Are hospitals any place for the elderly?

Another week and another upsetting report about the care of vulnerable people in the UK. After Panorama exposed the horrific treatment of people with learning difficulties in care at a hospital in Bristol, the latest report from the Care Quality Commission (CQC) examines the treatment of older people in acute hospitals. Cue more hand-wringing about the state of modern nursing and more casting around for scapegoats.

The treatment of vulnerable patients will not improve until we recognise that the familiar cycle of investigation, scandal and blame is not making a difference. These events are not exceptions, and rooting out bad nurses and managers in bad organisations is not the solution.

An excellent report – Dignity in practice: an exploration of the care of older people in acute NHS trusts (Tadd et al 2011) – offers a radically different way of looking at the problems. Win Tadd and colleagues' meticulous ethnographic research and interviews in four acute hospitals lead to a radically different conclusion – that these problems are systemic and need system-wide solutions.

They found, for example, that hospital managers and staff either don't see, or don't accept, that their core business is caring for older people. In one of the hospitals, a one-day census of patients in medical beds found that the average age of patients was 82; 10 per cent were over 90. Nevertheless, in interview after interview, staff insisted: 'they do not belong here; it's just not the right place for them; it would be better if they could go somewhere else.'

And they have a point. An acute ward is not the right place for an old person who may be confused and who probably has at least two long-term health problems. The physical design of an acute ward is wrong; nowhere to go away from the bed; no lounge; no dining area; physical hazards everywhere and poor signage. The majority of staff don't have the right training. The intense concentration on reducing lengths of stay and 'pulling' patients through the system means that patients are continually on the move through environments that are not therapeutic or conducive to rest or recovery.

One aspect of institutional life that is especially destructive is the way in which a corporate aversion to risk at board level affects interactions between older patients and staff, stopping staff thinking about the right balance of risk-taking and autonomy for individuals in their care. Observing conversations, the researchers found that the fear of patients falling – or otherwise coming to harm –on the ward has precedence over considerations of patients' dignity, autonomy and the need for control. In one exchange, a patient asked for help to go to the toilet, and was told: 'No, you'll fall, it's better to stay where you are and go in the pad.' In another, the patient asked for his reading glasses and was told: 'No, you can’t have them. You might roll on them and hurt yourself.'

Systemic problems require systemic solutions, and many of these are necessarily long-term. But the recommendations about changing mind-sets and cultures can't wait. The Welsh report calls for recognition at all levels that older people are the main business of our hospitals – it's no longer enough to say 'they ought not to be here'. It calls for compulsory induction and training for all staff in the provision of dignified care and the needs of older people, especially those with dementia. And for staff to have time to reflect on practice, to question inappropriate practices that have become accepted norms including task-driven activity at the expense of engagement with patients.

Time to reflect is exactly what Schwartz Rounds® offer. A Schwartz Round® provides a forum for staff from all disciplines and all parts of the hospital to reflect on the social and emotional issues arising in the care of patients. After two year-long pilots in two UK trusts, our Point of Care programme is helping trusts to set them up and run them. The Schwartz Rounds® provide the space to reflect that the report calls for: they are a place for staff to think about the conflicts and the pressures they are under, and to remind themselves of the value and importance of the real, human, messy business of caring for people who are vulnerable.

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#463 Rekha Elaswarapu
Author, 'Caring for dignity 2007'

Totally agree with the need for system reform to ensure dignified care for elderly in hospitals. No care professional gets out of bed planning a day to provide poor quality of care but it is the systems and processes (or lack of it) which causes compromise in dignity and quality of care. Alongside staff training and support it is also important to have commitment from the highest level in the organisation. It is shocking that many board members don't even visit the wards. There are definitely some places where the senior staff do visit the wards and provide role models as well as ensure problems are identified and resolved much more quickly. Another crucial factor is robust monitoring systems which measure what really matters - better outcomes!! In current times of austerity dignified care may be seen as aspirational and an add on rather than an integral part of patient experience.
Well done for 'Point of care' - proof that good quality care is achievable.

