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EDITORIALS: Marion E T McMurdo and Miles D Witham Health and welfare of older people in care homes BMJ 2007; 334: 913-914 [Full text]

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Primary Care's role in the health & welfare of older people in care homes

Gillie E Evans   (8 May 2007)

Important campaigns poorly served by misconceived editorial

Clive E Bowman   (8 May 2007)

Changing systems in residential care

Paul Whitby   (8 May 2007)

Legislation needed to ensure measurement of needs

Desmond O'Neill   (9 May 2007)

Better-targeted health care will ensure care home residents human rights and dignity

Jacqueline Morris, James Barrett, Win Tadd, Nadia Chambers,Philip Hurst, Judith Wardle, Adrian Wagg , John Gladman and Pamela Holmes   (9 May 2007)

There are young adults in care homes too

John Womersley   (9 May 2007)

My Home Life Programme

Julienne Elizabeth Meyer, Tom Owen, Belinda Dewar, Annie Stevenson   (11 May 2007)

Multidisciplinary Team Care is the Model for Care Home Medicine

Arnold G Zermansky, Gill Wittmann, Claire Standage, Liz Spooner.   (12 May 2007)

Primary Care's role in the health & welfare of older people in care homes 8 May 2007
Gillie E Evans, GP Jenner Health Centre, Whittlesey PE7 1EJ Send response to journal: Re: Primary Care's role in the health & welfare of older people in care homes	McMurdo & Witham have emphasised the role of secondary care in supporting primary care teams and care home staff in providing good quality care for older people in nursing & residential homes. As a GP with responsibility for 50 patients with dementia in a specialist nursing home, I would endorse the need for that support, but recognise that practical steps taken in primary care can have a major impact on the standard of care we offer to our patients. Seven years ago I presented an alternative to the reactive ("firefighting") approach to patients in care homes to my partners. Since that time we have taken personal responsibility for a care home each, managing the long term health issues of our patients and building constructive relationships with the staff and management at the 6 homes(& 142 patients) we look after. I visit "my" care home weekly, discussing patients with a fully briefed, supernumary member of staff, allowing for proactive planning of care as well as response to acute problems. Arising out of this has been realisation of the difficulties of providing good quality palliative care for patients with dementia. Discussion with the Palliative Care Consultant locally resulted in the formation, in 2005, of the Palliative Care in Dementia Group- a multidisciplinary group of interested health professionals drawn from primary and secondary care. With the expertise of the Group, and the willing involvement of nursing and care staff at the care home, we have introduced advanced care planning using the Gold Standards Framework, a pain assessment scale, an end of life pathway, syringe driver training and a monthly significant event meeting. Auditing the factors affecting emergency admissions of patients from care homes has also allowed me to challenge the approach of the local Out of Hours(OOH)provider. In particular, the "dial 999" response to an acute problem which resulted in 75% of patients being admitted without being visited & assessed OOH(the corresponding figure being 25% in GP hours) over a 12mth period from our six local care homes. I have also presented the GPs in Peterborough with the arguments in favour of a named GP from a committed Practice taking on responsibility for the care of all the patients in a particular care home. Historically in Peterborough, patients have not changed GP on entering a care home. This has resulted in Practices with small numbers of patients in as many as 17 different care homes across the city, and care homes consequently needing to liaise with up to 70 GPs in 17 different Practices. Arguably, this perpetuates the likelihood of the reactive approach to medical problems. It is my contention that patients need to be offered the choice of re-registering with a GP committed to the care of all patients in the home, but could choose to stay with their current GP if they so wished. This proposal is currently being formally considered by Peterborough PCT. Competing interests: None declared
Important campaigns poorly served by misconceived editorial 8 May 2007
