How can we make sure that frail older people experience the quality of care that they deserve?

Comments: 10

24 Oct 2012

In the third of our series of articles ahead of the Francis Inquiry report, Joanna Goodrich, Senior Researcher/Programme Manager, Point of Care programme, looks at the changes that can be made at all levels to significantly improve older people’s experience of care.

Frail older people, who often have complex needs, constitute the largest group of patients in English hospitals. For far too long, inquiry after inquiry has highlighted shortfalls in their care, and over many years campaigns have been launched to draw attention to and improve the sometimes fatal neglect that they suffer.

We know that previous public inquiries at Mid Staffordshire NHS Foundation Trust have shown that older patients were often not provided with adequate nutrition and hydration, their personal hygiene was not attended to, and they were not treated with dignity and respect. Often this was in spite of persistent requests and concerns voiced by family and friends who visited them.

This paints a pretty depressing picture, but there are changes that can be made at all levels to significantly improve older people’s experience of care. The challenge is that this requires a major shift in thinking to acknowledge that frail older people are the primary users of acute care and to respond to that by making their needs and preferences drive the design and organisation of that care.

Providing consistent reliable care for frail older people is challenging and complex, a concept discussed at a summit on the care of frail older people with complex needs held at Leeds Castle in November last year. Although we have seen dramatic improvements in medicine in the past 25 years, many of our health professionals were educated and trained for a different era. Now people in the United Kingdom are living longer, often with one or more long-term conditions, and better training is needed in the care of frail older people, especially those with complex needs. Older people’s services do not have high societal status and many of the staff providing physical and emotional care for them in hospital and at home have few qualifications, low pay and poor working conditions. This needs to be addressed. Action can be taken at different levels of the system but we believe that teams need to have the responsibility for quality of care and outcomes for their patients. Investing in good team working is vital.

Continuity of care within and between services is often lacking, yet it is constantly cited as being important both to patients and their families and for better health outcomes. Our report Continuity of care for older hospital patients: A call for action addressed the issues of continuity of care within hospital and made a series of recommendations for patients and carers, frontline clinical and support staff and senior executives and board members. These ranged from apparently simple recommendations – for example, that patients and carers should always know the name of the person in charge and when and how to get hold of this individual – to more challenging system recommendations – for example, that clinical and frontline staff should avoid moving older and frail patients within hospital unless it is clinically necessary.

Our Patient and Family-centred Care programme, which began last month, involves teams from 11 trusts in England and Wales who will work together to improve care for their patients in a chosen area. The first task for the teams is to understand their patients’ experiences. We encourage them to shadow a patient for as long as it takes to understand their care pathway and to be able to identify where and how it could be improved. We will offer the approach known as 'experience-based co-design' as part of the programme whereby patients and staff work together to understand the emotional ‘touchpoints’ in a patient’s journey and then to implement sustainable improvement.

Another vital part of the programme is teaching teams to undertake frequent measurement of the progress  being made in the areas of their service that are important to patients and clinically relevant.

Hearing the voice of the patient (and their family) and acting on what is heard means more than token patient involvement. It is about understanding that patients see their care in a way that staff caring for them cannot: they have the whole picture and can often see clearly what could be done differently. They and their family know the complexity of their needs, and they alone know the gaps in care that can occur in their transition between services.

Comments

#4510 Danielle Woods
dementia project manager

I agree with everything said in the article but i do have concerns that there are many projects underway which are covering the same areas, we need collaboration or else we are in danger of too many cooks and not enough chefs, we need to collaborate and utilise each others resources and research to change practice and deliver the best care. There are many charities and organisations which are looking into care delivery, patient centred care, individulised needs, care environment and many other contributory factors associated with patients and carers.

#4528 Rosalind Adam
Writer
Self-employed

Two years ago I campaigned long and hard for improvements in care for the frail elderly in Leicester's hospitals. My mother was badly neglected and this accelerated her death. I was given a personal promise from the Chief Executive of Leicestershire Health Trust that my concerns had been heard and would be acted upon. Sadly I've been told by many people that nothing has changed.

In response to your commenter above, it really does not matter how many people are campaigning. There can never be too many 'cooks' as she put it. We need as many people as possible to raise awareness so that someone, somewhere can finally put a stop to the inhumane treatment of our frail elderly.

#4662 Mick Smith
chairman
Haverhill Association of Voluntary Ogrnaisations

I am a governor at the West Suffolk NHS Foundation Trust and the following are my thoughts:
This paints a pretty depressing picture, but there are changes that can be made at all levels to significantly improve older people’s experience of care. The challenge is that this requires a major shift in thinking to acknowledge that frail older people are the primary users of acute care and to respond to that by making their needs and preferences drive the design and organisation of that care.
I wonder if this is the case at any private hospitals. How much extra cash on an on-going basis would any government be prepared to pay to ensure this extra care is affordable and thus provided? I have not read any further than this yet by the way so this might change if it is addressed further on in the article.

