Choice and responsiveness for older people in the “patient centred” NHS
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7430.4 (Published 01 January 2004) Cite this as: BMJ 2004;328:4
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We welcome Rowland and Pollock’s editorial and reflect on the
consequences to the NHS and social services of patients admitted into
secondary care in less than ideal circumstances. The editorial paints a
rather bleak picture of what happens after the horse has bolted. In
primary care we recognise such patients tottering on the brink of coping
with chronic illness, increasing frailty and confusion. In an increasingly
mobile society many have no significant others to offer support in
precarious circumstances. We agree that choice for such patients is now
presented as an obstacle to the efficient functioning of the system that
purports to protect them from destitution.
Our team recently reported a study seeking to identify such patients
in primary care and to offer them additional support over the winter
months in particular. The data suggests that it is possible to identify
such patients and work proactively to reduce the potentially for admission
to hospital and an uncertain future. However such effort requires a
concerted effort on the part of the primary health care team. It requires
visits, calls and interventions, which are welcomed even if not explicitly
sought. Despite having busy lives few of us wish to see our older
relatives become a burden to the state. Our experience is that the
involvement of an interested primary care team expressing concern is often
enough to move relatives to act when action is required. In New Zealand
substantial family input is reported to lighten the GP’s load by reducing
the need to resolve social issues. In the UK it appears that Health Care
professionals must take the initiative but we observe that when they do
the family isn’t far behind.
Dr. Moyez Jiwa.
Lead Research Fellow.
University of Sheffield
References:
1.Rowland DR, Pollock AM. Choice and responsiveness
for older people in the “patient centred” NHS.
BMJ 2004; 328: 4-5.
2.Jiwa M, Gerrish K, Gibson A, Scott H. Preventing avoidable hospital
admission of older people.
Br J Community Nurs. 2002 Aug;7(8):426-31.
3.Jones P. Elderly at home- lessons from New Zealand. Health and Ageing.
Dec 2003; 22.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir
I have read the recent article by Professor Allyson Pollock. I
believe that some of the interpretations on the details and impact of the
Payment by Results initiative are inaccurate. I wonder if it would be
helpful to produce a brief summary of the policy so that your readers
would have a more balanced reference point for any further debates. If
you think this has merit I would be happy to draft something.
Robert Dredge
Programme Manager for Financial Reforms
Finance and Investment Directorate
Competing interests:
None declared
Competing interests: No competing interests
David Wilkinson reports that with the new planned legislation, choice
for the elderly mentally ill will become even more restricted. This will
also be the case for those with Huntington’s Disease, an illness that has
complex physical needs often complicated by accompanying mental health
needs.
There is already little or no choice of nursing home placements for
people with this disease leading to an inordinate amount of pressure to
accept care home placements hundreds of miles away from their families and
friends.
Suggesting initial placements will be interim, until alternatives are
found, totally ignores the reality of the situation. These placements just
don’t exist, certainly for a person with this disease.
During my recent research it was overwhelmingly stated, by carers,
that there are few or no nursing home placements for a person with
Huntington’s Disease.
“As soon as you mention the word Huntington’s ……………either they were
full up or they didn’t have the staff or the expertise or they just didn’t
want to be involved”
“There aren’t any nursing homes, there aren’t any places that take
people with Huntington’s Disease.”
According to Priestly (1999) the White Paper for Community Care,
emphasised by contracting services out to private, voluntary and not for
profit organisations, consumers would have choice. It appears that the
people who have choice are the providers. They continually exercise their
choice to say ‘NO!’
Where does that leave the consumer?
The situation for these people and their families will continue to
deteriorate until there is acknowledgement of the true situation. There
just aren't sufficient or appropriate placements available and further
investment is the only answer.
Competing interests:
None declared
Competing interests: No competing interests
Rowlands and Pollock highlight eloquently many of the problems and
inequities to which this legislation may lead.
They do not mention that inpatients under the care of a psychiatrist have
been specifically excluded, although most psychiatric inpatients are also
occupying acute beds which in many places are in very short supply.
My service has always had an excellent working relationship with the
local Social Services Department and my experience has been that delayed
discharges normally have been due to manpower and resource shortages and
not laziness or incompetence.
It seems now that individuals will have to be prioritised for the
provision of services for financial reasons and not on the basis of need.
People living in the community will become a lower priority with
psychiatric inpatients the lowest priority of all. The Government does not
appear to regard the blocking of psychiatric acute beds as a problem.
