Autumn Speakers Series: A glimpse into the future of acute care for older people; innovation, connectivity, transformation

Professor Roger Wong is Executive Associate Dean, Education in the Faculty of Medicine, University of British Columbia (UBC). He is a consultant geriatrician at Vancouver General Hospital, where he founded the Acute Care for Elders (ACE) unit that is replicated across Canada and internationally. He tweets at @RogerWong10 and is a key opinion leader in geriatrics and ageing. In this blog article he discusses the determinants that can transform the future of acute care for older people. He will be speaking at the upcoming BGS Autumn Meeting in London.

For all of us who work with seniors in the hospital setting, we often wonder what the future holds for acute care for older people. While our crystal ball may appear blurry on some of the exact details, we can certainly take a sneak preview now on three determinants that can change and shape the future of acute care geriatrics.

First, disruptive innovation in the medical sciences has already begun to transform the delivery of healthcare in seniors. Take cancer for example, which affects a significant number of older people every year. Continue reading

Do attitudes toward older patients even matter?

Rajvinder Samra is a Lecturer in Health and Social Care at The Open University. She is interested in healthcare professionals’ attitudes towards older patients. If you’re interested in this topic at all, get in touch with her at Rajvinder.samra@open.ac.uk

doctorDoes it matter if doctors like older patients? Is there any point in working out if doctors have positive or negative attitudes towards older patients? Surely it’s irrelevant because doctors are professionals that can separate their personal and professional feelings. Maybe they can, but that’s not the point as to why these questions are important.

The US has a long history of looking at medical students’ and doctors’ attitudes towards older patients and seeing if this is related to their likelihood of working in specialties like geriatrics. It seems like you are more likely to consider geriatrics if you have more positive attitudes towards older patients than people with more negative attitudes. Well, that seems obvious, doesn’t it? Continue reading

Patients don’t just have dementia

Beverley Marriott is Birmingham Community Healthcare Foundation Trust Nurse Practitioner – Community Matron based at Heart of England Good Hope Hospital. She is currently undertaking a Fellowship in Older People at Kings College London. Here she reminds us that we need to see the whole person when looking at someone with dementia.

medical-pillsMany of us work within dementia care on a daily basis. As a community matron on an AMU department supporting safe and timely discharges for patients with dementia, I understand the importance of getting it right and what happens when we get it wrong.

Dementia has reached a critical point – over recent years the government has seen improvements in diagnosis, raising public awareness and promoting dementia friendly settings. However to deliver this level of improvement requires, time, resources and focus.  Continue reading

Benchmarking Older People’s Care in Acute Settings

Lindsey Ashley is the Communications Manager for the NHS Benchmarking Network and is a strong advocate for benchmarking our NHS services.

acuteIt is recognised in the NHS and the media that older people are a major service user cohort for health and social care services, both in hospital (the acute setting) and in the community. It is well described that the population is ageing, as people are living longer, and as a result, there are more older people as a proportion of the overall population. Whilst overall life expectancy is rising, there are also significant inequalities across the country in terms of life expectancy. Continue reading

Why rehabilitation must be part of acute care

Kenneth Rockwood is Professor of Medicine (Geriatric Medicine & Neurology) and consultant geriatrician at Capital Health in Halifax, Nova Scotia, Canada and Honorary Professor of Geriatric Medicine at the University of Manchester.

Many older people leave hospital frailer than when they started. Some of that is preventable, but much of the damage done by acute illness is baked in to how frailty works. Some of it is reparable. That is why rehabilitation must be part of acute care: if we cannot prevent damage, we should at least treat it, especially damage that we inflicted unnecessarily.

The gist of it is easy enough. When frail patients are unwell enough to come to hospital, they typically are not thinking, functioning and moving like they were before they became ill.  That is usually why they come. That, and whatever other symptoms (breathlessness, pain, something red or swollen) signal a problem.  Even when fixing the precipitants, modern care often does nothing to address the worse thinking / mobility / function in which the problems were packaged.  Such complexity of need defines frailty.

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The contribution of intermediate care to crisis response and acute admission avoidance in Catalonia

Inzitari Photo carnetMarco Inzitari is a geriatrician and Director of Healthcare, Research and Teaching at Parc Sanitari Pere Virgili, Barcelona, and Associate Professor of Medicine at Universitat Autònoma de Barcelona. Here he descibes “Subacute Care Units” which have been set up in Catalonia. He tweets @marcoinzi

An “unbelievable pressure on acute hospitals, with winter on its way…the rapidly ageing population and the increasing number of people with complex long-term conditions, frailty or dementia” describes the English healthcare situation, according to David Oliver’s recent post for The Kings Fund.

This scenario perfectly fits the reality of Catalonia, Spain. A predominantly bed-based intermediate care system is well established in Catalonia: aside from the traditional aim of facilitating early discharges from acute wards, new pathways have been implemented to reduce the pressure on acute hospitals and avoid unnecessary hospitalisation for older patients.

