meeting of seniors with many life experiences between them.
After a while, the clinical staff arrived as a train of bustling white coated specialists and settled down to dictate letters and answer queries in their rooms as we listened in from outside. In time, we were invited in to the consultant’s room. The specialist was very different in approach. He was deeply respectful and interested in my mother as a person and patient, speaking with her as an equal. In response, I now saw the educated and eloquent person I knew from childhood clearly articulating the symptoms experienced, what she thought caused them and what she was seeking. It was as if she had suddenly come alive when spoken to with interest and curiosity, now engaging and alive with energy. The difference was striking and the result of the consultation was very positive.
After seeing the specialist, we exited the calm comfort of the consulting room and once again entered the hurly burly of the corridors and cubicles. The next two hours were more of what had gone before. We took several cards for appointments, laboratory and blood tests and went for a chest x-ray. There were two more long walks through busy and disorientating corridors. Three and a half hours after arrival, we walked very slowly back to the car and I took my exhausted and very quiet mother home. On the journey back, I could not get one thought out of my mind: that what we had experienced was an ordeal. With support, my mother had got through it, but what must it be like to have go through that alone and without help?
How we can improve pathways of care
We consume 70 per cent of our healthcare in the last 18 months of our lives when we are likely to be old. The care delivery system people experience is designed and configured to meet the expectations of those who can walk for miles, for those who are not bothered by gossip and chatter and who can find their own way around a complex building. This is not a care pathway co-designed for the needs of those most likely to use it.
There are leadership challenges all through this personal account. They may best play out by considering the patient journey. At the very start, it is quite likely that stronger and better-resourced primary care leaders could have co-designed a video conferencing suite that linked GP, patient and specialist. Patients would no longer need to go to the clinic and the journey savings made could be badged under a low carbon care pathway scheme. The follow-up appointment could have been a telephone conference between the practice nurse, clinic nurse and patient.
The senior leaders in the hospital could have walked the patient journey, developing ways to shorten it or to provide electrically powered vehicles similar to those at airports to shuttle from the car parks. The patient services leaders could have worked with patient groups to help determine the spatial and ergonometric aspects of the care journey. Those leading the outpatient clinics could provide better staff training on the socially and culturally competent services that are most likely to help older people achieve the outcomes they desire. “Mystery patients” could have sat in the clinical waiting areas and helped to feed back to the staff that their conversations and opinions are clearly audible to those around them.
Clinicians: take action
These are small but crucial changes. We face a rising tide of complex care challenges as the population ages. This will include more patients presenting with dementia or moderate memory disorders, increasing the likelihood of disorientation. The new dementia strategy and last year’s carers’ strategy provide many ideas that can prompt and lead change. The challenge now is for us as clinical leaders to drive these changes.
My call for action is that we lead this redesign and change process with those who actually use the services. We need to walk along the patients’ pathways, experience with and listen to the experiences that happen along the way. In doing so, we can build the respect and dignity agenda in to all stages. This will influence those around us, changing their own perceptions and reactions. As leaders, we have a duty to those who through age and infirmity find it harder to self determine the care they deserve.