Our Patient and Family-centred Care programme, which began last month, involves teams from 11 trusts in England and Wales who will work together to improve care for their patients in a chosen area. The first task for the teams is to understand their patients’ experiences. We encourage them to shadow a patient for as long as it takes to understand their care pathway and to be able to identify where and how it could be improved. We will offer the approach known as 'experience-based co-design' as part of the programme whereby patients and staff work together to understand the emotional ‘touchpoints’ in a patient’s journey and then to implement sustainable improvement.
This is a positive step in the right direction but does have flaws in my humble opinion:
• How many staff who see a team member shadowing a patient are now going to ‘do it right’ rather than how they normally do things and by that I am not criticising their current actions merely asking that question
• What suggestions will there be to find additional funding on a permanent basis should this be deemed necessary; if simply altering attitudes and methods fails to make the required differences? I ask this as here in WSH we have the total care programme that sounds really good to everybody accept those having to do the extra work. We have already heard one governor telling us that staff are working flat out and will not be physically capable of maintaining that level for that long. This then will require extra staff that have to be paid.
Another vital part of the programme is teaching teams to undertake frequent measurement of the progress being made in the areas of their service that are important to patients and clinically relevant.
Oh dear… and what if there is something that is important to patients but not clinically relevant?

#6073 Geoffrey Cox
Small Nursing Home Group MD
Southern Healthcare

There is nothing wrong with anything that has been said here. I will be interested to hear about progress with the 11 trusts working to improve care, particularly the measurement of improvement. However, there has never been a shortage of well informed views of shortcomings, nor a lack of intention to bring about positive change, only that the positive results have been elusive. Why? There are three reasons. Firstly we operate a medical model of care that pre supposes we might fix things, and is not so well geared up to support well being when we can't. The relentless pursuit of a miracle cure for dementia compared to the generally indifferent level of dementia care is a case in point. The second thing is that we operate a Health and Social care system that is more geared to the needs of its personnel than those it professes to care fore. It is a step in the right direction to decide at last to hear from those we care for, and then perhaps to act on what is heard, but until now, that has not happened. Why should they hear, when its not about them, but us. Thirdly, we have to accept and acknowledge the lowness of the the starting point, which is that we live in a generally ageist society. We value youth and therefore devalue age, we prize independence and therefore devalue dependence, we value strength and devalue weakness. So our colleagues who do not suffer these prejucies but reach out themselves to care for others who do are themselves discriminated against with poor status, poor pay and poor conditions. So what is required? 3 things. Firstly honesty with acknowledgement of the awful truth from those in authority. Secondly a relentless, fundamental and commited campaign from the top right down to the bottom to bring about a different, better and more civilised societal culture towards one in which we actually care about each other. Thirdly, transparency, i.e. that those in authority commit to and accept responsibility and accountability for timely progress that can be independently measured. Unless these three principles of honesty, commitment and tranparent accountability are accepted, we will just go round and round in circles as we have done for decades, with evasion, fudge and failure.

#7103 Bev Fitzsimons
Programme manager - Point of Care,
the King's Fund

In response to Mick Smith's comment - just to reassure you, we work with teams and encourage them to see care through patients' eyes. The service improvements that the teams put in place are things that are important to patients, as well as what we might view as changes in the clinical processes of care (which of course, are also important to patients).

#39792 Carola Salvadori

I am ground down and appalled by the treatment I have witnessed of elderly people including my mother in my local hospital which included people being left to wet themselves,not washed not fed, not helped to drink and humiliated with derogatory comments. This was then compounded by by my experience of combined health and social care assessment teams who offered funding so low that only nursing homes with extremely worrying CQC reports could be applied for that did not meet specific identified needs. If complaints are made responses are invariably soothing management speak that do not address concerns and justify appalling practice. There is nowhere to turn to for support. It feels as though euthanasia is being practised by the back door. Nursing homes close and patients are shunted into others with resulting distress and confusion. How can we allow this to happen to people during the most vulnerable times of their lives?

#40005 DARYL MASSEY
nhs

Just on the "Too many cooks" bit, I think there is just a concern that with so many campaigns going on there is a danger that findings or recommendations to improve may become repetitive or watered down and therefore lose credence. This is a vital area which needs serious improvement to provide these wonderful people with the care and compassion which they deserve.

#40069 Mark Powell
NHS Worker
NHS Trust

I totally agree with the report. I just wanted to add a personal note. My Grandmother is in a South East London Hospital after a (non-Injury) fall. She is 98 and has dementia. The Nurses care notes read "Mrs C....... had a good breakfast of 6 teaspones of porridge. She has never liked porridge. No wonder she is now on day 28!!!!!!! with 2 infections. Where is the person centred care?

#40323 molefe
Project Manager
Kgopro Organisation

Dear Sir/Madam

We are from the most hard working Organisation , our pride is to serve Frail patients Holistically. At the moment our geriatrics are not funded. we are looking for sponsors or donors to assist us with stipends for the team.My fear as the project Manager is that once our team leave the Organisation we will end up closing the office.We therefore kindly request your Company or Organisation to assist us in anyway possible.

Yours Faithfully

Mr Molefe Motitsoe

0835314758

#289881 Maria Sklair
Teacher

Last week my 88 years old mother in law, who is in treatment for breast cancer, went to her GP in Sevenoaks worried about a new lump that she found, and the GP was unable to provide a throughout examination the doctor´s examination bed was not high-adaptable so she was not able to climb on... With so many elderly and disable patients, how can Health Centres don´t have the not that expensive and essential for a good diagnosis adjustable beds?

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