We need to talk about frail older patients

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How do you explain the actions of someone who ignores the plight of an older patient in a soiled bed? Or who fails to respond when a patient cannot reach a glass of water and has not eaten her meal?

The CQC report on the State of Care published last week attributed the neglect of older people to failures in leadership, resources (on some, but not all the wards that failed the inspection) and staff attitudes. But the media wanted answers to only one question: 'What has gone wrong with nursing?'

Some commentators, worried about community values, believe we have lost our capacity to care; others blame the move towards a graduate nursing workforce. But there is nothing new about vulnerable people receiving bad care – 40 years ago, Dick Crossman established the Hospital Advisory Service to inspect hospitals for the elderly and mentally ill patients precisely because they were so vulnerable. Equally, it is difficult to believe that educating nurses to degree level is to blame when research shows that the higher the level of education of nurses, the better the care.

What is so shocking in this report is that the neglect is taking place on acute hospital wards. The CQC is right: everyone who works in hospital knows there are good and bad wards. The scale of the problem is considerable – not confined to elderly care wards. Today, patients aged over 65 account for 70 per cent of hospital bed days and 80 per cent of emergency readmissions – 60 per cent also have a mental disorder (depression, delirium or dementia). From our work with NHS trusts (in partnership with the Health Foundation) we know that managers and staff are anxious about the quality of care for these frail, older people with cognitive impairments who can be found in almost every clinical area, not just in the elderly care wards.

But there are good examples of patient-centred care too. Northumbria Healthcare Trust demonstrates outstanding commitment to getting it right for every older person, every time, in every clinical area. The multi-professional team of consultant, matron and service manager lead the work using a three-pronged approach. They ensure that every patient who is cognitively impaired receives an accurate diagnosis to differentiate delirium and depression (which are treatable) from dementia (which is not). This means redesigning almost every care process in the hospital to make sure patients get a full cognitive assessment on admission and at regular intervals thereafter.

The trust is also driving a person-centred approach to the care of patients with dementia by incorporating the Alzheimer's Society's This is Me into the medical notes. This document is completed by the patient's carer and tells the professionals about the patient's past and current circumstances and individual preferences. Last, but by no means least, the trust executive wants to be assured that staff in every department and ward are confident in their ability to care for older patients and those with delirium and dementia. It has sponsored an education programme, taught in collaboration with local patients and carers, to challenge ageist stereotypes. So far, staff have loved the course and the results are visible – with improvements to the hospital's physical environment and to the patients' nutritional intake and the appointment of designated staff to help vulnerable patients eat and drink.

The example from Northumbria proves that influencing attitudes and transforming working practices is not simple. It is intricate, complex work and the change process itself needs good leadership and adequate resources. The rewards are surely worth it, but the drive to improve and sustain better care for frail, older patients must come from the top.

This blog was written in partnership with Tracy Young, Modern Matron, Orthopaedic Care, Northumbria Healthcare NHS Foundation Trust.


Anita Harris

Advocating Excellence
Comment date
20 October 2011
It is often those with the most complex and enduring care needs, requiring not only medical technical expertise but what I was taught as a student nurse 30 years ago, TLC (Tender Loving Care), who suffer most from the flaws in the system that allow poor practice to go un-noticed and unchallenged. Those patients who lack capacity, have severe mental health problems and/or are unbefriended, have the right to free, statutory, independent advocacy, an often forgotten and/or ignored part of the solution to these problems. What Independent Mental Health Advocates (IMHAs) and Independent Mental Capacity Advocates (IMCAs) have proved is that providing a properly trained, independent person who acts solely on behalf of their client, helping them to be understood and access the dignity, respect and care which is their right, makes an enormously positive difference, not only to patients, but also to the people who care for them, healthcare staff who find that they have a professoinal who can act as the translator between them and their most vulnerable patients.

For untrained Health Care Assistants in particular, who it seems are carrying out the bulk of 'personal care' (please lets get back to delvering TLC), the skills of an advocate are invaluable in making sure that they understand not only what their patient needs, but WHO their patient is, their likes and dislikes, values and beliefs.

Unfortunately, professional independent advocates are not available to all vulnerable patients - part of the vision of my own organisation is to support the development and provision of independent advocacy on every ward, in every A&E department - anywhere in fact that vulnerable people come into contact with the services on which they depend. But this is only one part of the solution.

Another significant part of the solution is, inevitably, about how the people who are charged with caring for our most vulnerable fellow citizens, are selected, trained, supported and managed. Tender Loving Care cannot be taught in a university lecture theatre, however gifted and experienced the lecturer. And it certainly can't be expected to materialise of its own accord, when an untrained person dons a uniform. It has to be modelled and expected by leaders, enforced by regulators and, most of all, cherished and rewarded by the rest of us.

june smith

Comment date
20 October 2011
I agree with the comments above, I do think that patients have now become service users which I feel is the wrong interpritation.
I also think that the degree status is possibly putting many young people off from entering the care system, which has become very complex in many areas.
We train our Nurses and carers to these high standards and we are forgetting that empathy and consideration to others are the basic requirements for delivering care.
Trained staff are then attracted to the private system of care when areas of their working environment becomes affected with a negative attitude.
This comes down to poor management and lack of control of public funding.

Mike Hobday

Head of Policy,
Macmillan Cancer Support
Comment date
21 October 2011
A related example of learning in action is the DH/Macmillan/ Age UK pilot looking at why the oldest people with cancer are disproportionately unlikely to get the treatment that others are. A combination of comprehensive geriatric assessment and social care support is offering some promising examples that could inspire.


