Acute care for older people – approaching consensus?
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. Some 300 physicians (geriatricians, acute physicians, emergency physicians), and some paramedics and primary care staff gathered at the Royal College of Physicians on the 26th June 2013, to discuss the topic de jour – acute care of older people. The day started of poignantly with Dame Julie Mellor (Parliamentary and Health Service Ombudsman) ensuring that patients and their families remain the focus of our efforts. Dame Julie expounded the defensive nature of hospital when it comes to complaint handling, with staff feeling that they either lack the authority to resolve the complaint or fearing punishment. Most complaints relate to the care of older people – the parallels with the Francis enquiry were evident. It is noteworthy that Dame Julie’s office does not hold individuals to account, but organisations. Suggestions were to bring complaints handling on a par with investigations into Serious Untoward Incidents, rather than leaving complaints to be handled by a complaint department at arm’s length from clinicians. There was a call for clinicians to be allowed sufficient time in job plans to address complaints in real time. On a more sobering note, there was acknowledgement that public expectations might need to be managed – even the best care in the world cannot prevent people from falling ill or even dying. The second session started with a primary care perspective, offered up by Prof Louise Robinson, who reminded us that not all older people are unwell or frail – GPs see octogenarians off on world cruises as well as frail fallers. A big issue in primary care is the limited consultation time – an average consult with an older person takes 13.5 minutes, yet the standard consultation tariff is 7 minutes; this should be increasing soon. Louise highlighted dementia as a specific issue which places a strain on patients, their families and health and social care services. Worryingly, the Newcastle 85+ study indicated under-diagnosis of dementia. A concern, given the available treatments. An area where GPs might have a useful role is in advance care planning. However, whilst this works well for people with cancer, it is more difficult in the uncertain care trajectories experience by those with with frailty or dementia. There are lots of changes underway in primary care to help older people – increased appointment times, increased training, better shared care protocols and integrated working with secondary care teams.. Phil Lumbard gave a broad overview of the ambulance service and underlined just how hugely complicated an ambulance service is to deliver. Paramedics cover a wide range of urgent care scenarios, but have limited specific training in older people, despite the fact that older people – especially those who fall - are a big part of their workload. Phil described an innovative service that involved a specially-trained paramedic and therapy team that is able to see and treat patients with fall in their own homes – as opposed to conveying them to the Emergency Department. Martin Bardlsey of the Nuffield Trust brought the audience down to earth with a salient reminder that enthusiasm needs to be matched with evidence. Martin described the initial results from the Nuffield evaluation of the virtual ward scheme. These schemes sought to offer case management including a holistic overview to people thought to be at high risk of future hospitalisation. The findings indicated no difference in hospital use compared to matched controls… After a fine lunch, David Oliver opened up the afternoon with a focus on the clinical challenges associated with older people and urgent care. A key highlight was the tension between specialty medicine and the growing need for generalists that are capable of managing the whole patient – not just the bone! Prof Suzanne Mason (emergency medicine in Sheffield) highlighted how the 4 hour target may well be driving clinically inappropriate admissions into hospital, rather than allowing more time to manage patients in the ED. Suzanne’s own research links with the experience of Phil Lumbard that pre-hospital care for older people can reduce ED attendances and admissions. Suzanne reported on the Leicester experience of embedding CGA into the ED setting, which does seem to offer up benefits. However, the paucity of research in this area was notable. Chris Roseveare from the Society of Acute Medicine introduced the audience to a serious new condition – ‘acute trimethoprim deficiency’, not to be missed! He then shared his experience of working in an integrated manner with a frailty service in Southampton; despite great inter-working and good access to community services, they still experienced ‘exit block’ – lack of beds. This appears to be a major issue and is undoubtedly complex and multifactorial, but a few factors of relevance include:
- The myth of admission prevention – as Martin’s talk showed, older people will continue to come to hospital in increasing numbers, we need to make the environment suitable and the service fit for purpose
- Lack of 7 day working – health and social care
- Paucity of generalists compared to specialists
Tom Downes went on to describe the evolution of the Sheffield Frailty Unit, developed by the staff using systems redesign and process improvement derived from the car industry. The Sheffield geriatric medicine service has been able to show some impressive reductions in bed-days but also mortality. A key piece of feedback is that if the environment is better for people to work in, they work better! The finale was led by Richard Wong, who regaled us with anecdotes about poor communication between primary and secondary care and how we all need to be better at the transfer of care and communicating accurately with our colleagues. He talked about advance care planning and thinking ahead using tools such as the amber care bundle, which help coordinate care and ensure care is appropriate. Key themes appear to be joint working across the interfaces, improving communication with patients and with colleagues, focussing on older people and ensuring that they receive high quality care that improves their outcomes. With Mr Hunt’s latest funding announcement and the Future Hospital Commission about to report, maybe now is the time to really sort out acute care for older people.. Further resources: