Geriatric medicine: changing staff attitudes

Despite our ageing population, our culture appears paradoxically youth-obsessed. Witness the populist portrayal of former Liberal Democrat leader Sir Menzies Campbell as a doddering old fool, discriminatory myths about older workers, or the glut of TV shows on how to avoiding the shame of looking older.

No-one wants to face up to the reality of frailty, disability or long-term illness. Much political attention on the NHS is focused on the potentially vote-winning concerns of more vocal, younger consumers. Likewise, little space is afforded to the grossly inadequate recognition and treatment of common problems for the elderly such as falls, dementia, incontinence or osteoporosis. Stories about sick children or younger patients denied IVF or cancer treatments are considered far more newsworthy.

Yet older people are the core users of NHS hospitals. Those aged over 65 account for around 60 per cent of admissions and 70 per cent of bed days in general hospitals. By 2025, the number of people aged over 65 will have increased by 50 per cent and the number over 80 by 80 per cent, with corresponding increases in physical impairment, dependency or multiple long-term conditions.

So why does the care of this major patient group still have Cinderella status? Part of the reason is ageism - pure and simple.

The 2001 national service framework (NSF) for older people recognised that general hospital care for the elderly had great room for improvement, but by 2006 numerous reports acknowledged that there had been inadequate progress in making hospitals 'age proof and fit for purpose'. In particular, the Audit Commission/Healthcare Commission report Living Well in Later Life stated that 'many hospitals and staff still show deep-rooted and negative attitudes towards older people'.

Cherry picking

I have heard numerous staff openly use terms such as 'crumble' or 'gomer' without embarrassment. Other examples: a surgeon asks staff on a geriatric ward: 'How do any of you stand working with all these old people?' Another colleague declares he is spending too much of his time market gardening (ie looking after older people who are cabbages). Would we see the same prejudice in 2007 applied to disability or ethnicity?

These people need to get used to the fact that looking after older people is their job whether they like it or not; public servants cannot cherry pick the 'interesting' bits. Handed down from mentors, these attitudes are not confined to medical staff - managers are not exempt.

Surveys of medical and nursing graduates repeatedly show few wish to specialise in older people and their training contains woefully little content on the specific needs of older patients. I would love to tell you this was all down to well-intentioned ignorance but unfortunately some of it is down to simple prejudice.

Unwitting ageism, even from their own relatives, can mean older people are infantilised. Deprived of their right to take risks or make major decisions about their own future care, they are talked about behind their back or over their heads.

It is true that older people's care has had a great deal of attention recently. As well as Living Well in Later Life we have had the reports Caring for Dignity by the Healthcare Commission, on hospital care for older people, and the parliamentary inquiry into older people's human rights. All focused on respect, communication, privacy, continence, environment and nutrition. These issues are of great importance to older people and their families, but tackling persistent ageism is a vital part of transforming care.

The older people's national service framework stated that all staff working with older people (which is nearly all staff) should have appropriate skills, training and attitudes - but this has patently not happened. Though it set out standards for rooting out age discrimination, which led to eradication of explicitly and arbitrarily ageist written policies on access to treatment, many implicit attitudes were untouched.

Older people still often receive unacceptable, inadequate assessment and treatment. They often present to hospital, not with textbook symptoms but because they are struggling at home, with immobility, incontinence, falls, are confused or because of the concern or stress they cause family and carers.

Likewise, patients slow to rehabilitate after elective surgery or acute illness often have a range of inadequately recognised or treated medical problems. Yet such patients are often disgracefully labelled as having acopia (jargon for being unable to cope but not any kind of diagnosis), being social admissions or as bed blockers. What they require is a rigorous diagnosis and treatment plan of the kind we would routinely expect for younger patients.

Frontline professionals are easy to scapegoat, but the care they deliver is severely constrained by organisational values and priorities. External pressures on trusts have a profound effect on care.

While performance indicators do include some standards that benefit older people, target fixation makes medium-term planning or strategic collaboration with local primary care and social services nearly impossible and diverts attention from patient care. Perversely, it often seems that the best way to secure investment in a service is for there to be a scandal or high-profile failure.

The system by which PCTs contract services from acute trusts is a further hindrance. While the care of acute patients is a major part of general hospitals' activity, it is now a loss leader, with revenue streams depending disproportionately on elective surgery. The unbundling of the tariff under payment by results is likely to add to this pressure, as the presence of older people in the system will effectively be losing money for most acute trusts.

Quality alternatives

Meanwhile, there are drivers and directives designed to keep older people away from hospital or discharge them ever earlier - but to what? The quality and outcomes framework does little to incentivise proactive primary care for frail older people, community hospital beds have been cut, many intermediate care places are inadequate, case management of long-term conditions has failed and there are severe shortages in community social services and continuing care provision. Of course, no patient of any age should be in a bed they do not need but there are not enough quality alternatives.

So older people are increasingly seen not as core users, but problems for the system, preventing hospitals from doing their 'real' work.

Finally, resource allocation is an issue we cannot ignore. Some change isn't cost neutral. Education and training costs money, as would paying senior staff more to remain at the bedside or providing adequate nursing for frail patients (surely key to providing dignified care). And rehabilitation requires therapy time.

A New Ambition for Old Age, the 2006 document outlying the next steps following the NSF describes a move away from targets, instead using other levers to drive up the quality of basic care. But I worry that the lack of additional resources and binding performance targets or penalties for hospital trusts mean that trusts will not show the flexibility and vision they need to move beyond a short-term and narrowly target-driven culture.

Counterintuitive though it may seem, getting the care of older people right will create dividends for the whole system; reducing length of stay and improving the access, capacity and choice on which external performance targets focus.

So, some solutions. There needs to be genuine investment in alternative community services. We also need genuine incentives, based on effectiveness, in performance frameworks, to avoid older people being fobbed off with second-class services, or discharged early with inadequate ongoing care.

Let us also be upfront about what we can and cannot afford. If we are to retain a culture driven by finance and targets above quality, it is imperative that some of these targets actually focus on the standards of care experienced by older people.

The education and training of healthcare professionals needs to change to reflect the fact that their day-to-day role will increasingly centre on the care of older people with long-term conditions rather than younger patients with curable single conditions. There is plenty of evidence that proper assessment and management of falls, immobility, incontinence or confusion improves outcomes - and that we currently do it very badly.

Within organisations we need to learn continuously from patient feedback, complaints and critical incidents and use this to make services genuinely dignified and patient-centred. For all the talk of matrons we surely need to change salary structures so that experienced clinical staff are incentivised to remain at the bedside as role models and mentors rather than moving into general management roles. For once they have done so, the need to have a corporate face results in a serious conflict of interest.

Organisational culture should actively encourage staff to be off-message and become challenging advocates for patient care; patently not the case in most NHS trusts.

Finally, organisations need to start showing more vision and creativity. Medium-term planning to improve the care of older people will have dividends for the whole system.