Long term care of older people

BMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7035.862 (Published 06 April 1996) Cite this as: BMJ 1996;312:862
  1. Edward Dickinson
  1. Senior clinical research fellow Research unit Royal College of Physicians, London NW1 4LE

    Strategic management would stop people going too early to the wrong place

    Car manufacturers have responded radically to the challenge of global competition; they have revolutionised assembly through technology, just-in-time inventories, team working, and a focus on quality; they have optimised component supply by forging long term contracts based on mutual help and trust; they have introduced customer focus into relationships with car purchasers. This exemplifies how industry has recognised the need for effective strategic management when crisis looms. Why then, when Britain faces the unprecedented strategic challenge of the long term care of older people, is there increasing evidence of strategic drift? Two issues are of particular concern and may lead to increased costs: they are the poor assessment of eligibility of older people for long term care, and poor quality of care.

    Evidence of the present inadequacy of eligibility assessment in Britain is beginning to emerge.1 A recent audit report disclosed a disturbing level of inappropriate placement, even after poor documentation was allowed for;2 only 11% of nursing home residents were definitely appropriate for nursing home care, and 54% possibly appropriate; the rest were probably more suitable for home or residential care. The lifetime cost, estimated by the authors, is £42250 per misplaced resident.

    Social services are responsible for eligibility assessment and must take much of the blame. Assessment methods are neither standardised nor systematic. (The Joseph Rowntree Foundation has commissioned a study of existing methods to improve this.3) The audit also showed that documentation was poor, with the result that the knowledge base of the multidisciplinary team in health care of older people is not being properly deployed. There was no medical information in 40% of cases, no social information in 70%, no nursing information in 35%, no occupational therapy information in 93%, and no physiotherapy information in 90%.

    But social services should not take all the blame. Major responsibility lies within the secondary health care system, since most older people entering long term care come from acute hospitals - 82% in this audit.2 The growing focus on acute medicine is marginalising rehabilitation,4 5 despite evidence of its effectiveness.

    The second likely contributor to high costs is the poor quality of care; documented examples range from failure to preserve individuals' privacy, to inappropriate use of drugs and mismanagement of incontinence.2 8 Legislation and inspection, though a necessary protection, are unlikely to ensure high quality care. Other approaches, such as clinical audit which empower staffs,9 are now being introduced.

    The difficulties with assessing eligibility and ensuring quality indicate the urgent need for some form of strategic review. Strategic management, which aims to match up where you are, what you have, and what you want to do, could bring together disparate information, activities, and stakeholders. It might include several approaches. First, the strategic environment could be evaluated using tools such as PEST analysis (which looks at political, economic, social, and technological factors) and scenario modelling. International comparisons may be useful; in Australia no one enters long term care without seeing a geriatric assessment team; in Japan a 10 year “Gold Plan” is being implemented by the ministry of health and welfare to tackle the longevity revolution; in Norway the government's health board is developing a major investment plan in specialist health services for older people.

    A second approach would be to identify the resources that are available to optimise long term care. These might include the knowledge base (which is apparently not being properly used2), people and their skills, and funding.

    Thirdly, in considering the future of long term care, it would be necessary to understand the perspectives of stakeholders: consumers (older people of current and future generations and their families); providers (the long term care industry); purchasers (both social services and the insurance industry); the health service (primary and secondary); the research community; and government.

    This audit report tells a tale of perverse incentives, dysfunctional relationships, and inappropriate time horizons. If it is generalisable to the rest of Britain, there is a severe problem with the entry to nursing home care which has long term implications for individuals, organisations, the health of the population, and the national economy. If we continue to adopt what has been described as a “prosthetic” rather than a therapeutic approach to the long term care of older people,10 the consequences for future generations may well be devastating. There is a need for national strategic development to stop people going too early to the wrong place. Agreeing a better way forward would be appropriate before the international year of older persons in 1999.


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