BGS Autumn meeting - 2015 conference report
The National Health Service is facing three big challenges according to the Chief Executive of The King’s Fund.
It must sustain existing services and standards but also develop new and better models of care and it must do both, at a time of ever increasing financial constraints, by engaging staff and reforming from within.
“Sustaining existing services means keeping the focus on quality of care and patient safety, recruiting and retaining staff, training the workforce of the future and balancing budgets,” Prof. Chris Ham told the autumn meeting of the BGS.
New models included more integrated care, embracing new technologies where they brought benefits, prioritising prevention and improving the health of the population generally.
“We must make every contact count towards active health promotion.” It could also mean extending the type of devolution already in action in Manchester where local politicians had more control over public services to other cities and regions.
It was also vital to understand and respond to what mattered to patients. There should be specific goals for improvement and systematic measurements of progress towards them.
Leaders must listen to and engage with staff and be visibly committed to patient centred care.
“Successive governments have relied on external pressures to reform and improve the NHS but much more emphasis should be placed on change being led locally,” he added. High performing health care organisations and systems around the world showed how this could be done. The King’s Fund had looked at examples in such countries as Sweden, New Zealand and America. Common factors included the ability to measure how many lives had been saved by best practice and an appeal to professionalism and commitment rather than compliance.
“This is a long march, real and sustainable improvement takes time. It occurs through aggregation of marginal gains not big leaps forward,” said Prof. Ham. “Improvement must draw on the intrinsic motivation of doctors and others to provide high quality care. Political leaders should set budgets and system objectives but not micro manage; political leaders and regulators should do no harm.”
General practice should be at the heart of new care models with practices working together by forming, for example, a system of federations which in turn could be building blocks for providing integrated out-of-hospital services and technological support. “It’s fascinating to see how federations have been established, not because of a policy document but because GPs see cause for working collaboratively.” There should be opportunities for specialists like geriatricians to work across both hospitals and the community as was already happening in some places. “We need to move away from the historic division of GPs in the community and specialists in hospital.”
Although there would be pressure to use resources and reduce waste, in the end more money would probably have to be found. “The government will not want to preside over the slow demise of the NHS,” he said. “It tops the list of things which make us proud to be British.”
Geriatrics in the community
The need to develop new care models for older people prompted by demographic changes was the major theme of the conference’s opening day organised by the Community Geriatrics Special Interest Group. The first session looked at the current state of intermediate care and its future.
Dr. Duncan Forsyth, consultant geriatrician at Cambridge University Hospital and chair of the National Audit of Intermediate Care, said that intermediate care (IC) had three main aims: to avoid unnecessary hospitalisation, to achieve independence after a stay in hospital and to prevent a move to residential care.
Although the concept had been established in 2001 and large amounts of money spent in the following years, it was not until the NAIC was set up three years ago that there was any clear indication of how intermediate care was being commissioned or what was working. The idea was to introduce standardisation of measures in order to analyse what worked well.
Last year the Audit looked at 124 providers and 472 services both home based and bed based and distributed 12,000 user questionnaires. The results to date suggested a 20 per cent degree of improvement. They also found that outcomes improved in proportion to the number of different professionals involved. “It shows the effectiveness of multi-disciplinary care,” said Dr. Forsyth.
“We tried to get a users’ perspective so we asked patients ‘what one thing would make IC better for you?’”. Themes which emerged included the need for punctuality, personalised care, joined up services and for professionals to communicate with each other so that patients were not repeatedly asked the same questions. Some felt abruptly abandoned at the end of the IC. “It was ‘listen to me and hear me, treat me as an equal, see me as a person’.”
His talk also had a warning. “Investment in IC does not appear to have increased and it’s estimated that we are under provisioned by half. This can mean increased waiting times for IC of between two to seven days for bed based care and up to six days for home based. And the longer you wait, the less likely you are to benefit.”
Intermediate care at risk
The speaker who followed Dr. Forsyth also sounded an alert. Giving the keynote lecture of the day on the future of IC for older people, Nigel Edwards, chief executive at the Nuffield Trust, said “Demand is growing and the system is creaking. Good plans are in short supply.”
To meet the needs of the ever growing number of over 65s it was estimated that the UK should have 40 new hospitals by 2022 – “and no-one is going to build 40 new hospitals.” There was also a predicted shortfall in the number of nurses – 100,000 in the next six or seven years – and the number of social care staff – perhaps by a million over the next decade. There was likely to be a shortage of geriatricians, GPs, specialists in emergency medicine, and psychiatrists as well as further reductions in spending. The Living Wage would also have significant implications.