Clive E Bowman, Medical Director BUPA Care Services,Bridge House, Outwood Lane, Horsforth, Leeds LS18 4UP Send response to journal: Re: Important campaigns poorly served by misconceived editorial	Sir, The editorial by Marion McMurdo and Miles Witham regarding the, Health and welfare of older people in care homes written largely to highlight the worthy campaigns mounted by Age Concern and the British Geriatric Society was misconceived, both with regard to two campaigns and the subsequent discussion. This disappointment was furthered by the BMJ’s perplexing choice of accompanying photograph that featured remarkably well looking, well dressed and I would venture to suggest well nourished older people patently enjoying civilised living who if they were in a care home clearly had chosen so to be rather than been “chosen” by circumstance. What was the message? Regarding Age Concern’s “Hungry to be heard” campaign (1) the editorial makes clear the campaign is targeting hospitals as indeed does Age Concern’s website so why include it in a piece on care homes? Surely it would have been better to discuss the difficulties of providing hospital care. The dignity campaign by the British Geriatrics Society, “Behind closed doors” (2) whilst not exclusive to hospital care is primarily targeting hospitals and sets standards that are no more and in some ways less than those expected by care home providers as well as their regulators in England and Wales - as well as Scotland. The difficulties of securing basic medical support for care home residents should not be underestimated now in 2007 as 10 years ago when Black and I wrote the BMJ editorial, “Community Institutional Care for Frail Elderly People - Time to structure professional responsibility” (5). There are pockets of good practice but generally the picture is dismal. It is regrettably likely that this will remain the case until, in England and Wales the Healthcare Commission and NHS Quality Improvement Scotland, undertake focused investigations on the health needs and health service response to care home residents. Such investigations could reasonably be anticipated to report serious failures or at the least uncover “unmet need” that would initiate new commissioning criteria and consequent innovation in provision. May I commend to Professor McMurdo, Dr Witham and others interested, the initiative of Help the Aged and the National Care Forum of developing a programme entitled, “My Home Life” (6) not only does this engage with older people but provides a programme bringing together best practise that should contribute to a new confidence and understanding regarding living and care in homes. Sincerely Clive Bowman 1) Age Concern Hungry to be heard http://www.ageconcern.org.uk/AgeConcern/hungry2bheard_overview.asp# 2) http://www.bgs.org.uk/campaigns/dignity.htm 3) The health and care of older people in care homes a comprehensive interdisciplinary approach A report of a joint working party of the RCP London, RCN and BGS Royal College of Physicians of London July 2000 4) Bowman C Whistler J Ellerby M A national census of care home residents Age and Ageing 2004 33 561-566 5) Black D Bowman C, Community Institutional Care for Frail Elderly People -Time to structure professional responsibility BMJ 1997 315 441-442 6) Help the Aged My Home Life http://www.helptheaged.org.uk/NR/rdonlyres/885B4732-528F-432F-B9C2- 8E75C8011792/0/wd_myhomelife_050207.pdf Competing interests: Medical Director of BUPA Care Homes, member of the advisory board, "My Home Life"
Changing systems in residential care 8 May 2007
Paul Whitby, Clinical Psychologist Green Lane Hospital, Devizes SN10 5DS Send response to journal: Re: Changing systems in residential care	It is never a bad time to bring to mind the poor level of care that so many elderly people have to tolerate when they find themselves in residential care and McMurdo & Witham have done a fine job. The question is how to alter the institutional system that so often seems to work against the interests of the individual. Firstly, I believe we underestimate just how stressful it is for nurses and care assistants to provide intimate, personal care non-stop, day in day out, week after week. Unlike junior doctors, who also have this sort of stressful contact, these people are generally not on an upward career track. A measure of stressfulness of anything is how strongly it is avoided and staff turnover is an enormous problem in care of the elderly. There is also the more subtle emotional avoidance whereby interactions are carried out in a forced cheery manner which ensures everything is kept at a superficial level. Nurses simply are not provided with sufficient resources to take on all their patients' problems. Secondly, institutions are also good at saying they are promoting one thing whilst, unwittingly, doing another (Kerr 1975). Many care systems, including the NHS, appear to reinforce almost anything other than good quality direct patient care. Respect, attention, praise and even promotion flow from joining working groups, writing procedures, teaching, attending meetings and so on. Good quality care tends to get ignored or taken for granted. Westrum (2004) described three patterns of institutional culture, the