“All patients were by legal definition vulnerable, but older patients who might be confused, frightened and without family were even more so and any doctor who ignored that would be condoning institutional abuse.”
The hard hitting message was delivered to the BGS’s Spring Meeting by guest lecturer Robert Francis QC, chairman of the Mid Staffordshire inquiry, who told us: “We know that most of the issues were nursing ones but medical leadership is the key to solving them. All doctors should be in a position to take the lead.”
Doctors in Mid Staffordshire had failed to intervene for a variety of reasons including a sense of disengagement, a reluctance to rock the boat or make a fuss, fears about discretionary payments or pensions. The result was a catalogue of horror stories, some of which he described to his audience to whom he issued a plea, “Remember these stories and don’t ever fall into those categories. The future is in your hands.”
His report had devoted a chapter to care of older people. “I came to the conclusion that it is crucial to what happened. The way in which we care for older people is the touchstone for the standards of general care. If we can’t get that right it’s open to question whether we can get anything right.”
Among his key findings was the need for nursing of older people to be properly recognised and valued, which it was not at the moment. “We need a special registered status like the one we have for nursing children. Much of the care given to older people is by unqualified assistants. There’s more regulation around minicab drivers and security men on the door than there is around the person who cleans the bottom of your grandmother.”
Other recommendations included the need for a consultant on every ward, the involvement of nurses in every ward round and clear identification of responsibility. “There should be a named doctor and a named nurse on the white board at the end of the bed. I see the white boards but there are hardly ever any names on them. It’s good that things are done by teams but that shouldn’t be a reason not to name the leaders.”
The importance of families and carers should always be recognised. “Too often they’re excluded because it’s thought inconvenient or for spurious reasons of confidentiality. We need to do away with attitudes which disassociate doctors from their patients. The this-is-not-my-patient attitude or I need to be somewhere else or this is a nursing problem.”
As well as seeing the tragedy of Mid Staffs he had also been greatly encouraged by examples of good practice and genuine concern. There was still, however, more talk than evidence of action. Many of his 290 recommendations did not need government or Quality Care Trust involvement. “You can do them for yourselves. Many don’t even require money and I’d suggest that in the end, proper care costs less than bad care. But if this opportunity for change is not grasped, there will come a point where public confidence disappears and then everyone will be in trouble.”
The need to alter attitudes was in fact, mentioned right at the start of the Belfast meeting in the opening session on nursing home medicine and geriatric liaison when Dr Maura Young, consultant in old age psychiatry at the Northern Health and Social Care Trust, spoke of the need to escape Descartesian dualism.
“Changing the culture can be very difficult as we in Northern Ireland know. But we need to transform our culture of care to become truly holistic and bring an end to the mind-body dichotomy.”
At the moment staff were frequently not equipped to deal with the ever increasing numbers of patients with dementia. “They’re often seen as bedblockers, the wrong patients in the wrong wards. Their mental health needs are often undiagnosed; yet physical and mental health are often intertwined. By liaising we can get staff to recognise when a patient is unwell so that they can be referred and action taken. Liaison services need to be a necessity rather than a luxury.”
The session had begun with Dr Richard Orr, GP medical advisor on integrated care for Northern Ireland’s Health and Social Care Board, describing strategies for improving care in nursing homes in order to reduce hospital admissions and length of stay. These had included medical examinations in the homes, improved links with GPs, families and community services, advanced care planning and medication revues. In one project where a prescribing pharmacist reviewed 1052 patients in 120 homes, 1170 medications were stopped and 349 new ones started. Overall admission rates to A&E had been cut by 55 per cent.
“This is a challenge to geriatricians,” he said. “It’s not about extra resources as we know that’s not going to happen. It’s about being pro-active to identify patients on the verge of needing help.” The session concluded with Dr Gary Heyburn, consultant orthogeriatrician with the Belfast Trust, describing how input from his speciality could be most effective.
A conference report from the BGS Spring Meeting in Belfast, by Liz Gill.
- Appraisal and doctors in court
- When I was a young ‘un – The changing professional life of the geriatrician
- Cyber-care – The benefits and drawbacks of new technology
- The social and economic contribution of our elders
- Old and still driving
- Chronic disease begins in childhood
The meeting in Belfast drew over 500 participants including ones from Israel, New Zealand, Australia, Sweden and Singapore, as well as all parts of the UK and Ireland. In addition to the professional programme there were social opportunities in the form of a buffet at the new Titanic exhibition and a dinner dance at the splendid City Hall.
The Autumn meeting in Harrogate in November will include sessions on Integrated care and geriatric care closer to home as well as sleep disorders, syncope, ultra sound in rheumatology and immunobiology. Bereavement, adult protection and integrated care will be among the non clinical subjects.