Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Choice is even more restricted for the elderly mentally ill
- David G Wilkinson (2 January 2004)
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Re: Choice is even more restricted for the elderly
- Gwen M Harlow (2 January 2004)
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Real or Distorted Choices for the Elderly
- John J Turner (2 January 2004)
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Premature Gloom
- Clive H. Smee (5 January 2004)
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Telecare and the new community care regulations
- James Barlow, Steffen Bayer and Richard Curry (5 January 2004)
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Community Care (Delayed Discharges) Act - Psychiatric Patients Specifically Excluded
- Gillian E Moss (7 January 2004)
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Choice - what choice for people with Huntington's Disease?
- Sandra D Lawton (9 January 2004)
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Payment by Results
- Robert Dredge (13 January 2004)
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Consequences to the NHS and Social Services of patients admitted into secondary care in less than ideal circumstances.
- Moyez Jiwa, Moyez Jiwa (13 January 2004)
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Choice and Responsiveness for Older People?
- William R Primrose, D. Gwyn Seymour and Susan E Campbell (20 January 2004)
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David G Wilkinson, Consultant in Old Age Psychiatry Moorgreen Hospital, Southampton SO30 3JB
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Rowland and Pollock should be commended for highlighting another of the inequities of the NHS 'plan', with its emphasis on acute hospital waiting and admission times to the exclusion of all else, and the consequent impact this will have on the elderly frail and chronically sick. One extra brickbat is that Elderly Mental Health beds will not be included in the delayed discharge legislation as they are not considered acute, though how one cannot regard beds which are needed to admit patients sectioned under the mental health Act as acute beggars belief. This exemption could, on the one hand, be seen as a recognition of the need for the careful and often complex community care arrangements in such patients. However, social workers,who are already unable to provide the care packages they need to discharge these patients from the 'acute' hospitals, once subject to fines for the delays, will inevitably see our patients with depression or dementia for whom they will not be fined with even lower priority than they do now.The staggering delays we already see will lengthen further with all the knock on effects that will have on the acute services. We already see patients being inapropriately admitted and languishing in acute wards unable to be discharged or transferred to suitable therapeutic environments due to lack of investment, some of which is spent on devising ever more inventive ways of manipulating waiting lists. The situation will not improve for this group of patients whose choice is already lamentable and will become even more restricted once this legislation is enacted. Competing interests: None declared |
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Gwen M Harlow, N/A N/A
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I wonder, whether this new regulation can be compatible with the (also new) "Fair For All, Personal to You" initiative, which is designed to promote patient choice of treatment location and so on? Competing interests: None declared |
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John J Turner, Consultant Physician University Hospital Aintree, Liverpool L9 7AL
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In a fashion all too typical of this administration we are seeing another 'let's get tough' approach with the introduction of penalties / fines for perceived breaches of new government targets. Pollock and Rowland rightly express concern. The combination of falling care home places, failure to implement a proclaimed increase in acute hospital beds in medical specialties or achieve the targets for intermediate care is going to prove a volatile and possibly explosive combination. Change is certainly needed and it is true that for too long Social Service Departments have been allowed to get away with poor response times while elderly patients are kept in inappropriate and often substandard hopital accommodation Up to 50% of designated rehabilitation beds are in effect community placement beds with around half of these relating to Dementia and mental health problems under the umbrella of Cinderella rehabilitation services. The discharging of older patients is being pushed in an increasingly aggressive manner to meet new targets some of which are based on flawed and dangerous comparisons with for example the Kaiser Permanante U.S. system. Standards of care for the elderly will be caught up in fierce budgetary battles between acute Trusts and social Services with many choices becoming an illusory lip service to the consumerism banner of the government. Competing interests: None declared |
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Clive H. Smee, Principal Advisor The Treasury, PO Box 3724, Wellington, New Zealand
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Rowland and Pollock's claim that the NHS Plan's target increase in general and acute beds and intermediate care beds "has not been achieved" sems a little premature. The target relates to 2004 but the latest data relates to 2002-3. In the three years to 20002-3 general and acute beds increased by 1,599 and intermediate care beds increased by 3,165, or respectively by two-thirds and three-fifths of the plan target.(See Department of Health. Hospital Episode Statistics. www.doh.uk/hes ) The UK government deserves praise for making progress in the target direction. It will be another year before judgements can be made about how fully the target has been met. Competing interests: None declared |
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James Barlow, Chair in Technology & Innovation Management Imperial College London. Business School, Steffen Bayer and Richard Curry
