Discharges from nursing homes

EDITOR, - In suggesting that their survey of discharges from nursing homes refutes the view that the NHS has become a dumping ground for increasingly dependent residents of such homes Jennifer M Henry and colleagues, perhaps accidentally, encourage policymakers and health commissioners to be complacent.1 The inadequacies of medical care for residents of nursing homes, with proved opportunities for treatment being missed, have been documented.2

The authors found that a quarter of residents were discharged to the community but do not state whether admission to a nursing home was appropriate. Planned respite care and intervention for domestic crises are justified, but how many residents were admitted because of medical problems instead of being referred to health services? A high death rate is to be expected among elderly people in nursing homes, but some uncertainty regarding the timeliness and nature of death must exist, especially when about a quarter of discharges are to the community and half are because of death.

My interpretation of the survey is that it supports the view that residents of nursing homes constitute a dynamic population in which much change, currently not supervised, occurs. A preliminary audit of admissions to my hospital from nursing homes suggests that people with an acute illness such as infection are referred to hospital, where treatment is frequently straightforward (and within the capability of many nursing homes), with medical advice and supervision. Admissions from nursing homes of people with remediable chronic conditions are uncommon; I presume that this is because the conditions are dismissed as acceptable deterioration related to age. I am concerned that some homes, fearful of acquiring a reputation of not coping or of “dumping” their problems, increase care rather than seek help, promoting dependency and morbidity.

The issue of high dependency care in the community and the appropriate use of health services is inadequately defined. A confidential inquiry into deaths in nursing homes similar to those into perinatal and postoperative deaths could initiate a greater understanding. This sounds ominous but is probably preferable to an increasing spiral of litigation and scandal. The individuality of residents in long term care makes audit of care difficult, while a review of care after death offers at least an indisputable outcome.