It was essential therefore to develop new models to keep people out of hospital. Possible solutions included patient empowerment and education, pro-active and participatory care perhaps with some people using personal budgets, peer support and more community engagement to support carers. Stronger partnerships with the voluntary sector should be forged and volunteering generally encouraged. Longer appointments might be useful for care planning and case management.
Those working in IC for older people needed to find new ways to work with primary care but integration was difficult, took time and required changes in relationships – “it means understanding each other’s attitudes.” The complex web of out of hospital services must be simplified – “the average complex patient will deal with between six and eight organisations” – and data organised to better identify patients at risk.
Standardisation and increased efficiency were vital – “it may be more about improving value than reducing cost,” he added. “It may even be about doing extra work for the same money.” IT was playing a growing role with innovations such as tele-monitoring, telephone consultations, web inter-actions and support via Skype.
The big question, said Mr. Edwards, was how to stretch the geriatrician workforce further and he invited his audience to think about this challenge, calling on them to experiment boldly with new projects. “Often things are too small or too short to make a difference. We need to make the economic case that IC is cheaper than hospital and we need more research to do this. Professionals like you need to come up with ideas and answers or someone else will do it for you and you won’t like it.”
Quality markers in intermediate care
Prof. John Young, national clinical director for Integration and the Frail Elderly for NHS England, spoke next on the development of quality markers in intermediate care. It was important, he said, to bring all the data sets together but also to look at the situation from the patient’s viewpoint. “It’s information gathering and information sharing, making the patient feel properly involved.”
One path to such involvement is through PREMs, The Patient Reported Experience Measure, as the following speaker Dr. Elizabeth Teale, consultant in elderly care medicine at Bradford Teaching Hospitals, explained. The 15 questions aimed to identify from a patient’s perspective aspects of care which did or did not happen: it was a measure of experience, not of satisfaction, which was subjective and could be high even when care had been poor. "It doesn’t tell us what should be done to improve the situation.” PREMs, however, by asking, for example, whether someone felt they were treated with dignity or had confidence in the staff, provided a way to improve quality through feedback from the service users.
Rehab and recovery
The key to successful outcomes in intermediate care was getting the right intervention at the right time, Prof. John Bolton, visiting professor at the Institute of Public Care, told the meeting. Studies in Australia and Canada had suggested that a little care at the wrong time increased the need for more. “You can inadvertently suck people into formal care.” New models looked for a better balance between helping older people in crisis but at the same time focussing on rehab and recovery so they needed less formal longer term care.
Preventing falls was an example since falls were the third highest risk factor in admissions to residential care. Similarly rehabilitation was often more successful when patients were given physiotherapy to do themselves rather than always having to rely on a therapist. Providing the right equipment including assistive technology and offering family or community solutions could make all the difference. Personalisation meant empowering older people to identify their needs and be involved in managing them.
It was estimated that between 20 and 30 per cent of residential admissions could be avoided with improved community care and that three quarters of assessments of older people in hospitals overstated their needs. This was a result of caution, ignorance of what was available in the community and assessment at the wrong time.
“Outcomes from IC may be related to poor risk averse assessments rather than poor intermediate care. So don’t assess during a crisis when someone is at their worst. Support them with health and care resources, preferably at home, and then assess for the longer term after 6 to 12 weeks.”
Prof. Bolton concluded by listing the markers of success. “You will know when IC is working when you find smooth and clear pathways from hospital to community and delayed discharges are not an issue. When numbers admitted to residential care are falling or when already reduced remain stable. When numbers of readmissions begin to reduce. And when each person has a clear health and care plan which focuses on recovery and managing long term conditions supported by all providers of health care.”
Intermediate care and occupational therapy
Occupational therapists could play an important part in IC bridging the gap between health and social care, said Cynthia Murphy, chair of the College of Occupational Therapists Specialist Section for Older People. Patients should be seen as soon as possible in order to engage with what was meaningful to them. One 70 year-old man, for instance, who had had a stroke wanted to be able to take his grandchildren on a bus outing. An 89 year-old woman’s goal was to be able to play a round of golf on her 90th birthday. “We concentrate on what individuals can do rather than what they can’t,” she emphasised.