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NHS Benchmarking Network publish older people in acute settings results

7382c36aab90e284dc2b6bbbb705b0f0_400x400Leigh Jenkins is Assistant Project Manager at the NHS Benchmarking Network. Dr. Gill Turner is a consultant geriatrician and Vice President, Clinical Quality for the British Geriatrics Society.

Wouldn’t it be great if you could benchmark the acute services provided for older people in your hospital, against others trying to do similar things? Might this be the start of a quality improvement process, allowing you to seethat other hospitals do things differently and possibly better?

This month saw the publication of a report which moved us closer to that ideal. The NHS Benchmarking Network have completed the first phase of a national benchmarking project looking at the care of older people in acute settings. Developed in conjunction with the British Geriatrics Society, the project explores the pathways that older people take through hospital by looking at four key areas of the acute pathway; admission avoidance in A&E, assessment units, inpatient care and supported discharge.

Over the course of the summer of 2014 the Network collected data from 47 Trusts and Local Health boards on a range of metrics. Within each area of the pathway the service models, activity, workforce and finance data was explored. A number of key quality and safety indicators were also collected, and participating trusts were encouraged to share any good practice and innovation that is happening locally. The findings of the first phase of the project provide a robust, up-to-date picture of the care of older people in acute settings in the UK.

We were keen to explore the availability of different teams in A&E who are dedicated to admissions avoidance. The results show that 24% of the Trusts who participated in the project have a dedicated geriatric team located in the A&E department, typically available for 9 hours per day during the week, reducing to 6.5 hours at weekends. Nearly two thirds of the 47 participating trusts have rapid access to social workers in the ED to support early turnaround and admission avoidance – whilst commendable – this means that over a third don’t have this facility- already an important comparator and a stimulus to discussion in those trusts.

We collected data on assessment units, with a particular interest in the use of Comprehensive Geriatric Assessment (CGA). 29% of participants have a frailty unit, and 90% are using CGA on the frailty unit. Senior medical cover on the frailty unit averages 13 hours per weekday, and 10hrs at weekends. It is perhaps disappointing that more than 10 % of specialist geriatric units do not provide CGA- again food for further discussion in those trusts.

77% have a short term assessment unit (up to 12 hrs expected LoS), with 44% of these performing CGA on this unit. Senior medical cover is available 17hrs per day during the week, and 6hrs at weekends. Finally, 85% report having an ‘other’ assessment unit (12 to 72 hrs expected LoS), with around a third of these units performing CGA. Senior medical cover availability averages 15.4hrs on weekdays and 14.4 hrs at weekends.

It was also found that 87% of elderly care wards deliver Comprehensive Geriatric Assessment, which reduces to just 23% of speciality wards delivering CGA, suggesting that outlying patients are not receiving CGA.

We were also interested in the staffing skill mix at each element of the pathway, particularly the nursing staffing ratio. We found a richer nursing skill mix is available at the front and back end of the hospital, with the use of unregistered nurses significantly higher within assessment units and care of the elderly wards. In the admissions avoidance teams in A&E the ratio of nurses was 80% registered and 20% unregistered, compared to 55% registered and 45% unregistered on the elderly care wards.

Excitingly the Network has already made the decision to repeat the audit this summer, and we anticipate increasing momentum with a greater number of trusts and health boards getting involved. The BGS Clinical Quality group are working alongside the project team to develop the measures of quality in several domains – we are keen to see how routinely collected data can help to assess efficiency, effectiveness and safety. We are looking at developing a Patient Reported Experience Measure (PREM) and examining how this could practically be incorporated into the project.

Data collection will open on 3rd August 2015, and is open to all member organisations of the NHS Benchmarking Network. To find out if your Trust is a member or for more information on the project please contact Leigh Jenkins of the NHS Benchmarking Network on leigh.jenkins@nhs.net, 0161 266 2113.

We don’t have all the answers – but we are starting to understand what questions we should ask. Please get involved and take a look at the report and contact us if you have things to say. We really want to hear from you.

Hundreds more metrics can be found in the full report, which can be accessed here.

Identifying health and social care costs for older people

queueRachel Elliott and Matthew Franklin are reporting on behalf of the Medical Crises in Older People (MCOP) research team at the University of Nottingham.

As part of a programme developing and evaluating care in older people, our team wanted to know the distribution of health and social care costs of older adults discharged from Acute Medical Units (AMU) in England across six care services (primary care, hospitals, intermediate care, mental healthcare, social care, and the ambulance service). This is the first study to do this in England.

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The Acute Frailty Network – solutions for urgent care for older people?

Dr Simon Conroy is Head of Geriatric Medicine, University Hospitals of Leicester, Honorary Senior Lecturer, University of Leicester and an Associate Editor for Age and Ageing journal.

