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Care of older people: maintaining standards

Sue Dorling
SRN
Head of Region
Friends of the Elderly

The recent report by Health Service Ombudsman, Ann Abraham, stated that the NHS is "inflicting pain and suffering on elderly patients and ignoring their most basic needs". It went on to say that "older people too often did not receive the care, compassion and respect they deserved".1

The report has, naturally enough, created much debate within health and social care. From all areas of our sector there have been messages of dismay, anger and shame that such events could ever have happened. Now, it is even more important that we work together to ensure that cases like these never occur again and consider if there are any lessons that could be learned from those of us providing services in the community.

Since the heady days of my training in the 1980s, the number of NHS hospital beds has reduced and care within hospitals now focuses on a more acute/curative role. The attitude of too many healthcare professionals appears to be that they are seen as having failed if a patient dies. Too much emphasis is placed on freeing beds and patients being discharged without necessarily checking that all the needs, care and requirements of that patient have been addressed, and that these needs can be met adequately in the place to which they are being discharged, be it in their own home, or a short- or long-term residential placement. The higher numbers of re-admissions following discharge are proof of this.

Nobody would argue that emergency treatment and care within the NHS is second to none. Advances in the treatment of many conditions have moved on dramatically and age is not now used as a determinant of treatment as it once was. However, while we are seeing many of our older people living longer, healthier lives, for some we are seeing increasingly complex issues of deteriorating physical and mental frailty. We need to be prepared for this, as the care of older people demands such a broad range of skills and expertise.

Time, consideration - and yes, money - must be made available for the ever-increasing numbers of older patients with long-term, complex co-morbidities who are being admitted to our hospitals. What are the priorities when a 75-year-old widow with diabetes and chronic leg ulcers, who is deaf and blind, has been admitted as an emergency, having been found by her carer on the floor complaining of abdominal pain? Of course, finding the cause of her abdominal pain is paramount, but all of her other conditions and issues should be addressed so that her plan of care can be a holistic one, where all her needs can be met, ensuring a positive, safe and successful discharge back home.

Compare this to a care home with or without nursing. This 'type' of resident is seen routinely in our homes. Our staff need to have knowledge and training in all of these conditions and many, many more. Where we consider admitting a resident with a condition or disease of which staff do not have specific experience, we will make sure that appropriate training is found and given before that person is even admitted. A comprehensive and thorough pre-admission assessment is always undertaken to ensure that the home has as much information as possible about the prospective resident.

Staff in good care homes get to know their residents and find out what is important to them physically, mentally, socially and spiritually. They talk and listen to them and to their families; they complete comprehensive life-story books and they write advance care plans, where residents' wishes and preferences, especially at the end of life, are discussed and documented. Similarly, should a resident require hospitalisation, a comprehensive transfer document with all relevant information about that resident will be sent into hospital with them, to give as much information about the resident as possible to the admitting staff.

Unfortunately, I witnessed the lack of care, respect and dignity given to older people when they have had to be hospitalised. Discharges to our care homes late on a Friday evening are not uncommon, despite our best efforts to avoid them. Homes may often only have two members of staff on duty at night. Our GPs are not accessible and if a crisis should occur, staff are often advised to dial 999 by the out-of-hours services. We often receive scant or no information on discharge papers and medication is often incorrect or not sent at all. I have been challenged on several occasions by hospital discharge co-ordinators when I have refused to admit a resident late on a Friday afternoon. Hospitals are under immense pressure to free up beds, but discharging a patient under these circumstances is often a recipe for disaster, and can result in distress for the resident and staff, and sometimes an inappropriate readmission to hospital within days of being admitted to the care home.

Among many articles debating Ann Abraham's report was an interesting blog from Malcolm Payne at St Christopher's Hospice (http://blogs.stchristophers.org.uk/one/). He made the salient point that the report was not just about the lack of care and compassion for older people, but also about the lack of good end-of-life care in the NHS. It is true that in few of the cases highlighted were end-of-life discussions held with either the patient or their family by the healthcare professionals. Time was not spent in giving information or realistic advice and support to these patients or their families. Instead they were left with feelings of 'mistrust', being 'let down by the system' and 'a lack of concern and sympathy' for both the patient and their family.

All nurses and carers should be trained in understanding the diverse needs of the older person. While some 90 and 100 year olds are completely independent both physically and mentally, needing minimal assistance and care, they are often treated as if they require it. Conversely, a 70-year-old person may have complex needs that require a lot of support, for example, with feeding, washing and dressing and pressure area care. Perhaps this is where issues of neglect come into play. We are not looking at our patients/residents in a person-centred, holistic way but as a stereotypical 'older person'. Attending to the 'basics', such as personal hygiene, nutrition and hydration are pivotal aspects of care that these days are often
overlooked.

The charity Friends of the Elderly has nearly 500 residential care beds across 14 homes and also works in the community, providing support including grant giving, telephone-befriending, one-to-one support for people in their own homes and day club services.

At Friends of the Elderly money was invested in putting all its care homes through the Gold Standards Framework (GSF) End-of-life Care Programme. This has not only improved the quality of end-of-life care for residents, but has also encouraged staff to build on their relationships with their local community teams, comprising district nurses, specialist palliative care teams and community matrons.

Trust and confidence in the care that staff can deliver from external professionals, as well as the residents and their families, has significantly reduced 'crisis' admissions to hospital and enabled many residents to be cared for in the place of their choice until they die. In many hospitals implementation of the GSF programme has been attempted but success rates are low in fully achieving the aims of the GSF programme.

Conclusion
A lot can be learned from the residential care home sector. Its has areas of weakness, with homes that are poorly performing and under scrutiny by the Commission for Quality Care, but also some fantastic success stories.

We need to go back and remind ourselves why we are working in the health and social care sector. Seeing our patients as they are, listening to them, hearing what they are saying and passing that information onto others is vital to enable us to meet the needs of this undervalued sector of our community. Remember that before the complaints even reached Ann Abraham's desk, all the families felt that their complaint had not been resolved sufficiently by their relevant NHS trust. That complaints of such magnitude were not taken seriously from the outset is unacceptable.

We need to rise to the challenge and work together, putting the older person at the heart of what we do. All staff must take the time to interact with those they support. We need to act in a person-centred manner and not just talk about it.

Reference
Parliamentary and Care Service Ombudsman. Care and Compassion? Report of the Health Service Ombudsman on ten investigations into NHS care of older people. London: The Stationery Office; 2011.