Letters

Long stay care and the NHS

BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7184.668 (Published 06 March 1999) Cite this as: BMJ 1999;318:668

Multidisciplinary assessment is needed

  1. W R Primrose, Consultant physician,
  2. B A Hamilton, Registrar,
  3. K T Muir, Lecturer
  1. Department of Medicine for the Elderly, Woodend Hospital, Aberdeen AB9 2YS
  2. Social Work Department, Robert Gordon University, Aberdeen AB10 1FR
  3. Information and Statistics Division, Common Services Agency, Edinburgh EH5 3SQ
  4. Social Work Department, West Dumbartonshire Council, Clydebank G81 1TG
  5. Greater Glasgow Health Board, Glasgow G3 8YU

    EDITOR—Long term care of frail elderly people remains neglected, as Turrell et al point out.1 A key factor in balancing demand, needs, and supply, and in the appropriate use of resources, has been the gatekeeping role of effective multidisciplinary assessment. In many areas the quality of this assessment has been undermined by the lack of a thorough medical review of older people.

    A recent joint audit involving social and health agencies looked into the assessment process over six months, for a base population of 26 000. Thirty three patients were identified as needing institutional care and requiring local authority finance. Only nine of 17 patients in the community had had any form of documented medical assessment, though this is viewed as mandatory by community care legislation.2 Opportunities for intervention and rehabilitation may well have been missed, and this small study supports the requirement for an independent specialist assessment to be a statutory part of the community care assessment, in addition to the information obtained from primary care.

    Many of the patients in this study did not wish to leave their homes, and the failure to assess their needs properly is a matter of concern. Over recent decades the age specific rate of institutionalisation has risen3; this can be reversed by improved assessment procedures, proper access to rehabilitation, and augmented home support.

    Turrell et al do not specifically mention the responsibilities of the NHS for long term care of people with specialist care needs.4 The population with complex care requirements that cannot be met in primary care settings is small, but these patients require protection and an appropriate environment and staffing. Most elderly people requiring institutional care can be well supported through the provision of independent, voluntary, and local authority residential and nursing homes, although the need for improvement in the quality of medical support is widely recognised.

    References

    Scottish Health Resource Utilisation Groups measure is helpful

    1. Gordon Brown, Information consultant,
    2. David Burke, Area manager,
    3. Helen Watson, Research assistant,
    4. Linda de Caestecker, Consultant in public health medicine,
    5. John Womersley (publichealth.gghb{at}dial.pipex.com), Consultant in public health medicine
    1. Department of Medicine for the Elderly, Woodend Hospital, Aberdeen AB9 2YS
    2. Social Work Department, Robert Gordon University, Aberdeen AB10 1FR
    3. Information and Statistics Division, Common Services Agency, Edinburgh EH5 3SQ
    4. Social Work Department, West Dumbartonshire Council, Clydebank G81 1TG
    5. Greater Glasgow Health Board, Glasgow G3 8YU

      EDITOR—Turrell et al describe the consequences of the lack of information in the United Kingdom about the health needs of older people in long stay homes.1 In Scotland a measure has been devised by a group comprising geriatricians, nurses, and staff of the Information and Statistics Division to provide a measure for describing the characteristics of elderly people in all forms of continuing care. This, the Scottish Health Resource Utilisation Groups measure, comprises three categories of care need and three of dependency.

      Care needs are described in terms of needs for special care, clinically complex treatments, and behaviour; dependency is described in terms of feeding, toileting, and transferring position. Supplementary information includes details of clinically complex conditions, continence, visual and hearing impairment, and problems of communication for the resident. The method has also been developed to incorporate social care variables.

      Trained interviewers obtain data from care staff who know the residents well. These staff are asked to provide a profile of each resident based on observations over the previous seven days. Responses are scored, which takes roughly 90 minutes for 20 residents. Individuals are grouped into small numbers of care categories, which are each described in terms that would be readily understood by care professionals—for example, “has behavioural difficulties and low dependency.” Reliability testing shows satisfactory test-retest characteristics. Development studies show that the resource costs of each of the categories has a range of nearly three from the highest to the lowest.

      The categories of the Scottish Health Resource Utilisation Groups provide a relatively cheap method of estimating resource use. They also provide a basis for dialogue about the nature and quantity of services provided, including unmet need and changes over time. The measure is evolving with experience, although it is important to maintain a constant core dataset to analyse changes over time. At present the measure is used in 86% of NHS continuing care beds and in increasing numbers of nursing and residential homes in Scotland. In addition, the Information and Statistics Division is piloting an admission and discharge record for residents of nursing homes that is similar to hospital based information. This is completed by nursing home staff and provides demographic data, funding source, whether admitted from home or hospital, outcome, and length of stay. The two datasets could ultimately be linked.

      References

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