bureaucratic (obsessed with rules), the pathological (obsessed with power) and the generative (obsessed with outcome, in our case this would be good patient care). Too few wards and homes that I know of could be called generative. Thirdly, when things go wrong in care institutions, as they often do, when professional codes and roles break down, there is little restraint on the rivalry and hostility that is potential in any situation involving two different groups of people (Hewstone, Rubin & Willis 2002; Zimbardo 2004). The route from empathy to indifference and then on to contempt, hostility and abuse is well understood. It is not all bad news. There are some shining examples of good practice in various areas of health care. For example, when I asked, Action on Elder Abuse were unable to find any reports of abuse or neglect from hospices in the UK. We desperately need to learn from these examples. We also require urgent investment at the Ward Sister, Matron, Head of Home level so that these people become the Clinical Heroes who can protect, inspire and lead their staff in the Sisyphean task of long term care of the elderly. References: Hewstone, M., Rubin, M. & Willis, H. (2002). Intergroup Bias. Annual Review of Psychology, 53, 575-604. Kerr, S. (1975). "On the Folly of Rewarding A, While Hoping for B." Academy of Management Journal, 18(4): 769-783. R Westrum (2004)A typology of organisational cultures Qual. Saf. Health Care, 13: ii22 - ii27. Zimbardo, P.G. (2004) A situationist perspective on the psychology of evil: understanding how good people are transformed into perpetrators. In A.G.Miller (ed.) The Social Psychology of Good and Evil. New York: Guilford Press. Competing interests: None declared
Legislation needed to ensure measurement of needs 9 May 2007
Desmond O'Neill, Associate Professor of Medical Gerontology Adelaide and Meath Hospital, Dublin 24, Ireland Send response to journal: Re: Legislation needed to ensure measurement of needs	Despite recurrent scandals, the ongoing problem of inadequate care of our most frail populations of older people - those in nursing homes - is evidence of a failure of our society to engage with the complexities of population ageing. This is seen in other sectors of health care (1), but is most visible in nursing homes, because of the high prevalence of disability (2) and a failure to either measure resident needs appropriately (3) or to provide for them. What is most shocking is the societal tolerance for care failures that would not be tolerated in surgical theatres or oncology units. A part of this arises from a misconception of what this care entails: indeed the phrase 'care home' as opposed to 'nursing home', while possibly well-meaning, conceals the need for complex care. A key element for change is the transparent and systematic measuring of resident needs, and in this the UK and Ireland have been slow to follow on the lead of the USA. After nursing home scandals over 20 years ago, it is a legal requirement that all nursing home residents must have a comprehensive electronic record of care needs, the Minimum Data Set (MDS), administered on admission, quarterly, and with any deterioration in status. The MDS collects assessment information on each resident's characteristics, activities of daily living, medical needs, mental status, therapy use, and other elements involved in comprehensive planning for resident care. The MDS is used to assess every resident in state-licensed facilities on admission, with a quarterly review and annual reassessment. Significant change in a resident's condition causes a new comprehensive MDS (including review of the care plan) to be completed to ensure the resident receives appropriate care. The MDS can serve as the basis of the primary clinical assessment tool for all residents within nursing facilities, as it is a comprehensive yet reasonably brief assessment. It can also be used to generate Resource Utilization Groups (RUG-III), effectively a case mix system which sets levels of dependency for a resident based on the functional support requirement and medical needs of each resident. So the MDS is clinically useful, reasonably brief, computerized, and fulfils four goals: it supports individual care plans, it can help generate dependency levels (through RUGS), it assists regulatory authorities and allows for the collection of meaningful statistics nationwide. Overall, it has been deemed to be successful by both nursing home staff and regulators (4) and is now used widely through the developed world. It is perhaps unique in its robust ability to support improved standards and research in nursing homes (5), although it will not do so on its own, and needs to be implemented in a context which recognizes the importance of appropriate philosophies of care, staff training and resourcing. Even more importantly, implementation of mandatory MDS reporting could highlight, and help to remedy, the yawning deficit between the funding needed, and the funding provided, for this complex and important provision of care. This was calculated to be £1 billion for UK nursing homes in 2002 (6), and is the source of much needless suffering for residents, staff and concerned professionals. References: 1) Walker A, Pearse J, Thurecht L, Harding A. Hospital admissions by socio- economic status: does the 'inverse care law' apply to older Australians? Aust N Z J Public Health. 