#464 SJBurnell
Focused_On Health

There are no excuses. Bad or invisible management would be a problem but cannot be an excuse for giving poor care or (even worse) gross neglect. Would they treat a young child with the same contempt or indifference to their needs?

#465 Phil Sanmuganathan
Consultant Physician
Worcestershire Acute Hospitals

Elderly patients come into hospital to get there illness diagnosed and treated and to be cared when this process goes on. It is wrong to say that Acute Hospitals are not for this group of patients. If we agree with this proposition then where do these large proportion of acute ill patients, who are old and frail go to have their treatment. Do we have an alternative pathway? I am afraid not for the severely ill.

It is important to get the ethos of care for the elderly ingrained into all Acute Hospitals. Care of an ill patient is Acute Hospitals responsibility. We need to get this right, not by blaming and scapegoating, but by changing attitudes and importantly funding these nurses and carers.

Let us do a trial where one group of Hospital does only outpatient activity procedural activity i.e. cardiac catheter, endoscopy etc and the other group inpatient Acute medical and surgical. This will be trialled out in practice in the future. Wait for the results - two tier system one productive and the other struggling.

#466 Joan Higgins

Thank you for drawing my attention to this excellent pirece of research.

#467 Akin Falayajo
Acute Medicine SpR

A few days working on an MAU makes it obvious to the uninitiated that a significant proportion of the patients we see are elderly.

While I agree that acutely ill elderly patients need cared for within the confines of an acute hospital, alternative pathways do exist for some that do not require specific interventions only provided in hospitals and would be better served being cared for in their more familiar environment - home. Involvement of Geriatricians at the front door is one way to facilitate this. And, I am aware that there is talk and plans to fund hospital-at-home for appropriately selected elderly patients in the near future.

There can never be any excuse for poor care, but I dare say that undue pressures from poor staffing in some instances can encourage less than optimal care for the most vulnerable.

#468 Peter Williams
Risk and Governance Applications Manager
St George's Healthcare NHS Trust

An excellent report form the CQC focussing the spotlight on the often less than optimal care of the elderly population in acute 'fast stream' hospitals. As a nurse, I am all too aware of the staffing and resource constraints on both nursing and medical staff in today's NHS and the impact that this has on the provision of care, however there is never any excuse for poor and sometimes neglectful care. The fact is that the population is aging and this needs to be factored in when planning future health provision. When working as a bed manager it was all to common at times to hear health professionals from consultants down talk about the elderly patients in negative terms such as s 'bed blockers' and crumblies' and view them as resource drains. Elderly patients come into hospital because they need acute care, treatment and diagnosis and the system needs to reform and develop better pathways and options for the elderly.

#469 Robert Boorman
Cambridgeshire Older People's Enterprise

Cambridgeshire Older People's Enterprise Forum campaigned hard to retain Brookfields Hospital which was a rehabilitation hospital for mainly older patients who were in need of longer term care to enable them to return home and look after themselves.
Many died in situ however they were kept comfortable and their families were grateful.
These facilities were considered vital by Geriatric Consultants but were seen as an unessessary luxury by the PCT.
Promises were made to provide Care in the Community to enable early discharge which sounds good and many patients are happy to be sent home often to die however the level of support has often been inadequate depending on the location of the indevidual.
Some are sent to Care Homes however the policy of social services has been to reduce to a minimum use of these facilities ,which means that most of the residents now suffer from dementia or similar.
In the final analysis management determin the quality of care in an institution and individuals need to be held to account for their treatment of the elderly.

#496 Taher Mahmud
Consultant Physician

Thank you very much for drawing attaention to this report and the importance of compassion in clinical settings. Clearly there are some completely unacceptable practices which cannot be tolerated in modern clinical practice.

I would like to draw attention to the DH policy of involving patients and families and looking to get patient feedback. pateint feedback has many benefots for clinical teams and can identify patient and family concerns with ther service. Patients can asked for feedback every time we have a clinical contact. It is possible to obtain feedback in real clinical settings some examples from from different specialities at

#39814 lesley smith

​you have highlighted a very relevant topic that touches us all and the research is brilliant in the report. It is so true that elderly patients are too suffering in the care they receive and patients and their families require much more than medical assistance; compassion and care will make the world of difference

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