Solutions were often relatively simple: a piece of equipment in the home to prevent de-skilling or loss of confidence or assistive technology to monitor movement or detect taps not being turned off, for example. One study had shown that for every £1 spent there was a saving of £12.
Other speakers during the afternoon session described examples of best practice in the integration of acute hospitals and local community services in Islington and Homerton in London and in Hull.
Crossing disciplines, crossing countries
With much of the conference emphasising the need for integrated care and the importance of multi-disciplinary teams it was perhaps appropriate that it was co-hosted by AGILE and that there were 70 physiotherapists among the 720 attendees who also included other allied health professionals as well as visitors from Finland, New Zealand, Holland, Hong Kong, Australia and Belgium.
AGILE, the organisation of chartered physiotherapists working with older people, ran a whole morning on orthogeriatrics for the 21st century which opened with Antony Johansen, consultant orthogeriatrician at Cardiff Trauma Unit. In his keynote address he stressed the importance of collecting hip fracture data as a way of analysing, criticising and improving the system. “You can show that good care is cheaper than bad care.”
As an example of small, relatively inexpensive initiatives he cited the importance of post operative nutritional support which was often difficult if patients could not reach their food or were not motivated to eat. When his own grandmother broke her pelvis his mother had come in every day to help feed her. After witnessing the contribution this made to his grandmother’s recovery his department now paid the WRVS to come onto the wards as dietetic assistants. The initiative had helped halve mortality in that group.
Looking to the future he argued that it was important to change the attitude of anaesthetists who were often risk averse towards emergency surgery on older patients. “In fact dying under anaesthetic is not a bad way to go, rather than lingering in bed with a broken hip while the world unravels. It’s only a problem if it’s not been talked about. You have to tell the anaesthetist that not all patients will come a cropper under anaesthesia but they will die if they don’t have surgery.”
He was followed by Karen Barker. a physiotherapist and clinical director of the musculoskeletal directorate at the Nuffield Orthopaedic Centre in Oxford who spoke about non-surgical management of vertebral fractures. There was, she said, increasing evidence that exercise, progressive strength training and manual therapy could be safe and effective. Spinal orthoses could also help reduce pain and fatigue.
Dr Nigel Hanchard, also a physiotherapist and a reader in orthopaedics at Teeside University, then gave a talk on the ‘older shoulder’. “Ten per cent of people over 50 will have shoulder pain,” he said. “The prevalence increases with age, the problem lasts longer and it can have a big emotional impact.” Ordinary activities like getting dressed, carrying bags, driving, even opening doors, could become very difficult.
Although stiffness and pain, caused either by impingement or a frozen shoulder, could be helped by exercise, manual therapy and steroid injections, GPs often lacked confidence in diagnosing the problem thus prolonging suffering and fuelling anxiety. “The issue is therefore one of knowledge translation,” he added.
Although malnutrition is a widespread problem among older people, its opposite, obesity, is also a cause for concern and one that is likely to increase in the coming years as younger overweight people age.
Dr. Philip James, Honorary Professor of Nutrition at the London School of Hygiene and a past president of the World Obesity Federation, said, “In the last 50 years there has been a collapse in the need to do physical activity because of cars, mechanical aids and computers which means we cannot use the same food as our grandparents.”
Obesity was a major factor in premature mortality, substantially increasing the risk of cardio-vascular disease, type 2 diabetes, arthritis and colon cancer and possibly even of Alzheimers and vascular dementia. “This is a major medical problem which we know is going to get worse. Obesity hasn’t reached epidemic proportions in older people yet but in five to ten years you will be seeing it in 75 year-olds.”
With older people who were already obese, switching to a Mediterranean diet rich in olive oil, fruit and vegetables could have a remarkable effect in improving disability, frailty and mortality as well as weight loss.
His co-speaker in the session, Dr. David Haslam, chair of the National Obesity Forum, outlined some of the possibilities for dealing with what he described as “today’s principal health concern. Nearly two thirds of men and half of all women are overweight or obese.” Being too fat accounted for 18 million sick days a year, a cost to the NHS of £500m and a wider cost to the country of £2bn. It was the largest cause of cancer after smoking and shortened lives by an average of nine years.
Although obesity could be tackled by diet, exercise, a very small number of drugs and in the most extreme examples bariatric surgery, weight loss was difficult and was not always appropriate in the old. Lowering cholesterol and blood pressure by other means and in some cases just offering palliative care might be more fitting, he added.