This legislation may also be counterproductive to multi-agency
working as inevitably resentment will build up when mental health teams
see their patients marginalised in favour of general hospital inpatients.
Old Age Psychiatrists may understandably think twice before
transferring patients from medical/surgical beds to psychiatric assessment
beds knowing their social care will be prioritised if they stay where they
are. This is likely to lead to admissions to residential/nursing home care
for people who may have been rehabillitated to home given more time and
appropriate multi-disciplinary and multi-agency assessment and treatment.
Competing interests:
None declared
Competing interests: No competing interests
Rowland and Pollock’s editorial presents part of the story. Telecare
– the use of information and communications technology (ICT) to reduce
the risks of home-based care – is widely seen as having potential to
reduce delayed discharges and improve patient choice over the location of
their care. It is possible to imagine a model whereby telecare forms an
element of an individual’s care package, along with domiciliary and home
nursing care, conventional assistive technology and home adaptations, and
medication and therapy.
It is not well known that the government has set ambitious targets
for the widespread introduction of telecare by December 2010. Rowland and
Pollock note that the £100m per year allocation to pay reimbursement costs
resulting from delayed discharges ‘underestimates the underfunding and
current lack of capacity in the community care sector’. This sum needs to
be seen in the context of possible investment in telecare. In February
2003 the Government made available £133.4m to support home and
intermediate care via the Integrating Community Equipment Service (ICES)
initiative. In addition, intermediate care and extra care housing is being
expanded – for example, the Department of Health is making available £87m
to be spent within 2004-06 to provide an additional 1,500 Extra Care
places. Funding for telecare should also be available under the Integrated
Care Record System (ICRS) and the Office of the Deputy Prime Minister’s
Supporting People initiative.
So far telecare has been limited to a small number of pilot and
demonstration schemes, but these suggest that it may have substantial
benefits in reducing capacity constraints in the care system. However,
these benefits can only be reaped if the discharge regulations allow the
relationship between the acute sector and social and housing services to
develop in a constructive way. A benchmark of two days, after which fines
have to be paid by social services in individual cases, ignores the whole
system nature of the health and social care system. For complex
individualised care packages including telecare, even if the technology
installation is straightforward, the short time period is not realistic.
Regulations which give incentives to reduce the average discharge time,
instead of focusing on the time for individual cases, are far more likely
to reduce delayed discharges and provide appropriate care to patients than
the proposed system. Under such a regime telecare could maximise its
potential.
There are major challenges in meeting the telecare implementation
targets, partly because there is no clear responsibility for telecare. In
particular, there need to be clearer links with the ICRS and ICES
(Integrating Community Equipment Service) initiatives. Clear funding lines
and specific budgets for telecare still need to be established and
business models which embrace health, social services and housing
departments will have to be agreed. However, the potential for using ICT
to help support a modernised, consumer-focused care delivery model is
greater now than at any time.
Competing interests:
None declared
Competing interests: No competing interests
Rowland and Pollock's claim that the NHS Plan's target increase in
general and acute beds and intermediate care beds "has not been achieved"
sems a little premature. The target relates to 2004 but the latest data
relates to 2002-3. In the three years to 20002-3 general and acute beds
increased by 1,599 and intermediate care beds increased by 3,165, or
respectively by two-thirds and three-fifths of the plan target.(See
Department of Health. Hospital Episode Statistics. www.doh.uk/hes )
The UK government deserves praise for making progress in the target
direction. It will be another year before judgements can be made about how
fully the target has been met.
Competing interests:
None declared
Competing interests: No competing interests
In a fashion all too typical of this administration we are seeing
another 'let's get tough' approach with the introduction of penalties /
fines for perceived breaches of new government targets.
Pollock and Rowland rightly express concern. The combination of falling
care home places, failure to implement a proclaimed increase in acute
hospital beds in medical specialties or achieve the targets for
intermediate care is going to prove a volatile and possibly explosive
combination.
Change is certainly needed and it is true that for too long Social Service
Departments have been allowed to get away with poor response times while
elderly patients are kept in inappropriate and often substandard hopital
accommodation Up to 50% of designated rehabilitation beds are in effect
community placement beds with around half of these relating to Dementia
and mental health problems under the umbrella of Cinderella rehabilitation
services.
The discharging of older patients is being pushed in an increasingly
aggressive manner to meet new targets some of which are based on flawed
and dangerous comparisons with for example the Kaiser Permanante U.S.
system.
Standards of care for the elderly will be caught up in fierce budgetary
battles between acute Trusts and social Services with many choices
becoming an illusory lip service to the consumerism banner of the
government.
