Community institutional care for frail elderly people

BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7133.780a (Published 07 March 1998) Cite this as: BMJ 1998;316:780

“Unitary care” homes might be the answer

  1. William R Primrose, Consultant physician
  1. Department of Medicine for the Elderly, Woodend Hospital, Aberdeen AB15 6LS
  2. St Margaret's Hospital, Swindon SN3 4QP

    EDITOR—Black and Bowman rightly emphasise the importance of preadmission assessment and ongoing medical supervision in caring for frail elderly people.1 Current practice in many areas does not provide for formal specialist input at the time of admission and undoubtedly some older people are moving into homes prematurely. The pressure to clear beds leads to inadequate opportunities for rehabilitation and the possibility of missing remediable disease. Furthermore, the balance of local provision between residential and nursing homes may encourage misplacement in both directions. A recent survey of new admissions to nursing homes noted that 23% of residents funded by the local authority, when independently assessed, were not dependent on nursing.2 These people seemed more suited to a residential environment, and some could possibly have stayed in their own homes given sufficient time, rehabilitation, and community support.

    A more radical suggestion about the overlapping nature of residential and nursing institutional provision would be to move towards a “unitary care” home, with a dependency matched scale of charges. Closer integration of health and social work provision has long been advocated and would allow many anomalies to be resolved. Joint ownership of the issues would lead to responsible and responsive organisation of services rather than the present buckpassing and lack of coordination, which often reflects funding shortfalls and the absence of realistic resource transfers.

    With regard to the provision of continuing care for most frail elderly people, the lack of mention of ongoing NHS responsibility for those requiring specialist care was surprising. Some health authorities have not clearly recognised their obligation to provide continuing NHS care for those too complex for the primary care and nursing home sector. Recent guidance is definitive, though the scale of such provision is not specified. However, the need for increased support for both nursing homes and primary care is long overdue. Black and Bowman's third and fourth options may be similar in practical terms, and both should be explored further as a matter of urgency. To provide good care for this complex population requires investment by both primary and secondary care and the development of closer working relationships. More doctors should be encouraged to take the diploma of geriatric medicine, and the training programmes for specialist registrars must cover the competencies relating to continuing care of elderly people. The speciality risks having to rediscover itself if these issues are not addressed soon.


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    A multidisciplinary, multiagency approach should be the rule

    1. D Mukherjee, Consultant geriatrician,
    2. Helen Newton, Consultant geriatrician,
    3. David Howard, Consultant geriatrician
    1. Department of Medicine for the Elderly, Woodend Hospital, Aberdeen AB15 6LS
    2. St Margaret's Hospital, Swindon SN3 4QP

      EDITOR—While welcoming Frank Dobson's call for social services to fund placements for elderly hospital patients, 1 2 we are concerned about the potential for indiscriminate and inappropriate transfer of frail elderly people out of hospital.

      Like many trusts we face the problem that social services are unable to fund appropriate nursing home placement while accepting liability. The inevitable consequences are prolonged, inappropriate hospital stay; bed blocking; and cancellation of elective surgery. As a trust we have experience of using nursing home beds in an emergency and as a planned procedure. In an emergency, when selection is by departments unaccustomed to assessment of complex medical and social risks, inappropriate placement can ensue, with surgically fit but medically ill patients requiring readmission at a later date.

      We recently piloted a scheme in which geriatricians screened and selected inpatients. These patients were placed in nursing homes but remained the responsibility of the trust both clinically and financially. The scheme ensured that only patients who were medically stable and who had had appropriate hospital based rehabilitation were moved. Continuation of multidisciplinary input was ensured by a team of therapists and specialist nurses. Of more than 420 patients transferred to nursing homes, 102 (24%) required social services funding for continuing care. The remainder went home with care packages. The main obstacle to discharge from trust care was the excessive time patients spent waiting for previously agreed funding from social services.

      What is needed is a joint strategy of care so that elderly people can get the medical care and rehabilitation they need in accessible locations. A multidisciplinary, multiagency approach should be the rule, and the lead responsibility for care management should be mutually agreed between the agencies concerned for each person. Black and Bowman's article is a welcome addition to the debate on whether commissioning is to be within a national framework or to develop according to local pressures.3 In our experience, indiscriminate transfer has been ineffective and has caused dissatisfaction. Dobson's support for the process of discharge and assumption of responsibility by social services is welcome, but hospitals must ensure that the right people are sent and that they are able to share in ongoing care when necessary. The role of the geriatrician as advocate and ongoing support to frail elderly people is paramount. Elderly people have complex problems, and forcing simplistic solutions risks failure to deliver appropriate care.


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