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Rowland and Pollock’s editorial presents part of the story. Telecare – the use of information and communications technology (ICT) to reduce the risks of home-based care – is widely seen as having potential to reduce delayed discharges and improve patient choice over the location of their care. It is possible to imagine a model whereby telecare forms an element of an individual’s care package, along with domiciliary and home nursing care, conventional assistive technology and home adaptations, and medication and therapy. It is not well known that the government has set ambitious targets for the widespread introduction of telecare by December 2010. Rowland and Pollock note that the £100m per year allocation to pay reimbursement costs resulting from delayed discharges ‘underestimates the underfunding and current lack of capacity in the community care sector’. This sum needs to be seen in the context of possible investment in telecare. In February 2003 the Government made available £133.4m to support home and intermediate care via the Integrating Community Equipment Service (ICES) initiative. In addition, intermediate care and extra care housing is being expanded – for example, the Department of Health is making available £87m to be spent within 2004-06 to provide an additional 1,500 Extra Care places. Funding for telecare should also be available under the Integrated Care Record System (ICRS) and the Office of the Deputy Prime Minister’s Supporting People initiative. So far telecare has been limited to a small number of pilot and demonstration schemes, but these suggest that it may have substantial benefits in reducing capacity constraints in the care system. However, these benefits can only be reaped if the discharge regulations allow the relationship between the acute sector and social and housing services to develop in a constructive way. A benchmark of two days, after which fines have to be paid by social services in individual cases, ignores the whole system nature of the health and social care system. For complex individualised care packages including telecare, even if the technology installation is straightforward, the short time period is not realistic. Regulations which give incentives to reduce the average discharge time, instead of focusing on the time for individual cases, are far more likely to reduce delayed discharges and provide appropriate care to patients than the proposed system. Under such a regime telecare could maximise its potential. There are major challenges in meeting the telecare implementation targets, partly because there is no clear responsibility for telecare. In particular, there need to be clearer links with the ICRS and ICES (Integrating Community Equipment Service) initiatives. Clear funding lines and specific budgets for telecare still need to be established and business models which embrace health, social services and housing departments will have to be agreed. However, the potential for using ICT to help support a modernised, consumer-focused care delivery model is greater now than at any time. Competing interests: None declared |
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Gillian E Moss, Consultant in Old Age Psychiatry Meadowbrook, Stott Lane,Salford M6 8DD
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Rowlands and Pollock highlight eloquently many of the problems and inequities to which this legislation may lead. They do not mention that inpatients under the care of a psychiatrist have been specifically excluded, although most psychiatric inpatients are also occupying acute beds which in many places are in very short supply. My service has always had an excellent working relationship with the local Social Services Department and my experience has been that delayed discharges normally have been due to manpower and resource shortages and not laziness or incompetence. It seems now that individuals will have to be prioritised for the provision of services for financial reasons and not on the basis of need. People living in the community will become a lower priority with psychiatric inpatients the lowest priority of all. The Government does not appear to regard the blocking of psychiatric acute beds as a problem. This legislation may also be counterproductive to multi-agency working as inevitably resentment will build up when mental health teams see their patients marginalised in favour of general hospital inpatients. Old Age Psychiatrists may understandably think twice before transferring patients from medical/surgical beds to psychiatric assessment beds knowing their social care will be prioritised if they stay where they are. This is likely to lead to admissions to residential/nursing home care for people who may have been rehabillitated to home given more time and appropriate multi-disciplinary and multi-agency assessment and treatment. Competing interests: None declared |
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Sandra D Lawton, Self Employed - MSc in Disability Studies SO31 7GQ
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David Wilkinson reports that with the new planned legislation, choice for the elderly mentally ill will become even more restricted. This will also be the case for those with Huntington’s Disease, an illness that has complex physical needs often complicated by accompanying mental health needs. There is already little or no choice of nursing home placements for people with this disease leading to an inordinate amount of pressure to accept care home placements hundreds of miles away from their families and friends. Suggesting initial placements will be interim, until alternatives are found, totally ignores the reality of the situation. These placements just don’t exist, certainly for a person with this disease. During my recent research it was overwhelmingly stated, by carers, that there are few or no nursing home placements for a person with Huntington’s Disease. “As soon as you mention the word Huntington’s ……………either they were full up or they didn’t have the staff or the expertise or they just didn’t want to be involved” “There aren’t any nursing homes, there aren’t any places that take people with Huntington’s Disease.” According to Priestly (1999) the White Paper for Community Care, emphasised by contracting services out to private, voluntary and not for profit organisations, consumers would have choice. It appears that the people who have choice are the providers. They continually exercise their choice to say ‘NO!’ Where does that leave the consumer? The situation for these people and their families will continue to deteriorate until there is acknowledgement of the true situation. There just aren't sufficient or appropriate placements available and further investment is the only answer. Competing interests: None declared |