Competing interests:
None declared
Competing interests: No competing interests
I wonder, whether this new regulation can be compatible with the
(also new) "Fair For All, Personal to You" initiative, which is designed
to promote patient choice of treatment location and so on?
Competing interests:
None declared
Competing interests: No competing interests
Rowland and Pollock should be commended for highlighting another of
the inequities of the NHS 'plan', with its emphasis on acute hospital
waiting and admission times to the exclusion of all else, and the
consequent impact this will have on the elderly frail and chronically
sick.
One extra brickbat is that Elderly Mental Health beds will not be included
in the delayed discharge legislation as they are not considered acute,
though how one cannot regard beds which are needed to admit patients
sectioned under the mental health Act as acute beggars belief.
This
exemption could, on the one hand, be seen as a recognition of the need
for the careful and often complex community care arrangements in such
patients. However, social workers,who are already unable to provide the
care packages they need to discharge these patients from the 'acute'
hospitals, once subject to fines for the delays, will inevitably see our
patients with depression or dementia for whom they will not be fined with
even lower priority than they do now.The staggering delays we already see
will lengthen further with all the knock on effects that will have on the
acute services.
We already see patients being inapropriately admitted and
languishing in acute wards unable to be discharged or transferred to
suitable therapeutic environments due to lack of investment, some of which
is spent on devising ever more inventive ways of manipulating waiting
lists.
The situation will not improve for this group of patients whose
choice is already lamentable and will become even more restricted once
this legislation is enacted.
Competing interests:
None declared
Competing interests: No competing interests
Choice and Responsiveness for Older People?
Choice and Responsiveness for Older People?
Your recent editorial raises many worrying points relating to the
welfare of older people, and especially the most vulnerable and frail
requiring care in acute hospitals.1 Demography, amongst other factors,
will dictate an increasing need for such care.2
The pressure to discharge from acute facilities, with the crude leverage
of average lengths of stay and fines is likely to lead to quite
inappropriate practice. Older people, especially those in their eighties
and beyond, are a most heterogeneous group, with functional impairment and
cognitive capacity having the most importance in relation to outcome and
lengths of stay. As part of a large international study into the
relevance of case-mix and outcome for older patients admitted to medical
care 3,we present some local data of interest .
On the third day of their hospital admission, we assessed 200
patients aged 65 years and over admitted urgently for medical problems.
Mean age was 80.3 years and 64.5% of patients were female. Patient status
was thereafter assessed every 7 days. Excluding 17 patients who died
during their hospital stay, 74 (40%) were still in hospital on day 17. Of
these 74 patients, 30 were undergoing rehabilitation, 33 were requiring an
acute medical setting, 7 were awaiting social care arrangements before
going home and 4 were waiting for alternative accommodation. By day 45,
all but 25 patients had been discharged, and of these 7 were still
undergoing active treatment and 6 were needing in-hospital
rehabilitation. One of the 25 patients was awaiting long-stay hospital
care and 11 were recorded as delayed discharges due to unavailable social
services provision , giving a rate of 5.5% ,- with 4 patients awaiting
arrangements to go home and 7 alternative accommodation. While not
underestimating the undesirability of delayed discharges for these 11
individuals, our study underlines the importance of allowing older
patients the necessary time to recover and rehabilitate, with some
requiring prolonged stays prior to a successful return to the community.
Rehabilitation may be integrated alongside acute care facilities, or
in suitable step down arrangements – but all such resources should be
properly equipped and staffed with an appropriate level of medical,
nursing and allied health professional support. Artificially accelerated
discharge arrangements are most unlikely to benefit the older patient
needing the time and appropriate environment to optimise their recovery
and enable a return home, the objective of most. Legal challenge is quite
likely to arise in those proving to be disadvantaged by such legislation,
and we would hope that reflection on some of these proposals will amend
the guidance.
Yours sincerely
W R Primrose
D G Seymour
S E Campbell
References
1.Rowland D R, Pollock A M, Choice and responsiveness in older people in
the “patient centred” NHS. BMJ 2004; 328: 4-5. (3 January)
2. Wood R, Bain M. The Health and Well-being of Older People in
Scotland. Insights from national data. Information and Statistics
Division. Edinburgh: Common Services Agency for NHSScotland, 2001.
3.ACMEplus Website, www.abdn.ac.uk/acmeplus/.
Competing interests:
DGS was the lead grant holder for the EU funded ACMEplus project
Competing interests: No competing interests