An often overlooked area for research is sexually intimacy among older people, a knowledge gap which Dawne Garrett, professional lead for older people and dementia care at the Royal College of Nursing, is hoping to help fill with the subject of her Ph.D.
She was, however, encountering problems with recruitment: there were too many gatekeepers. She had anticipated having to deal with ethical questions concerning safeguarding and mental capacity – “one of my early findings is that we should have more older people on ethics committees.”
She had also encountered abuse on the grannynet website and a reluctance of local authorities, voluntary organisations, charities and community groups to publicise her requests for interviewees. Yet the subject was vitally important and not discussed enough with patients. She told the nurse and allied health professionals session, “It’s the last taboo.”
For the purposes of her research intimacy covered a range of behaviours from full sexual intercourse to anything the participants saw as intimate: kissing and cuddling, teasing, being naked. “I wanted to look at older people in their normal lives which, after all, is where they mostly are. Although we see them in hospital that’s only a small component. “
Early findings from interviewees she had managed to contact had some interesting components. There was a trend for some older couples to ‘live apart together’ – they did not live in the same home but saw themselves as a partnership. Men and women in new relationships often kept their lovers separate from the rest of their lives, perhaps fearful of disapproval from family and friends. Changing residences – downsizing, moving in with a son or daughter or into a care home – could make it difficult to continue intimacy
There was a wide variation in actual behaviour. “Some were content to muddle through, adapting to their ageing bodies; others wanted to maintain the gold standard of earlier years and sought medication to help them. This can lead to cascade prescribing: the man comes for Viagra and then later the woman comes for lubrication because of discomfort.”
There could be inequality of desire where one partner liked sex and the other did not, which created great tension. “Intimacy also had to be adapted to changing health and there was always the spectre of death, maybe the death of a previous partner or the feeling ‘ it’s great now but...’ .”
Her interviewees did find it difficult and tiring to talk about sex but she also found there was a rhythm to the way in which people revealed details of an intimate relationship. “They dance in and out of the subject before getting to the big reveal. If you watch a few of these dances you can begin to see where this is going to occur and at that point you can draw them out.”
A personal perspective on pain
One of the draws of a BGS meeting is the chance to hear from patients directly about experiences which have prompted action. This was the case in the Pain Toolkit workshop with Peter Moore who himself suffered for years, spending thousands on relief for his chronic bad back and at one point feeling near-suicidal, until a pain management programme increased his confidence, mobility and provided him with the skills to cope.
“The pain itself is just the tip of the iceberg,” he said. “There’s loss of fitness with weak muscles and joint stiffness, sleep problems, fatigue, the side effects of medication, weight loss or gain. You get boom and bust so if you have a good day you overdo it and then the pain increases and you need to rest and recover. Also, most of us expect doctors to be able to fix us so we become ‘doctor shoppers’, always seeking one who can solve the problem.”
Instead the solution lay in self management in a shared action plan between the patient and the doctor or other healthcare professional. “Of the 8,760 hours in a year people with pain or long term health condition receive on average three hours of professional care so for the other 8757 hours we have to self manage.”
The Pain Toolkit which Mr Moore wrote, backed by the Department of Health, is a guide to the key skills involved in this approach. Patients have to assess their own needs including what is important to them, what they can do to help themselves and what ongoing support is needed. A twelve step programme begins with accepting that one has persistent pain and then moving on through the various stages which include building a support team, learning to prioritise and plan, developing relaxation skills, stretching and exercise and having a set-back plan. “Managing pain doesn’t go in a straight line, it’s up and down, so you need to plan and be patient.”
Over half a million copies of the Toolkit have been printed in the UK and 200,000 downloaded from the website. There is also a half day workshop for doctors led by Mr. Moore and a team of GPs aimed at showing them how to support their patients in the plan. An estimated 14 million in the UK now live with persistent pain with numbers increasing every year.
Learning pain management skills could be particularly helpful with older people who were often complicit in ageist attitudes to suffering – they assumed it was an unavoidable part of old age. Instead they could learn active strategies which would give them control over and distraction from their pain, helping them prioritise valued activities, maintain independence and continue to feel socially useful. There was also a special cartoon book Medikidz aimed at helping grandparents explain their experiences to their grandchildren.
