A new beginning for care for elderly people?BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7290.807 (Published 07 April 2001) Cite this as: BMJ 2001;322:807
Not if the psychopathology of this national service framework gets in the way
- John Grimley Evans, professor of clinical geratology,
- Raymond C Tallis, professor of geriatric medicine
The National Service Framework for Older People,1 discussed in last week's news,2 displays a personality split between its ERG and its IG. An external reference group (ERG) of selected experts offered advice,3 but the framework was written by an “in group” (IG) of civil servants. The IG subserves a political agenda, and that agenda, unchanged over 50 years, is to keep old people out of hospital.
IGians believe that care in proper hospitals is too expensive for old people. This partly reflects a preoccupation with cost per institutional day (money that might be saved by closing something down) rather than with cost per satisfied patient (money properly invested). But savings from putting old people in cheap, ill resourced accommodation are rapidly lost in unnecessarily prolonged lengths of stay, not to mention human misery. IGian fantasies are fed by studies of “inappropriate” use of hospital beds by older people. The definition of inappropriate is contentious, and the term is too readily attached to the patient rather than the treatment. Certainly some older people stay in hospital longer than they want because of the complexities and underfunding of social service care. There are probably many more old people, invisible to IGian research, who would benefit from acute hospital admissions that they are denied. The clearest expression of the IG agenda is the framework's performance indicator, that demands an annual increase in acute admission rates for people aged over 75 of less than 2%. No evidence is offered to suggest that this percentage will match clinical need. The proposal is institutionalised ageism and effectively betrays IGian moralising against ageism as cant.
The IG seems to misunderstand the logic of medical science. Meta-analyses are not the highest form of evidence in health services research; that position is held by systematic observation of what happens in real life if the proposals generated by research are implemented. It is not enough that a service ought to work, or did so in Orpington, if in practice, or in Slagthorpe, it fails or is irrelevant. The framework demands the creation of a falls service in every centre but without any requirement for local evaluation to see if it works—at least until 2003, when the “achievements” of the service will be documented by means yet to be devised. This reveals a lack of concern for the real world of health care. The opportunity costs of redeploying staff from whatever is now filling their time will vary from place to place. The benefits from replicating service structures developed for a randomised controlled trial will also vary from place to place, not least because of variability in what else is happening locally.
To meet this problem, a topic working group of the central research and development committee, commissioned to recommend priorities for NHS research relevant to the ageing population,3 called for the creation of a development and implementation network of trusts and practitioners. Before new services became imposed as national policy, participants would evaluate them in typical NHS settings; this would inform managers on the real world variance in cost effectiveness. In the framework's plans for research, this sensible and modernising proposal has been ignored in favour of a purely advisory network, thereby showing, with insouciant irony, the respect civil servants pay to advice.
Similar concern is aroused by the framework's espousal, again driven by preoccupation with preventing old people from occupying hospital beds, of various hospital at home schemes, despite the variability in costs, acceptability, and effectiveness shown in published trials.
But probably the most worrying feature of the framework is its proposals for developments in intermediate care. An extra 5000 intermediate care beds are to be created. The spirits of geriatricians with long memories will droop. In the 1960s there were many intermediate care beds outside acute hospitals, into which “bed blocking” old people were transferred in the hope that somehow they would disappear from the system. Geriatricians of those days spent their lives getting such beds closed and their staff resources transferred to acute hospitals to provide the specialist rehabilitative care that older people need to get safely and expeditiously home. Specialist geriatric rehabilitation units are crucial elements of comprehensive acute hospital services but are expensive. In medical care, as in anything else, you get what you pay for. It is convenient for managers to confuse convalescence (spontaneous recovery) with the more expensive rehabilitation that is necessary to make non-spontaneous recovery happen. Those geriatricians who have contrived to defend specialist rehabilitation units against the cutbacks of the past 20 years may now have to fight to prevent their being downgraded to intermediate care. Indeed, managers may seek to close rehabilitation units to free money for purchasing intermediate care beds in private sector nursing homes. Those “extra” beds will have to come from somewhere.
Worse yet is the implication, for which the text acknowledges there is no justifying evidence, that older patients could be sent directly to intermediate care, bypassing the skilled diagnostic evaluation that the complexities of disease and disability in old age require.4 This must not be allowed to happen, at least until the unconvincing and overbureaucratic proposals for a single assessment process have been properly evaluated as adequate for the purpose.
But geriatricians are professional optimists, and the ERG has put some good things in the framework. The proposals for hospital geriatric services will encourage any laggard trust where such services are not already in place. The framework gives clear and robust guidelines for the treatment and prevention of stroke, and its performance indicators will capture important elements of good care. Many deaths and much disability will be prevented if the guidance is matched by resources. The proposals for mental health follow conventional wisdom, and an increase in surgical interventions to reduce disability will be welcome.
The danger from the framework's split personality will lie in deceptive implementation. Clinicians will enthusiastically endorse the ERG's good intentions, but the managerial caste will follow the IG agenda. Best hope would come from the general public and its older people taking a more informed and active interest in their own welfare. This would need the Iron Curtain on NHS information, created by the internal market, to be lifted. Trusts should be required to make their operational data available to public scrutiny. People could then judge for themselves whether they are the victims of ageist practice. Practice is substance, policy mere spin. There is no public access to unspun data in the framework's recommendations for information in the NHS. Whatever happened to open government?