Older Mind Matters

Not the whole of the story - care in acute hospitals

Recently I did a short interview on a local radio station as an “expert” in mental health and ageing. They were interested in changes at a local hospital, which was trying to improve how they treated older adults with multiple health problems admitted to acute care. I was asked about what needs to change in hospitals to provide good care for older adults.

What a question!

Roughly two thirds of people in acute hospital beds are over 65 and roughly one quarter of people in general hospitals have a dementia. The system wasn’t designed for them. Cutting out multiple moves, which increase confusion and increase length of stay, has to be a good thing. Concentrating treatment where people are cared for by staff trained to look at the whole person with a complex mix of physical, mental health and social problems has to be a good thing. Making sure that the person’s unique wishes and life choices are acknowledged and taken account of in their care plan has to be a good thing.

But that’s not the whole story is it? Context is important. If hospitals change then primary and community care have to change and vice versa. If a person can be safely cared for, and receive the treatment they need, outside hospital, preferably in their own home, without incurring the risks of a hospital admission, then that has got to be good too. Alongside that we mustn’t set up a system that deprives people of hospital care just because they are very old and have complex comorbidities. It’s about how the system works together, including not just hospital and home care, but the whole of health and social care, including the role of residential and nursing homes. And where is prevention in all this? How do we take action to prevent admission? People shouldn’t have to become acutely ill or reach the stage of not coping before they get the care they need.

Reading links:

Dignity in dementia: transforming general hospital care. The Royal College of Nursing 2011

Hospitals on the edge? The time for action. A report by the Royal College of Physicians 2012

The National Audit of Dementia 2013

Worcester University evaluation of changes at New Cross Hospital Wolverhampton 2012

2 comments (Add your own)

1. Victoria Sharfman wrote:
Reading your blog also reminded me about my recent reading in preparation for our supervision cafe discussion - Bateson on Conscious Purpose versus Nature and I thought you illustrated the idea of things that connects very well with the touch of '... it has to be a good thing ...' Bateson was also concerned about technological advancement on top of traditional premise causing more disturbance in the system ... Perhaps to demonstrate access to life one needs to survive resuscitation and a case of the whole bigger than its part.

Tue, October 8, 2013 @ 6:18 PM

2. David Jolley wrote:
Thanks for the blog and apologies for the delay in response. This is in part due to a holiday in Suffolk but also waiting for papers to be published.

General Hospitals are safe places to go when you are not well - or at least they should be. They are identifiable and have history of providing for the acutely ill of localities which goes back over centuries. The foil of chronic sickness hospitals which were inherited on the creation of the National Health Service has been phased out: they were less fashionable, saw fewer patients recover and more people die: no-one wanted to own that part of the story. The role has been displaced to the independent sector of nursing homes, care at home and, to a small extent, to hospices.
The problem is that this manoeuvre has not rid us of the phenomenon of pre-death identified by Bernard Isaacs and his colleagues: www.thelancet.com/journals/lancet/article/PIIS0140-6736(71)91851-4/abstract
When the going gets tough and individuals begin to decompensate as a result of multiple accumulated pathologies, they and those caring for them naturally turn to the hospital for haven and further help. More than half of admissions to general hospital now and for the future occur in the setting that that the patient will die somewhere within the next 6-12 months. This is not what people want to know. It is not the image which general hospitals want to project, it is not what healthcare commissioners seem prepared to acknowledge, it is not a way of things which any of the major political parties want to be associated with. It is reality; but it is denied.
Thus we have general hospitals designed to service the fantasy world of patients which they, the general public and media and those who commission them would prefer: patients, each with one pathology at a time, which will respond to the most up to date treatment (regardless of expense) to return them to health and independence.
I have been associated with two papers from Tameside where we attempt to bring some sanity into this situation by providing a link between Willow Wood Hospice and the Medical Admission Unit of Tameside General Hospital: it is a small beginning. It is not focussed on dementia or any other particular pathology but on the phenomenon of dying which is predictable and is likely to be helped by a palliative approach rather than frantic investigation and attempts to reverse the tide of nature:

Tapley M, Piling L, Jolley D, Daniels, A, El-Mahmoudi B (2013) Hospice transfer for patients at the end of life: part 1. Nursing Standard 28 (8) 42-48

Tapley M, Hoey L and Taylor C (2013) Hospice transfer for patients at the end of life: part 2. Nursing Standard 28 (9) 44-49

In addition I played a small part in the review of activity at Stepping Hill Hospital which identified factors associated with delayed discharge

Challis D, Hughes J, Xie C and Jolley D (2013) An examination of factors influencing delayed discharge of older people from hospital. International Journal of Geriatric Psychiatry May 9th doi: 10.1002/gps.3983 [E pub ahead of print]

The symptoms of dementia are strong predictors of longer time in hospital and difficulty in arranging appropriate discharge

The positive approaches to improving the care of people with dementia when they enter hospital being taken following the RAID model (Liaison Psychiatry) and the New Cross model (General Hospital ownership) are hugely encouraging. Making specialist skills available within a Primary Care setting will reduce the need for patients to go to hospital to receive the help they need (Clarke et al 2013).
In addition I would ask that hospitals be redesigned to address the needs of patients who are using them. Peter Horrocks showed the way some time ago (Bagnall et al 1977)

Bagnall et al (1977) Geriatric medicine in Hull: a comprehensive service. BMJ 2: 6079: 102-104

Clark M, Moreland N, Greaves I, Greaves N and Jolley D (2013) Putting personalisation and integration into practice in Primary Care. Journal of Integrated Care 21(3) 105-120.

Leung D and Ward E (2013) The New Cross Hospital Dementia Project http://dementianews.wordpress.com/the-new-cross-hospital-dementia-project-context/introducing-the-new-cross-hospital-dementia-project/

Tadros G et al (2013) The Birmingham RAD model. The Psychiatrist 37 (4) 4-10

Mon, November 4, 2013 @ 12:09 PM

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