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Robert Dredge, Programme Manager for Financial Reforms Department of Health SW1A 2NS
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Dear Sir I have read the recent article by Professor Allyson Pollock. I believe that some of the interpretations on the details and impact of the Payment by Results initiative are inaccurate. I wonder if it would be helpful to produce a brief summary of the policy so that your readers would have a more balanced reference point for any further debates. If you think this has merit I would be happy to draft something. Robert Dredge
Competing interests: None declared |
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Moyez Jiwa, Lead Research Fellow Univ of Sheffield, Institute of General Practice, Community Sciences Centre, NGH. Sheffield. S5 7AU, Moyez Jiwa
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We welcome Rowland and Pollock’s editorial and reflect on the consequences to the NHS and social services of patients admitted into secondary care in less than ideal circumstances. The editorial paints a rather bleak picture of what happens after the horse has bolted. In primary care we recognise such patients tottering on the brink of coping with chronic illness, increasing frailty and confusion. In an increasingly mobile society many have no significant others to offer support in precarious circumstances. We agree that choice for such patients is now presented as an obstacle to the efficient functioning of the system that purports to protect them from destitution. Our team recently reported a study seeking to identify such patients in primary care and to offer them additional support over the winter months in particular. The data suggests that it is possible to identify such patients and work proactively to reduce the potentially for admission to hospital and an uncertain future. However such effort requires a concerted effort on the part of the primary health care team. It requires visits, calls and interventions, which are welcomed even if not explicitly sought. Despite having busy lives few of us wish to see our older relatives become a burden to the state. Our experience is that the involvement of an interested primary care team expressing concern is often enough to move relatives to act when action is required. In New Zealand substantial family input is reported to lighten the GP’s load by reducing the need to resolve social issues. In the UK it appears that Health Care professionals must take the initiative but we observe that when they do the family isn’t far behind. Dr. Moyez Jiwa. Lead Research Fellow. University of Sheffield References: 1.Rowland DR, Pollock AM. Choice and responsiveness for older people in the “patient centred” NHS. BMJ 2004; 328: 4-5. 2.Jiwa M, Gerrish K, Gibson A, Scott H. Preventing avoidable hospital admission of older people. Br J Community Nurs. 2002 Aug;7(8):426-31. 3.Jones P. Elderly at home- lessons from New Zealand. Health and Ageing. Dec 2003; 22. Competing interests: None declared |
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William R Primrose, Consultant physician Department of Medicine for the Elderly,Woodend Hospital ,Aberdeen, AB15 6XS, D. Gwyn Seymour and Susan E Campbell
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Choice and Responsiveness for Older People? Your recent editorial raises many worrying points relating to the welfare of older people, and especially the most vulnerable and frail requiring care in acute hospitals.1 Demography, amongst other factors, will dictate an increasing need for such care.2 The pressure to discharge from acute facilities, with the crude leverage of average lengths of stay and fines is likely to lead to quite inappropriate practice. Older people, especially those in their eighties and beyond, are a most heterogeneous group, with functional impairment and cognitive capacity having the most importance in relation to outcome and lengths of stay. As part of a large international study into the relevance of case-mix and outcome for older patients admitted to medical care 3,we present some local data of interest . On the third day of their hospital admission, we assessed 200 patients aged 65 years and over admitted urgently for medical problems. Mean age was 80.3 years and 64.5% of patients were female. Patient status was thereafter assessed every 7 days. Excluding 17 patients who died during their hospital stay, 74 (40%) were still in hospital on day 17. Of these 74 patients, 30 were undergoing rehabilitation, 33 were requiring an acute medical setting, 7 were awaiting social care arrangements before going home and 4 were waiting for alternative accommodation. By day 45, all but 25 patients had been discharged, and of these 7 were still undergoing active treatment and 6 were needing in-hospital rehabilitation. One of the 25 patients was awaiting long-stay hospital care and 11 were recorded as delayed discharges due to unavailable social services provision , giving a rate of 5.5% ,- with 4 patients awaiting arrangements to go home and 7 alternative accommodation. While not underestimating the undesirability of delayed discharges for these 11 individuals, our study underlines the importance of allowing older patients the necessary time to recover and rehabilitate, with some requiring prolonged stays prior to a successful return to the community. Rehabilitation may be integrated alongside acute care facilities, or in suitable step down arrangements – but all such resources should be properly equipped and staffed with an appropriate level of medical, nursing and allied health professional support. Artificially accelerated discharge arrangements are most unlikely to benefit the older patient needing the time and appropriate environment to optimise their recovery and enable a return home, the objective of most. Legal challenge is quite likely to arise in those proving to be disadvantaged by such legislation, and we would hope that reflection on some of these proposals will amend the guidance. Yours sincerely W R Primrose D G Seymour S E Campbell References 1.Rowland D R, Pollock A M, Choice and responsiveness in older people in the “patient centred” NHS. BMJ 2004; 328: 4-5. (3 January) 2. Wood R, Bain M. The Health and Well-being of Older People in Scotland. Insights from national data. Information and Statistics Division. Edinburgh: Common Services Agency for NHSScotland, 2001. 3.ACMEplus Website, www.abdn.ac.uk/acmeplus/. Competing interests: DGS was the lead grant holder for the EU funded ACMEplus project |
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