Innovations in the delivery of care
We all know the reality of an ageing UK population, but rarely do we all share ideas that work for older people.
The King’s Fund conference in June presented a welcome opportunity to explore best health care practice across the whole UK. I was delighted to be invited to report on an inspirational day.
A pre-conference seminar on dementia enabled a range of healthcare professionals to discuss improving services for dementia patients. Examples included Schwartz Center Rounds®, a USA concept now used in UK hospitals, where monthly meetings allow all staff to discuss challenging psychosocial and emotional issues; and the Devon Dementia Quality Kite Mark which recognises quality care for dementia.
Ageing is a wonder of nature
The keynote address by Professor Lewis Wolpert, author of “You’re Looking Very Well: The Surprising Nature of Getting Old”, reaffirmed that age must not be seen as a disease but a wonder of nature. He reminded us that 60 per cent of older people are very happy with their health with the happiest age being 75 years. Discussing different theories of ageing and health, he stressed the importance of positive attitudes to ageing.
Professor David Oliver tackled the difficult topic of ‘How can we make our services work for an ageing population?’ When the NHS was founded, 48 per cent died under 65; now it is 14 per cent. His key message was “stop catastrophising about ageing” and view ageing as a victory for modern healthcare. However, as most over 75s have three or more diseases, we need to design healthcare around their needs. He advocated lifelong public health education that lifestyle choices impact on ageing. Two examples illustrated the reality of current healthcare systems. Firstly, a moving animation (‘Mrs Andrews’, HSJ) illustrated what can go wrong for older people in hospitals1. Secondly, he asked us ‘Who has found navigating the health service for an older relative bewildering?’ Most hands in the audience (all healthcare professionals) went up!
His suggested solutions included seeing situations from others’ perspectives, sharing ideas and learning from others. The learnist page2 via the King’s Fund has seventy examples of good practice. The ‘Ten components of care for older people’ approach, with integration and the patient at the centre, should make health and care systems better fit an ageing population3.
Older people: the NHS’s core business
Professor Ham examined policy levers for effecting change and reminded us the goal must be better outcomes not simply integration. He reinforced the fact that older people are core business in the NHS: “if you don’t want to be involved with complex medical older patients then don’t become a doctor/nurse/allied healthcare professional in 2014”.
Discharge planning and post-discharge support
The theme was shared ownership. Dr Ralston and Tracy Taylor (Birmingham) described seamless transitions in older people’s care. An unwell older person, seen by a Rapid Response Team clinician within two hours, is assured of a diagnosis, extra support and medication delivered direct to them, averting a turbulent hospital admission. Other innovations included a single point of access, manned by a clinician, and optimising accident and emergency assessment, enabling appropriate discharges home.
Computer system incompatibility and diverse criteria on referral forms impede good transition of care. Introducing a single referral form and increasing step down (subacute community) beds reduced length of stay. Patients sent home earlier had a care plan and follow-up arranged within five days.
Another insightful example was the award-winning Leicestershire HART programme. When the hospital has not identified complex needs, the team undertakes assessment at home on discharge, arranging reablement, and immediately providing equipment, and reassurance.
Innovative care across the four nations
Five projects were showcased. Greenwich’s ‘P2P Marketplace’ provides individuals with choice, control and independence in selecting their care. Wales showcased their rapid support programme ‘Care and Repair’, ensuring homes are safe for discharge. Scotland highlighted their Older People Acute Care (OPAC) Improvement programme focusing on their ‘Think Delirium’ campaign. Sheffield’s ‘Discharge to Assess’ quality improvement programme impressively reduced length of stay from 6.7 days to 6 hours. ‘Keep Active’ was an excellent example of effective rehabilitation from a London charity partnership.
Dr Hannah Johnson explained how simple environmental changes (colours, flooring, room layout, memorabilia) in a Berkshire hospital created a truly dementia-friendly ward with significant benefits.
The Royal Voluntary Service (RVS previously WRVS) ‘Home from Hospital’ scheme focused on identifying discharge patients at risk e.g. with no family nearby. From transport home to ensuring they were settled and followed up, they provided support, friendship and security. As David McCullough, RVS, said: “I still believe in the magic of two people and a cup of tea as part of social prescription to support older people.”
Professor Thomas addressed end-of-life care in care homes reminding us that 30 per cent of hospital patients are in their final year of life, and that it is important to live and die well. People dying well in care homes must be a measure of success, not failure. The Gold Standards Framework is designed to ensure this.
The closing session considered the pivotal role of interface geriatrics and a primary care based model for frailty. Dr Eileen Burns, Leeds, challenged whether hospitals are the safest place for older people, highlighting the community geriatrics role. Professor John Young emphasised that frailty must drive primary clinical practice changes. It is important to identify sub-acute issues indicating frailty onset and apply this to care, support and planning in line with the patient’s wishes. This requires more than a purely medical viewpoint.
It is impossible to do justice to all the diverse, inspirational examples at the conference. My take-home messages were:
- Discuss amongst your team - most care solutions are likely found locally
- Always remember the 10 components of care
- Learn from others; share ideas. As David McCullough, said: “ If we were in the private sector and had this many great ideas we wouldn’t be keeping them to ourselves”.
ST5, BGS Trainees Committee Communications Representative
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