2006;30:467-73. 2) Falconer M, O'Neill D. Profiling disability within nursing homes: a census- based approach. Age Ageing. 2007;36):209-13. 3) Worden A, Challis DJ, Pedersen I. The assessment of older people's needs in care homes. Aging Ment Health. 2006;10:549-57. 4) . Marek KD, Rantz MJ, Fagin CM, Krejci JW. OBRA '87: has it resulted in positive change in nursing homes? J Gerontol Nurs 1996;22(12):32-40. 5) Mor V. A comprehensive clinical assessment tool to inform policy and practice: applications of the minimum data set. Med Care 2004;42(4 Suppl):III50-9. 6) Laing W. Calculating a fair price for care: A toolkit for residential and nursing care costs. London: The Policy Press, 2002. Competing interests: None declared
Better-targeted health care will ensure care home residents human rights and dignity 9 May 2007
Jacqueline Morris, Chair of the British Geriatrics Society Policy Committee Marjory Warren House. 31 St John's Square. London EC1M 4DN, James Barrett, Win Tadd, Nadia Chambers,Philip Hurst, Judith Wardle, Adrian Wagg , John Gladman and Pamela Holmes Send response to journal: Re: Better-targeted health care will ensure care home residents human rights and dignity	We welcome the publication of Professor McMurdo and Dr Witham’s interesting editorial on Care Homes and the sentiment that Care staff should be supported rather than blamed for the lack of respect shown to residents. Our multi-agency campaign led by the British Geriatrics Society (BGS) chose toilet access and use behind closed doors as a marker of human rights and dignity (1). While we share their concerns we are of the opinion that they have underemphasised the major health and social issues, which arise from the lack of effective health support to care homes and thus threaten residents’ human rights and dignity. We agree that there has been inadequate shift of health care resources and that current health care provision to homes is not sufficiently targeted or skilled. The population in care homes has become increasingly frail and unwell. Many older residents have multiple medical problems and have often been prescribed multiple medications. Seventy per cent of residents suffer from Dementia (2) and 40% are thought to be depressed. People moving into Nursing homes have a median survival of 12 months in contrast with 24 months for those moving into to residential care (3). Both health and palliative care are often poorly organised in these settings and are associated with out of hours’ crises and resultant high anxiety and unpredictability for staff and residents. GPs and district nurses regard this work as additional to their normal workload (4). The lack of clarity around clinical leadership for care homes may result in GPs only visiting when called. Many older people are moved into care homes without a comprehensive geriatric assessment (5) or opportunity for rehabilitation. If discharged from hospital the accompanying discharge letter is usually brief and without an adequate advanced health care plan discussed with either the resident or their family. Older residents invariably have medical problems, which are complex. Failure to identify and treat reversible conditions may lead to a loss of dignity (1), progressive functional decline, urinary and faecal incontinence, sepsis, pain, malnutrition, (2) adverse drug reactions, pressure sores, behavioural problems and death. We therefore agree with Professor McMurdo and Dr Witham’s recommendation that specialist locality /secondary teams should be established to support the primary care team in line with the recent joint publication by the British Geriatrics Society and the Royal College of General Practitioners on the “Interface between primary and secondary medical care in the new NHS in England: the care of frail older people by GPs and consultant geriatricians” (6). The introduction of a nominated GP, regular visits, regular medication reviews and following proven protocols are easy processes to implement and will start the transformation of health care for the residents of care homes. Help the Aged’s publication “My Home Life”(7) sets the current scene in Care Homes. There is now a need for voluntary and professional organisations to work with Care Home providers and commissioners to plan an effective system for the future. 