British Geriatrics Society

The care of frail older people with complex needs: time for a revolution

In November 2011, The King’s Fund invited academics, practitioners, policy-makers and representatives from patient and voluntary organisations to discuss the care of very old frail people with complex health problems.

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The key messages outlined in a report on the summit make the point that while there have been significant improvements in medicine in the past 25 years, many of our health professionals were educated and trained for a different era. While successive governments have tried to introduce policies and guidance to take account of the complexity of and growing number of people living with one or more long-term medical conditions, the challenge lies in turning the rhetoric of personalised care into the reality of everyday care and practice. The majority of staff providing physical and emotional care for older people are on low pay and have poor working conditions.

The report goes on to set out the scale of the challenge with well-known demographic statistics. It hastens to point out that “most patients in hospitals and recipients of home care rate their experience positively...it is evident that all the professions involved are lucky enough to attract a great many individuals with a vocation to work with older people.” However, the prevailing model of acute care is unsuited to patients with complex needs but this can be counteracted by taking action at different levels of the system. “We believe that the responsibility for quality of care and outcomes for patients is firmly located at the level of the team.”

The summit produced five recommendations:

For team leaders: The position of team leader / ward manager should have higher status in the wider organisation. S/he should be provided with opportunities for education and career progression and remuneration should reflect the value, complexity and importance of the role. This recommendation assumes team leaders to be involved in all aspects of patients’ care and that team leaders are likely to be ward managers, not doctors. In domiciliary services, the team leader will be the immediate supervisor or manager of a team of care assistants and social workers.

Senior leaders: Should understand and acknowledge the reality that frail older people with multiple health conditions are core service users and should plan their services accordingly.This includes specifying care pathways in detail and in advance; the pathways should include plans for geriatric assessment, care planning, transitions of care and how transitions are to be handled.

For professional bodies: Those bodies responsible for education and training, revalidation and appraisal should develop strategies to change the perceptions of older people’s services and to create the future workforce that older people need.

For policy-makers, government, the NHS Commissioning Board: Design structures and incentives that support the development of the professional workforce and drive better outcomes for frail older people. Limit the volume and frequency of detailed instructions and guidance issued to those closer to the frontline of clinical care because it can distract senior leaders from their primary task and obfuscate the picture in organisations. Set guiding principles, not rules, to emphasise the responsibility of senior leaders and clinicians to deliver better outcomes for patients and staff.

To think tanks and commentators: We should be pleased that we are living longer. Challenge deep-seated social prejudices towards older people. We have seen this done with divorce, children born out of wedlock, homosexuality, HIV/AIDS etc. The care of frail older people should be a priority for health and care services, with the concept of human rights as a standard point of reference.