A new beginning for the care of older people in hospital?

Our ageing population is a game-changer for health and care services. When the NHS was founded, nearly half of the population died before the age of 65. Now life expectancy is 79 years for men and 83 years for women, with the ‘oldest old’ (those over 85) the fastest growing demographic. Yet, although the care of older people will be ‘core business’ for the foreseeable future, numerous reports have highlighted serious failings in that care.

The Royal College of Physicians’ Hospitals on the Edge report found that hospitals are struggling to cope with fewer beds and rising emergency admissions, driven largely by the increase in older patients. Our hospitals were designed around young and middle-aged people with ‘single organ’ or infectious diseases, not older people with multiple co-morbidities. Of course it’s right to focus on prevention, living well with long-term conditions and improving integrated care. But even if we achieve all these things, large numbers of older people will continue to be admitted to hospital – even demand levelling off would be a ‘result’ over the next few years.

We cannot solve these problems by taking a Canute-like approach and pretending that older people will not be in hospital beds – or by taking the ‘right bed, wrong patients’ attitude highlighted in recent studies, including the Fund’s report on the care of frail older people with complex needs. We need to ensure that our hospitals are geared up to the needs of the people who actually use them. And that includes the culture of the organisation: strong leadership; the training, skills and values of the staff; and the way the hospital is organised. We also need to incentivise hospitals to focus on the things that matter to older patients and their families.

Before the Francis Inquiry reported there had been some welcome moves from the government. For example, the sustained focus on dementia care in both the national dementia strategy and the Prime Minister’s dementia challenge, and the very clear commitment in the NHS Mandate, NHS Constitution and Equality Act to improve care for older people and minimise discrimination.

But will the government’s response to Francis’s recommendations help to ‘age-proof’ hospitals and to improve the quality of older people’s care? They have made it very clear that safety, dignity, compassion and person-centred care are key priorities. Empty platitudes – the cynics may say – but they lay down an important marker about values and priorities.

Their response also gives a clear acknowledgement (mainly for nursing staff but with application to all) that the care of older people is a skilled endeavour and an emotionally demanding job. It requires much more than compassion and empathy – education, training and a rigorous skilled approach are key. Many older patients would not still be in hospital, or be immobile, confused or incontinent if doctors adopted the right approach to diagnosis and treatment and used a comprehensive assessment of needs. All hospital doctors need to realise that they are accountable for the whole process of care, including some of the ‘softer’ issues such as discharge planning, nutrition or essential nursing care. The response does go some way towards addressing training needs – for example, the ‘staff leadership college’ aims to equip clinical leaders with bespoke skills and qualifications; however, non-clinical leaders in large organisations are apparently not required to attend, nor are they required to receive more exposure to the realities of frontline practice.

I am pleased to see the recognition of the need to ‘care for the carers’. However, I think it’s a shame that the government backed down from creating an older people’s specialist nurse role when we already have many excellent nurse consultants and practitioners specialising in the care of older people who add real value to care. Allied professions have also been written out of the public conversation. For many issues of concern – such as safe discharge, rehabilitation and nutrition – occupational therapy, physiotherapy, dietetics and speech therapy play a crucial role. I couldn’t do my job without them, yet debates tend to focus on doctors and nurses.

I applaud the push for all ward managers to be supernumerary and supervisory and for ‘evidence-based’ staff/patient ratios to be published openly – so long as those ratios take into account the high level of skill and time required to care for the oldest old, and those with dementia, incontinence or immobility. The Royal College of Nursing’s report on nurse staffing levels showed that specialist wards for older people are severely disadvantaged when compared to adult medicine or surgery – let alone paediatrics. This historical bias has to change.

Also to be praised is the idea of a set of national minimum standards for care – to complement quality standards and NHS outcome indicators – backed by consequences for failure to deliver. If organisations had been held to account over areas such as continence, compassion, nutrition and communication as much as they had been for hospital-acquired infection, waiting times, or financial balance, we may have been further along the road to improvement.  But we must ensure that these standards don’t become another box to tick – they need to be measured meaningfully.

Finally, as highlighted by the response, we must make candour and openness far easier to deliver. Many older patients are reliant on support and advocacy from family caregivers, and it’s generally these caregivers who raise concerns and complaints about the quality of care, as Francis acknowledges. These complaints could be avoided if we were proactive and open from the outset: giving explanations, managing expectations, and involving families in decision-making and discharge planning. And many of the problems at Mid Staffs and other scandal-hit organisations would never have developed if staff had been encouraged to raise concerns and be involved in delivering solutions. Organisational leaders must have a duty to listen rather than slapping down ‘challenging’ staff members. And leaders must accept that they cannot expect all the solutions to improving older people’s care to be mandated from Leeds or Whitehall – they have a key role to play.