Death and DoLs
The subject of other workshop at the Brighton meeting was the work of the coroner’s court with Louise Hunt, the coroner for Birmingham and Solihull, who listed the reasons for investigating a death which included where death was violent or unnatural, where the cause was unknown and where it occurred in state detention. The latter category would cover police custody, prisons, mental hospital and, particularly relevant to the elderly, when someone had been subject to a deprivation of liberty order. The workshop had in fact opened with a ‘mock inquest’ into the death of an 86 year-old man with a complex medical history who had been the subject of a DoLS (Deprivation of Liberty) application with the audience challenged to reach a conclusion.
Although the purpose of an investigation was to establish the facts of a death – who, when, where and how – and not apportion blame either civil or criminal, there was provision, Ms Hunt explained, to add neglect as a rider. This was where there had been gross failure to provide basic medical attention to a person in a dependent position which had directly caused or materially contributed to their death. Examples might be failing to put a care plan in place to prevent pressure sores where indicated or failure to switch on a non invasive ventilation machine in a patient who had COPD. A coroner was also able to highlight issues and suggest measures which might prevent future deaths from the same cause.
For doctors called to give evidence at an inquest she had some advice. “Be prepared, speak in clear language, confirm the facts and offer an opinion if necessary. Try and understand the family’s issues. It’s not nice if they are angry but they can be calmed. Explain, ‘I did that and it contributed but the treatment had to be done.’ It’s easy to be defensive but remember, this is a grieving family. Hardly anyone ever offers condolences but it can mean a lot.”
In addition to the workshops there were three sponsored symposia. The first, sponsored by Astellas, looked at choosing the right treatment for older patients with over active bladders with examples taken from three case studies. There was still a lot of nihilism about this ‘geriatric giant’ the symposium heard, but in fact much could be done. Solutions included drug treatments as well as lifestyle changes and bladder training.
Another symposium, sponsored by Abbot Nutrition, looked at the causes and consequences of the loss of lean body mass in older adults and the need for nutritional strategies to combat it.
A third, sponsored by Britannia Pharma, asked whether early stage Parkinson’s patients would also benefit from non-oral therapies.
The Friday lunchtime symposium was the start of an afternoon session devoted to the disease including a talk on the work the UK Parkinson’s Excellence Network which brings together health and social care professionals to work towards transforming the care of people with PD.
The Friday morning session had concluded with the guest lecture entitled, ‘a critical look at our post-acute care’, given by Prof. Finbarr Martin, consultant geriatrician at Guy’s and St. Thomas’s Hospitals in London.
In it, he looked at the factors which predicted readmission including prior admissions, length of stay and functional disability. Although clinical experience could generally identify at risk groups “the variability between individuals is to do with something else, something more like resilience.”
Some of the factors which produced longer term destabilisation in older patients, however, were potentially reversible: a poor nutritional state before and during hospitalisation, low mobility, length of stay and persistent delirium. Examples of measures at or after discharge which might help included comprehensive medication review, education on the self management of a disease and detailed communication with outpatient health professionals.
In many cases though such interventions did not seem to make a difference and a multiple domain approach was needed to restore resilience, rebuild lost reserves of strength and endurance, restore functional capacities and some degree of autonomy in a patient’s social role. More work was also needed too, on finding the behaviour change techniques most effective at increasing older adults’ self-efficacy and physical activity.
“How people get better is not a simple story: the journey from being well then ill then better again is a challenging and complex journey,” he added. “We do acute reasonably well and quickly but we don’t focus so much on what happens next. If we’re not getting that right we’re causing problems like readmissions. We need to identify the post acute period as a phase with its own science and practice.”
The conference also included sessions on diabetes, kidney disease, end of life care, pressure ulcers, polypharmacy, frailty and liver disease. In the latter, Dr. Gideon Hirschfield, consultant hepatologist at Birmingham University, was keen to dispel various myths including the belief that patients over 65 could not have transplants. Although there was a cut off age of around 74 or 75, up till then other factors were more relevant.
In the frailty session Dr Kate Walters, senior clinical lecturer in primary care and epidemiology at University College London, told the audience that the best evidence so far was for resistance and balance training. Goal setting might also help promote new behaviours though it was important to appreciate that older people might choose different goals from those of health professionals. “Motivation is key and fears of increased dependency and dementia appear to be the strongest motivating factors.”
There were nearly 70 posters dealing with a wide range of subjects and 14 abstracts were presented from the stage. Attendees also had opportunities to network and socialise with a drinks reception on the first evening and a conference dinner at the Hilton Metropole on Thursday with entertainment provided by the Forties style trio the Hotsie Totsies.