1. Behind Closed Doors http://www.bgs.org.uk/campaigns/dignity.htm 2. The National Council for Palliative Care: Exploring Palliative Care for People with Dementia. A discussion document : August 2006. 3. Andrew Bebbington, Pamela Brown, Robin Darton, Kathryn Miles, Ann Netten's Survey of Admissions to Residential and Nursing Home Care. 30 month follow-up April 1999. Discussion paper 1537. 3. Hungry to be heard http://www.ageconcern.org.uk/AgeConcern/ hungry2bheard_overview.asp 4. C. Goodman et al. Int J Palliative Nurs.2003 Dec; 9 (12) :521-7 District Nurse involvement in providing palliative care to older people in residential care homes 5. Comprehensive Assessment for the Older Frail patient in hospital: http:// www.bgs.org.uk/Publications/Compendium/compend_1-4.htm 6. The Interface between primary and secondary care in the new NHS in England http://www.bgs.org.uk/Publications/Compendium/ compend_4-14.htm. 7. My Home Life http://www.goldstandardsframework.nhs.uk/content/ care_homes/My%20Home%20Life%20Summary. Competing interests: None declared
There are young adults in care homes too 9 May 2007
John Womersley, retired consultant in public health Disability Information Greater Glasgow , Chapel street, G20 9BD Send response to journal: Re: There are young adults in care homes too	McMurdo and Witham emphasise that yet more legislation, regulation and standard setting is unlikely to be effective in improving the health and welfare of older people in care homes. We used Big Lottery funding to the NHS in Glasgow to establish a small multi-professional team to engage with managers, staff and residents in about a dozen care homes over a three-year period: to listen to and to observe at first hand their problems and experiences. Admission to a care home resulted in very diminished access to services compared with people in their own homes, including nurse specialists, specialists in rehabilitation, and specialist equipment. People provided with special beds and other equipment when living at home had to return these on admission to a care home. When specialists from the NHS did visit a resident they frequently excluded staff from discussions and left little information about their findings and recommendations: so these occasional visits were not used as learning opportunities for staff. Senior nurses were often too busy with paperwork, with no time to promote a learning culture or to give leadership. Care assistants did not feel that it was their responsibility to report concerns to their seniors, and if they did so they were rarely informed of the outcome. Continuing input of only a few hours per week to each home from a nurse specialist, physiotherapist and occupational therapist however made a very big difference: for example in promoting independence; encouraging enquiry; motivating and training staff; improving communication between staff at all levels; challenging ‘traditional’ practices; improving physical function and self-esteem; and involving care home staff in providing simple interventions between visits from professionals. We had a particular interest in young ‘physically’ disabled adult residents of care homes, of whom there are some 1000 in Scotland. In many respects these residents fare considerably worse than elderly residents - and many have 40 or even more years life expectancy ahead. Some had been admitted because of insufficient community care and support. The activities available were targeted to older peoples’ interests, with few having the opportunity to venture from the home on a regular basis. Few homes provided help for younger residents to gain skills to enable them to move on to community living. And it was not unusual for younger adults to be transferred from specialist rehabilitation facilities to a care home with no provision for their continuing rehabilitation. All care home residents should have the same access to specialists, to specialist equipment and to rehabilitation as people living in their own homes. However younger adults in care homes are a special case. Many should be living in supported accommodation in the community. Those who do require residential facilities need access to rehabilitation services and opportunities to live to their full potential – rather than being left to develop progressive reduction in mobility (even contractures), increasing dependency and social isolation. For how much longer can ignore the needs of these most vulnerable, isolated and unrepresented people be ignored? john.womersley@virgin.net Competing interests: None declared
My Home Life Programme 11 May 2007
