HSJ readers have many ideas and examples of good practice for improving the care of older people that could be rolled out across the system – with a little pushing, Alison Moore reports
When HSJ launched its Commission on Hospital Care for Frail Older People we knew our readers would have ideas and experience of how care could be improved. So we asked them for their suggestions – and about 300 people contributed, highlighting areas they felt could be improved and giving examples of what they had seen working well in the UK and other countries.
‘We have to make sure that our current workforce feels comfortable and able to look after elderly people with complex needs’
Many of these were not rocket science. As one of our commissioners, former national clinical director for older people David Oliver, points out, there is a degree of professional consensus about what good care for this group looks like.
But the key is often in how to implement this and, crucially, the human factors around care. John Young, national clinical director for integration and the frail elderly at NHS England, says that frail older people, people with comorbidities and people with dementia occupy two-thirds of beds.
So what are readers seeing done in their own organisations and others – and think could be rolled out across the system? The answer is lots of good practice but it sometimes takes a little pushing for it to become obvious.
Treatment of dementia patients
One common theme was the treatment of and communication with dementia patients. One reader, an ex-non executive director, found it hard to get information on their elderly mother as senior staff were not available during visiting times. “I have no idea whether she is terminally ill, has a short illness or has been forgotten,” they wrote. Basic nursing care was also lacking and she could no longer ask herself for things to be done to make her comfortable.
However, when they took in photos to give her the comfort of something familiar, staff produced a “this is me” book designed to remind staff of the productive and interesting lives led by patients in their care.
Other readers urged hospitals to ensure that frail older people were well hydrated, helped with meals if necessary and encouraged to get dressed, if possible, to encourage a sense of normality.
And while many older people would be better looked after in the community, continuity of care was identified as important if they were in an acute setting – this could be helped by placing them in a ward where they were known and under the care of a geriatrician, rather than through accident and emergency into a different ward.
“We have to make sure that our current workforce feels comfortable and able to look after elderly people with complex needs,” says Professor Young. He argues communication skills – and how staff related to people with conditions from deafness to dementia – are a huge part of this.
The importance of workforce
One thing that comes out of this discussion for me is the central importance of workforce – training, skills, attitudes, planning, flexibility, preparedness to work for older people and even enthusiasm for doing so.
Having the right workforce in the right place at the right time to support older people and recognising that the care of older people is a skilled endeavour – every bit as much as being a nurse specialist on intensive care or special care baby unit or a psychiatric ward.
I think the issue of a workforce fit for future care needs would unite interest among managers and clinicians and clinician-managers and is also central to the response to the Francis report and the work of the Care Quality Commission as well as, for instance, the agenda on integration and delivering more care outside hospital and more coordinated care.
Professor David Oliver is president-elect of the British Geriatrics Society
But to provide high quality care to dementia patients, staff may need additional training and skills. Dementia champions may be a way of improving care but readers felt that everyone in an organisation who dealt with patients – from consultants to cleaners – needed to be involved. Simple improvements to the environment, such as improved signage and self-closing doors, could also be helpful.
A day hospital approach – where elderly patients could be assessed by a multidisciplinary team and given written advice before being discharged – was one suggestion, although another contributor felt that GP practices would be the right approach. But as one reader pointed out, sometimes frail older people do need to be in hospital: the issues may not be that they are there inappropriately but that they need to have shorter length of stays.
As well as having everyone aware of and responsive to their needs, frail older patients also need continuity in who is looking after them. A named clinician helps build trust with patients and family, and can provide a better pathway for patients than when they see many different doctors, suggested readers. A single care record can help avoid duplication in tests and measurements. A set of core competencies can ensure a single member of staff can carry out tasks such as changing dressings, checking vital signs and risk assessment.
‘Frail older people often went downhill in a hospital environment, which can affect their ability to live independently once discharged’
But there are some roles which can be handed over to nurses, such as discharge. Provided there is understanding of what is needed before discharge can take place, this can eliminate the need to wait for a consultant. This can ensure discharges happen earlier in the day so the frail older person can be settled at home – and beds are freed up.
One reader was involved with an integrated discharge team involving both the NHS and social care teams, and the third sector. This ensures that ongoing care plans are appropriate and flexible and can avoid unnecessary readmissions – and that patients’ holistic needs are met. In one case, this involved third sector support to walk her dog. A pilot of this has seen lower readmittance rates.
Professor Young sees links into the integration agenda and community services. “There is clearly work to be done and it is good that people recognise it,” he says. “We would aspire to move from the current discharge system, which is termed a ‘push’ system, to a ‘pull’ system in which community services take greater responsibility for the discharge process.”
Several readers pointed out that frail older people often went downhill in a hospital environment, which can affect their physical and mental ability to live independently once discharged.
Hospital falls in frail patients can be serious: putting patients at risk of falling together, with a much higher nurse-patient ratio, could be one way forward as already done by Nottingham University Hospitals Trust, suggested a reader.
Not a priority
But underlying many of these problems is that elderly care is sometimes not seen as a high priority or high prestige area. One point which came out was that healthcare assistants in geriatrics were sometimes employed at a lower banding than elsewhere in a hospital: a not-so-subtle message about status.
Professor Oliver points out RCN research has shown wards for elderly people have tended to have lower nursing numbers than equivalent wards elsewhere in hospitals, despite the complexity of many of the patients. Ageist attitudes can mean caring for the elderly is seen as “less skilled and less glamorous” than other parts of the health service, he says.
Incentives could be built into the tariff system to reward hospitals for better treatment of the frail elderly: based in measures such as outcomes, readmission rates and friends and family test scores.
But in the end acute hospitals are not the right place for many frail older people. Support at home and in the community is the way to reduce excessive use of hospitals, but readers pointed out these were often lacking. One suggested small local clinical units, which could offer overnight stays, backed up with care at home.
Pathways need to stretch out of hospital into community services, with patient needs identified prior to discharge rather than afterwards. Funding needed to recognise this to avoid frail older people feeling they were “stuck in the middle of a disjointed NHS which fails to support them properly”, as a reader put it.
‘Acute hospitals are not the right place for many frail older people. Support at home and in the community is the way to reduce excessive use of hospitals’
Care needed to be based around the patient with long term conditions reviewed in one visit by a clinical team responsible for coordinating their care. Patients on multiple medications needed to have these all reviewed with the King’s Fund recommend on polypharmacy and medicines optimisation adopted.
Examples of good schemes suggested by readers were not limited to the UK. In New Zealand, the Christchurch earthquake provided the impetus to boost care at home as many hospitals and nursing homes had structural damage and bed numbers were reduced. The local district health board set up a community-based supported discharge team, which has since been extended to take referrals from general practice to avoid admissions altogether. This scheme can provide support at home for up to six weeks with continued clinical assessment to ensure the patient does not deteriorate.
So there are plenty of good ideas and good practice in hospital care: but why are they not taken up across the country? Professor Oliver points to the evidence around factors that support the development of joint working: strong leaders, continuity in leadership and recognition that a problem is pressing. Ensuring these are in place could help drive change.