Urgent care of frail older people is rapidly becoming the core business of acute hospitals; it is often described as a ‘wicked problem’. This year has been one of the most challenging periods for staff and patients in the NHS in many years. The debrief is on-going, but candidate theories include ‘too many old people’ (sic), lack of primary care, poor ED staffing, and reduced outflow relating to social care cuts. The truth is likely to be a combination of all of these factors, and many others. An important output from the post-mortem is to determine what we can do about it in the future?

Undoubtedly one of the drivers is the ageing demographic, which does mean that hospitals need to expect more older people coming though their doors, many of whom will be frail. Whilst there have been significant improvements over the last few years in the acute care response to older people, there is still a long way to go. There have also been some significant misunderstandings about what is required for older people accessing urgent care. It is not just geriatricians! Rather it is the technology to which geriatricians can usefully contribute to or even coordinate – Comprehensive Geriatric Assessment (CGA). But CGA is not an exclusive club. Every physician involved in managing frail older people should be able to play a useful part in CGA. It’s just that geriatricians are specifically trained to do it, although increasingly other physicians are developing their skills in this area which is key for future-proofing urgent care. Yet we see significant variation in the interpretation of what constitutes CGA. I have taken the liberty here of illustrating some of the key concepts.

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The 12 Days of Christmas – a hospital doctor’s lament

4980cbdcDavid Oliver is the current President of the BGS, a visiting Fellow at the Kings Fund, and a consultant in geriatrics and acute general medicine at the Royal Berkshire NHS Foundation Trust.

This time last year, I wrote the “Geriatrics Profanisaurus” – all about words and phrases which should be banned when discussing older people. It triggered plenty of  responses “below the line”, adding to the list of ageist and ignorant language regarding healthcare for older people and went a bit “viral” online. Indeed, the BGS is now being followed by Roger Melly’s Profanisaurus on Twitter, as is occasionally “sweary geriatrician” Dr Wyrko.

As I started the precedent of a festive Presidential blog, I couldn’t resist my own re-write of the old favourite “The 12 Days of Christmas”. I say this as a frontline doctor who frequently disappears into an uber-busy acute medical unit, or emergency department and has inpatients who are increasingly frail and complex and often requiring step down health and social care services which are themselves over-stretched. It’s a very challenging environment both for staff, patients and families and one that I know colleagues right across the four nations face, especially in the winter months. Its important in letting off steam on this site – mainly read by clinicians, that we are all deadly serious about trying to provide the highest quality care for patients. So no fun is intended to be at anyone’s expense.

But here goes anyway: do join in, especially with a hearty “Five Interims”.

On the twelfth day of Christmas,
My true love sent to me:
Twelve “vacant” locums,
Eleven “bed meetings”,
Ten “points of access”,
Nine winter pilots,
Eight re-admissions,
Seven day working,
Six delayed transfers,
Five Interims,
Four hour breaches,
Three Iberian Nurses,
Two Norovirus,
and  an over-crowded ED…

I also sometimes find other songs going through my head that seem strangely appropriate to the jobs we all do. Here are one or two:

“Back in Black” …”I want my bed base back”  – with thanks to Los Bravos.

Or indeed “Back to Black” by Amy Winehouse. “Black Alert” that is – when we have as many beds as Bethlehem had room at the Inn. At such times, though I am a Man City Fan, “Simply Red” would be a welcome sight for once.

Talking of Amy, if I had a quid for every patient whom I have wanted to send to intermediate care for ongoing rehab, but has preferred either to stay in hospital or to go home with no rehabilitation and support, surely “They tried to make me go to rehab, I say No, No, No” fits the bill.

Allied to this is the Beatles “Hard Day’s Night” – not only applicable to overstretched on call teams and nurses but also when patients who don’t want to stay another hour in hospital say to me “Doctor, when I’m home…” and I do feel like replying “I know…everything seems to be right”.

Sadly it’s hard for many patients to understand that hospital consultants can’t click their fingers and magic up social care or community rehab places; I can see these patients singing Gwen Stefani’s “What you waitin’, what you waitin’ for?”

When it comes to falls resulting from postural instability, then we have to acknowledge the sage words of Miss Meghan Trainor: “It’s all about that Base”

Now over to the readers of this blog, for your suggestions! Nothing disrespectful or inappropriate, please or our Digital Media Editor will be in like Flynn and remove the post,  but if you can think of any more songs for the thread or any more lyrics for those twelve days, we’d like to hear from you!

Finally, let me wish you all a very Happy Christmas. And remember, winter pressures or not, the health service is an immensely rewarding place to work: our colleagues are troupers and caring for people at their neediest is a privileged occupation, however demanding it may be. But perhaps a bit of dark humour can help through the worst two clinical weeks of the year.