For the majority of these patients, care is fragmented and aimless. The physical care environment is often bewildering and even poses risks. Early findings from our Enhancing the Healing Environment projects show how simple changes – such as changes to lighting, floor coverings and signposting – can make a big difference, reducing falls, incidents of aggressive behaviour and the use of anti-psychotic medication. However, acute hospitals have not been designed with these patients in mind.
Many commentators recently have been blaming all-graduate nurse training for poor standards of nursing care for these patients. But the problem is more systemic – these patients need proactive care to ensure they are washed, helped to the toilet, fed, hydrated and mobilised. A team approach is needed, where people with the right skills and experience are able to work effectively together to provide co-ordinated care. This will involve care assistants, cleaners and clinical staff working together.
On a recent visit to Leeds, I observed a multidisciplinary team providing old age liaison psychiatry across two sites at the Leeds General Infirmary and St James's University Hospital. The team – made up of old age psychiatrists, nurses, and occupational therapists – are referred older people from across the trust, including people with undiagnosed or uncontrolled dementia and delirium who are admitted for other medical or surgical treatment. They perform a holistic assessment of the patients' mental health and wellbeing, talk to family and carers about the support at home, their circumstances and their history, and review their medications. The review and actions are recorded on an electronic record used by the mental health trust. Their work has shown good results with reduced lengths of stay, but funding is uncertain.
There is a set of new tariffs to pay mental health trusts but these would not cover treatment of patients whose main reason for admission was not related to their mental health. Acute trust tariffs do not fully reflect the costs of delivering mental health care to a patient admitted for a hip fracture or cancer treatment either. If high-quality integrated care for people with mental and physical conditions is the goal, then tariffs and contracts need to be designed to overcome the organisational divisions that get in the way.
The team in Leeds spend a lot of time training and supporting other staff across the trust to raise awareness of how to diagnose, treat and manage mental health problems in the elderly, advising on how to adapt the environment for these patients.
We need to rethink how we care for frail elderly people with mental health problems in hospitals. While some of these patients could be prevented from admission with better community and home care, some have acute needs that require hospital care. It will mean redesigning buildings, services and roles. It will also mean ensuring that basic standards of care are met – poor nutrition and hydration can exacerbate delirium. If we fail to face this challenge, our hospital beds will continue to be filled with patients who feel lost and confused, and there will be many more families who feel let down by the NHS.
For more on patient experience and quality of care, see our Point of Care Programme