Julienne Elizabeth Meyer, Director, My Home Life Programme Centre for Care Home Studies, City University, Philpot Street, London, E1 2EA, Tom Owen, Belinda Dewar, Annie Stevenson Send response to journal: Re: My Home Life Programme	Given that McMurdo and Witham suggest the way forward for improving the welfare of older people in care homes is through a non-blaming whole systems approach, I would like to draw the attention of your readers to a new initiative (My Home Life Programme – MHL) funded by BUPA and led by Help the Aged and National Care Forum (not-for-profit care homes), in collaboration with City University and a number of other key stakeholders including English Community Care Association (for-profit care homes), Commission for Social Care Inspection, Care Commission, Residents and Relatives Association, Skills for Care, National Association for Providers of Activities and National Care Homes Research and Development Forum. MHL is taking an Appreciative Inquiry approach (Reed, 2007) to work with the sector to share best practice in relation to quality of life for those living, dying, visiting and working in care homes, using a whole systems thinking. It is recognized that the most likely way to improve quality of life of older people in care homes is by increasing funding to the sector to allow for more competitive market, greater status, training and pay for staff, greater access and equity across the health and social care system in staffing, services and profile. Help the Aged is not in the position to control for these factors, but its continuing campaigning role can aim to influence this. The evidence-base underpinning My Home Life programme is provided by a review of the literature on best practice (NCHR&D Forum, 2007) that can be downloaded from the Help the Aged website (www.helptheaged.org.uk) along with an executive summary and short report (Owen et al., 2006). My Home Life is about growing a movement for change and trying to communicate a vision of practice to be owned and realised by the sector. Priorities include supporting a learning culture within care homes, fostering evidence -based relationship-centred care and promoting a positive identity for the care sector. In addition to developing a web- based learning network for care homes to share best practice and a number of educational resources; activities will include working with all the country-level regulatory bodies, training and skills agencies, commissioners and key policy influencing bodies to create awareness and buy-in to the My Home Life vision and evidence base. Readers wishing to learn more about or become involved with the MHL should contact Joanna.Edler@helptheaged.org.uk. References NCHR&D Forum (2007) My Home Life Programme: Quality of life in care homes for older people. Literature Review. Help the Aged, London. Owen, T and NCHR&D Forum (2006) My Home Life Programme: Quality of life in care homes for older people. Short Report. Help the Aged, London. Reed, J (2007) Appreciative Inquiry. Research for Change. Sage, London. Competing interests: None declared
Multidisciplinary Team Care is the Model for Care Home Medicine 12 May 2007
Arnold G Zermansky, General Practitioner Park Edge Practice, Asket Drive, Leeds LS14 1HX, Gill Wittmann, Claire Standage, Liz Spooner. Send response to journal: Re: Multidisciplinary Team Care is the Model for Care Home Medicine	McMurdo and Witham cannot be allowed to get away with their outrageous putdown of general practitioners’ craft and skills in their dismissive “Older people in care [homes] often have complex medical problems, YET their care is mostly provided by general practitioners” (our emphasis).1 We thought we had moved beyond the era in which professional skill was judged by tribal allegiance. Today’s general practitioners, geriatricians, psychogeriatricians, nurse practitioners, community psychiatric nurses, community matrons physiotherapists and clinical pharmacists are highly trained and usually highly motivated individuals with a broad range of clinical skills. There are shortcomings in clinical care received by care home residents, but we suggest that these reflect the huge resource deficit of their care rather than inappropriateness of the speciality of their doctors. Quality care needs a lot of time, and it is best to utilise the skills of the professionals appropriate to the nature of the problem. To imply that we might use geriatric specialists for all medical care of care home residents is naïve. Even if we did, what evidence is there that overworked geriatricians are any more effective than overworked general practitioners? Let us throw away our totems and adopt collaborative team care strategies that best utilise our diverse professional skills. Multidisciplinary proactive models such as our own are beginning to change the face of care home medicine – all that is required is for Primary Care Trusts to commission such services. Competing interests: The authors form the Care Homes for Elderly Extended Role Service (CHEERS) Team at Park Edge Practice.