The British Geriatrics Society (BGS) is the only professional association, in the United Kingdom, for doctors practising geriatric medicine. The 2,200 members worldwide are consultants in geriatric medicine, the psychiatry of old age, public health medicine, general practitioners, allied health professionals, and scientists engaged in the research of age-related disease. The Society offers specialist medical expertise in the whole range of health care needs of older people, from acute hospital care to high quality long-term care in the community.

Geriatric Medicine
Geriatric Medicine (Geriatrics) is that branch of general medicine concerned with the clinical, preventive, remedial and social aspects of illness of older people. Their high morbidity rates, different patterns of disease presentation, slower response to treatment and requirements for social support, call for special medical skills. The purpose is to restore an ill and disabled person to a level of maximum ability and, wherever possible, return the person to an independent life at home.

The Society is delighted to be given the opportunity to contribute to this debate and would comment as follows:

1. We recognise that terminology can be complex in this area, and the names given to particular packages of care (for instance, ‘NHS Continuing Healthcare’) can cause confusion. We are keen to receive any suggestions for how these core concepts could be re-named to better describe the services they provide.

1.1 We will make our suggestions on terminology as we answer the questions.

2. Currently, Strategic Health Authorities hold policy responsibility for local Continuing Care policies. Following the introduction of the National Framework, we are considering moving this overall responsibility to Primary Care Trusts as the local commissioning bodies for NHS services. We would welcome your contributions on this proposal, and any particular benefits or potential obstacles to achieving this.

2.1 We have no concerns about the transfer of care of responsibility from the Strategic Health Authority to Primary Care Trusts as long as the Primary Care Trusts recognise the importance of Comprehensive Geriatric Assessment (CGA*) as part of the Assessment Framework for older frail people for NHS funded Continuing Care.

*CGA is a multidimensional interdisciplinary diagnostic process focused on determining a frail older person’s medical, psychological and functional capability in order to develop a co-ordinated and integrated plan for treatment and long term follow up

3. The National Framework sets out to assess individuals on the basis of their need for care, rather than their diagnosis, condition or where the care is provided, as the fairest way to determine eligibility for NHS funding. Does it achieve this or are there other factors which should be considered?

3.1 The National Framework should ensure that older frail people have the benefit of a full Comprehensive multi-disciplinary assessment and the opportunity to get better and rehabilitate where possible and at the same time should ensure that the patients who really need NHS funded continuing care receive it. Practitioners should pay some regard to the expected trajectory of the underlying “disease, diagnosis or condition” because catastrophic symptomatic deterioration may be imminent but not manifest at the time of assessment. The clinical changes are likely to take place faster than the responsiveness of the bureaucracy as it reassesses eligibility.

4. We assess whether an individual’s primary need is a health need with reference to four key indicators – nature, complexity, intensity and unpredictability. Do you think these are the correct indicators, or are there any omissions?

4.1 We are not sure whether the use of the word “nature” is appropriate. We would suggest the use of type as an alternative.

5. Do you have any views on the statements used to describe the key indicators?

5.1 We are happy with the statements used to describe the key indicators but are concerned that there is no mention of the end of life or palliative care aspects of care although they are emphasised in paragraph 34, 35 and 36 on page 8 in Core Values and Principles. As is stated NHS Continuing care is often given to those who are dying as the result of other conditions apart from Cancer.

6. Assessors will determine whether a primary health need is established by looking at the key indicators in terms of eleven generic ‘care domains’:

a. Behaviour

b. Cognitive Impairment

c. Communication

d. Mobility

e. Nutrition

f. Continence

g. Skin (including tissue viability)

h. Breathing

i. Drug Therapies and Medication

j. Psychological/Emotional Needs

k. Seizures/Altered States of Consciousness

Bearing in mind that professional judgment is paramount and assessors can add to/overrule these on a case-by-case basis, are these the right core areas of need to assess?

6.1 We suggest that cognition should replace cognitive impairment.

Assessors should also look at hearing and vision as part of communication. Breathing should include references to aspiration and the need for sunction as a priority. Pain must be included, as a primary health need. Assessors must be aware that whatever is decided must unambiguously award NHS healthcare to people with the same needs as Miss Coughlan and Mrs Grogan because that is the law as it stands.

7. What are your views on the process shown in the Assessment Framework? What are the potential implementation issues?

• We welcome the introduction of the process shown in the Assessment Framework but have major concerns about the implementation when dedicated rehabilitation wards for older frail people are being closed in England. (The BGS study in 2005 demonstrated that 1399 beds had been closed) We are aware that bed closures have continued since our study. Without rehabilitation beds or sufficient numbers of beds for frail older people recovering from problems such as strokes or fractures and acute on chronic disease older frail patients may receive hasty and poorly co-ordinated assessment and may not have the opportunity to make an adequate recovery. People who in the past would have gone home or to social service funded care may not reach their maximum potential and hence will require intensive NHS funded Continuing care. Appropriate review after assessment for Continuing Health Care should also consider whether opportunity has arisen for rehabilitation, eg. Resolution of delirium.

8. Do you agree with the concept of a national screening tool to help promote proportionate and appropriate assessments and to direct resources where they are most needed?

8.1 We welcome the concept of a national screening tool, as this will prevent a post-code lottery.

9. We would welcome views on the concept of the national Decision-Support Tool to promote greater clarity and consistency in decision-making nationally.

9.1 We welcome the use of a national decision tool but are concerned that the assessment tools which are illustrated in the consultation pack are not the recognised standardised tools we currently use to measure, function, mood, mental state, mobility and respiratory and cardiac function. We would recommend the use of the Mini -mental state examination “MMSE”, “Clox” and IQ code for cognitive function and the Barthel score or equivalent for physical function.

10. Do you think that the care planning process is the best place to establish whether an individual requires care from a registered nurse? What are the alternative processes for determining eligibility for NHS-funded Nursing Care?

10.1 We are of the opinion that the care planning process is the best place to establish whether an individual requires care from a registered nurse.

11. What are your views on the principle of removing the banding system for payments of NHS-funded Nursing Care?

11.1 We welcome the principle of removing the bands for payments of NHS-funded Nursing Care.

12. We would also welcome your views on the following supporting documents:

a. ‘Core Values and Principles’

b. Public Information Leaflet

c. Consultation Presentation

d. Partial Regulatory Impact Assessment

12.1 We found the supporting documents most useful.

13. If you would like to say anything else about the issues raised by the National Framework for NHS

Continuing Healthcare and NHS-funded Nursing Care, please do so.