Why continuity of care is crucial for patients

Today marks the end of the Commission on Dignity in Care for Older People's public consultation on ‘Delivering Dignity’. The Commission was established following the recent parliamentary and health service ombudsman’s report into the treatment and care of older people.

Continuity is a different, but related, aspect of providing dignified care, and our new report Continuity of care for older hospital patients seeks to draw attention to the issue of poor continuity within the acute setting. As we get older, many people will develop chronic conditions such as dementia or become frail. Primary care has developed systems which try to integrate services and maintain continuity using methods such as care plans, multidisciplinary teams or care co-ordinators. But within hospital, we falsely assume that this will take care of itself.

When you go into hospital, you want reassurance that the doctors and nurses know your name, can explain what is happening and that there is someone who is ‘in charge’ to answer your questions or worries. Good continuity of care inspires trust and confidence whereas poor continuity is viewed by patients and families as a worrying indication that the overall quality of their care may be poor.

In many ways, hospitals are not designed to meet the needs of their biggest group of clients. Too often, patients are moved between different wards, regardless of frailty, sometimes in the middle of the night and usually without informing the patient or carers in advance. In one story detailed in our report, a daughter described how her elderly mother was transferred between six wards in seven weeks while the family were unable to find a consultant who knew enough about her to update them on her condition.

Poor communication between staff and inadequate handovers across shifts result in details being lost, forcing patients or carers to repeat the same information to numerous people. For patients with cognitive impairment, calling them by the wrong name, misplacing their personal possessions or failing to check if they are properly hydrated all increase confusion and anxiety.

Continuity and co-ordination is essential for safe, effective and high quality care and it matters to everyone. However, for older patients it has fundamental importance. A stay in hospital can lead to isolation from familiar settings, loneliness, confusion, depression and exposure to infection, all of which may have life-changing consequences.

If things don’t go well, a man who is continent and mobile on admission may end up bed bound and incontinent as a result of a hospital stay. Appointments for chiropody or physiotherapy, fundamental for mobility and independence, are cancelled whilst the patient is in hospital, and may not be reinstated afterwards. Medication errors can creep in. Losing possessions such as dentures or glasses during ward transfers takes its toll on a person’s wellbeing and state of mind. As the majority of hospital patients are over 75, the cumulative effect of apparently ‘minor’ failings will have huge implications for quality and cost.

Our report describes practical interventions that can strengthen continuity of care in hospital, ranging from focusing on relationships and communication, to initiatives that aim to improve continuity along the entire patient journey.

For example, Leeds and York Partnership NHS Foundation Trust have developed a psychiatry liaison service based in the local acute trust for those aged 65 and over. Departments across the hospital refer patients to a multidisciplinary team, who carry out an assessment and suggest a course of action for those with serious mental health needs. The team also provide advice to staff on wards caring for those with mild or moderate dementia and support staff to manage the effects of poor physical health on mental wellbeing. This holistic approach integrates the treatment of patients with physical and mental health needs, and the evaluation reported improvements in patient experience and health outcomes.

So if the problem is known, and there are interventions which begin to solve it, who is best placed to drive change?

First, senior leaders need to find out if there is a problem with their organisation, determine how serious it is and make a commitment to involve patients in deciding what needs to change and how to do it. Second, to echo the Commission’s recommendation, all hospital staff, and particularly clinicians and managers, must take personal responsibility for improving care for older people today.

Read our new reports: Continuity of care for older hospital patients: A call for action and The care of frail older people with complex needs: time for a revolution

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Comments

#1126 Tony Butcher

I believe these reports show that integration between health and social care is important but also that this needs to be a two way process and the better elements of social care need to be embedded within the health care system as well as the other way around.

Personalisation has been a strong, recurrent theme though social care for some time now and the Kings Fund is right in saying this needs to be so in health care with the introduction of dedicated key workers.

#1127 Duncan Bruce
Local Authority

The shocking revelations in your report are typical of the NHS disjointed, command and control 'management factory', and the corrosive effects of the target culture in the NHS. In a way, what you found was predictable.
I would first Google W. Edwards Deming and Taiichi Ohno and do some reading around Systems Thinking, looking at end to end care from the patient inwards. Remember, targets are never a good thing - they always distort the purpose of the organisation. By all means have a clear aim/vision and support it with good measures, but never put a target against a measure - otherwise good people will be aiming to hit the target just to survive, and patient care is ignored. Long term continuing care is an ideal candidate for the systems approach!

#1129 Kathy Torpie
Speaker - Patient Experience

Duncan, I agree with you that approaching quality improvement from a systems perspective is what is required. Dealing with challenges independent of the overall context in which they occur can actually create new problems. Working in "silos" creates solutions that are neither comprehensive or enduring.

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