Expose the worst – but remember to praise the best

BGS Logo CMYKProfessor Adam Gordon is Honorary Secretary of the British Geriatrics Society, a consultant geriatrician, and Honorary Associate Professor in the Medicine of Older People at Nottingham University Hospitals NHS Trust.

It can be tempting when faced with inadequate care for an older relative, to believe that all such care is inadequate. As someone who regularly advocates on behalf of older people with frailty, I know that I frequently feel let down by an NHS or long-term care sector that seems ill-equipped to care for older people.  Lots of things can get in the way: cumbersome bureaucracy, lack of expertise and training, a culture that at times seems obsessed with diagnosis and cure at the expense of comfort and care, and at other times seem almost unduly pessimistic about prognosis. This often seems to take place without consideration of the individual choices of patients or their carers, as the system strives hard to stay afloat by maintaining “patient flow”.

There is, in the midst of this, a need to campaign, to educate and to proselytize. We need to share how bad it can get, as a cautionary tale. The work of the families of mid-Staffordshire and of Morecombe Bay has been essential.  The work undertaken by Nicci Gerard and others as part of John’s Campaign, raising the profile of family carers on wards for older people, is something to which we should all be lending our support. The Panorama exposés on the sometimes scandalously poor quality of care in the long-term care sector are necessary. Yet if all we ever do is report the bad stuff, then we all – patients, families, carers and professionals in health and social care – might be left feeling bereft and believe that all is lost.

In her recent blog for the Telegraph, Judith Potts quite rightly draws attention to the desperate plight of a friend who received suboptimal care at the hands first of an acute hospital and then from a care home.  She focuses on the British Geriatrics Society’s Fit for Frailty guidance, but closes the piece with an assertion that there is too much talk and not enough action.

I’m not sure how constructive this line of argument is. I’d like to hope that those colleagues who are doing an excellent job to raise standards in older peoples’ care, working excessively long hours in excessively frustrating conditions, will have their efforts recognised. In their zeal to reveal the worst of care, campaigners can sometimes risk underestimating the impact of other professionals who are striving to achieve the best for their patients, to educate others, and improve things more broadly.

Some of the most exceptional care I have ever witnessed has taken place in care homes.  When it’s good, with attention to individual choices, an understanding for the role that cognitive impairment plays in day-to-day choices and behaviours, appropriate and tactful exploration of end-of-life discussions, and normalisation of life and living, it can – and has – reduced me to tears.

Yet these examples of care seldom make headlines, or even go reported.  When MyHomeLife, led by Professor Julienne Meyer and funded by Age UK and the Joseph Rowntree Foundation, set out to empower care homes around the UK to raise standards, they decided that the only way to make progress with care homes was to start from a position of appreciative enquiry, to show them that we recognised that much about the long-term care sector was right, even at the same time as there was much to be done to ensure that all residents can access the best care. Research and experience told them that horror stories and admonition just left the best people – the ones we’re depending on to improve things – simply feeling lost.  You can read about MyHomeLife’s achievements at their own website: they’re considerable, and they start from a position of appreciating the best about long term care, without denying the considerable work required to improve the situation for those experiencing the worst.

When we conducted the Staff Interviews in Care Homes study general practitioners and care home staff told us that they recognised the same difficulties in both sectors.  Older people with frailty are complex, they have multiple problems and unpredictable health trajectories.  This requires specific training, which staff in neither group felt they had adequately received.  It requires clear lines of responsibility for care decisions within primary care, within care homes and between both sectors that, for the most part, have not been explicitly negotiated. Both sectors spoke of limited resources and governance frameworks driven by government and the Care Quality Commission, which left them working harder to gather evidence about the most basic practices, when they wanted to be striving for excellence.

So this is difficult.  It is not, though, insurmountable. Fit for Frailty outlines how the evidence-base can be used to structure effective day-to-day care in older people with frailty.  Our Care Homes Commissioning guidance has illustrated how health commissioners can structure care around care homes to deliver more expertise, in a more ordered and timely fashion, with more clearly delineated roles and responsibilities.  We know that where these types of recommendations have been put into practice around care homes – in Salford, Sandwell, the Humber, Peterborough, Nottingham, South Glasgow and numerous other towns and cities around the UK – that care has improved as a consequence.  Other initiatives, including the Gold Standards Framework for End-of-life-care and the Dementia Care Matters programme have helped to spread good practice around long-term care.  Again, these have focussed on praising the best and spreading the wisdom derived from care already taking place within the long-term care sector.

There is much to be done.  But let’s not forget the considerable progress that’s already been made.  The challenge is not that care for older people is universally bad.  Rather the problem is that it is not universally good. Let’s remember to praise the best, whilst continuing to expose the worst.  And let’s remember that it’s through the continued, concerted action of people within the acute and long-term care sectors, working to evidence based documents like Fit for Frailty and the Care Home Commissioning Guidance, that standards are most likely to improve.

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