Aligned Consultancy
Comment date
27 October 2011
We need to talk about frail older people...we need to talk about frail older people some MORE because it seems some parts of the system aren't responding positively enough and in a timely and consistent manner. By the parts of the system I'm meaning Executive Boards in acute trusts not seemingly looking to a qualitative analysis on how older people are being cared for and clinical professional leads (at Exec or other levels) seemingly not creating methods that are robust enough to hear the voice of people who are vulnerable due to age and frailty.
If such processes were in place and robust would this help manage the organisations response to the poor quality of humane care?
There is also the reflection on the role of Commissioners in this debate - what checks and balances are in place for Contracting and Performance regimes - CQUIN and similar initiatives to REALLY drive up and sustain care in providers settings.
Finally, I would like to comment on the involvement of local people in shaping all of the above - often we talk a lot on co production, involvement and engagement, indeed in the World Class Commissioning cycle this was an integral feature.
I appreciate some people have talked about frail older people, some people NEED to talk more and more often it seems!

ruth smith

community matron,
Comment date
28 October 2011
I agree wholeheartedly with the comments regarding advocacy. It saddens me professionally to hear some of the shocking stories reported in the media about frail elderly patients being subjected to such treatment. Many a time, when I hear them, I question why is this happening? Some of it I am sure is poor nursing standards, poor leadership and management, but I also think pressed resources and ever advancing medicine/healthcare have a part to play in the blame.
With an increasingly elderly population, some of whom are admitted to hospital because an acute bed is the only available resource where they can be looked after 24 hours a day, in order to keep them safe. There is a lack of other 24 hour resources for some of these frail elderly, who need tender loving care with some good basic nursing and some basic medical care, not an acute bed on a busy ward with high technological care. Here, the nursing staff are so busy trying to keep up with the monitors alarming, phones ringing, doing tasks like cannulation that the doctors used to do that there is less time to do this basic good nursing care. Basic care is then left to the health care assisitants and I question who is training them in good basic nursing care. Perhaps, it really is time to bring back the old enrolled nurse who excelled in this.
The situation is complex and I don't profess to have all of the answers, but I would suggest that it is time to consider the old cottage hospital, or a more modern version of that. Whilst we drive towards more patient self care, there are still our very senior citizens to care for in the last years of life and we need some infra-structure to sustain this and prevent them being inappropriately in acute beds where they are at risk of a lack of basic nursing care.

Mike Nicholls

RESEC Cornwall
Comment date
30 October 2011
I see the same disregard for those with dementia and their carers. There are many organisations providing advice, but practical hands on help is no longer available except in crisis situations. Carers into their eighties, many of whom have their own medical problems, are expected to care single handedly. The sufferer can never be left alone in case they cause damage to themselves or the home. Since many sufferers cannot tell the difference between day and night the carer often has disturbed nights, this is what I mean by 24/7. Added to the many physical demands are the mental strain the carers endures. The person they are caring for is "absent" for most of the time, just vey occasionally there is a glimpes of recognition. Then there is the repetitious behaviour. On a visit to residential home I came across a carer and a resident. The resident said "Where's George?" the carer replied " George died we went to his funeral in September". Resident "Oh yes thats right, where's George?"
Returning more than half an hour later I was greeted by "Where's George?"
The carer dealt with the questions with great patience and she knew that her shift would come to an end and she would return to her family and could forget all about George. The sole carer has no such escape.

If foriegners working for a gang master had to put up with such conditions there would be a national outcry, it would be the first or second item on the televsion news and there would be a national outcry, but then they are only old people! The prime minister said we should protect the vulnerable. I know of no more vulnerable group.

Ed Macalister-Smith

NHS Buckinghamshire
Comment date
31 October 2011
I started my working life in the NHS nearly 30 years ago, and was appointed as the Chief Officer of Bath Community Health Council.

We developed an approach to how the lay members of the CHC could make an effective contribution to the scrutiny of care standards in the institutions that we had oversight of. Our Chair, Rachel Worsley who had held a number of senior nursing positions but had been long retired at that point, wanted us to be able to take an effective stand where care standards fell below acceptable levels (you see, this is NOT a new problem!).

We developed the "I-test". The I-test asks the simple question that any individual can legitimately ask, whether they are a care professional, a manager, or a Board member. The question is "how would I feel if that patient (that we have observed) was my mother / my child / my neighbour / my friend? Would I be satisfied with their care?".

I maintained this approach throughout my career as an NHS CEO, but as an accountable manager I added a further question to the simple formula.

So the I-test became not just "If that was my mother, how would I feel about her care?" But in addition - "If it is not acceptable, what am I going to do about it?" And I encouraged managers (clinical or otherwise) to ask exactly the same question of themselves.

Of course, to be able to ask the question requires that the manager, or the Board member, spends time on the front line - on the ward, with the GP, or wherever. This is no bad thing and is frequently neglected, and regretfully explains how it is that Boards can preside over corporate failure of clinical standards.

Answering the question "...what am I going to do about it?" allows a response which is appropriate to the role of the particular observer. For example, it is not the role of a NED (in my view) to directly challenge front-line care providers, but rather to ensure that quality reports to the Board are honest and comprehensive, and in the face of contrary evidence to be extremely persistent in ensuring that they are realistic.

I dare say that others have developed similar approaches - these are not rocket science, but they do firstly promote the importance of the "innocent eye" in determining whether basic standards are being met, and they promote the personal responsibility of all managers and leaders to act in the face of unacceptable practice.

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