Hard Truths after Francis
Professor Paul Knight is Director of Medical Education and a Consultant Geriatrician for the Elderly at the Royal Infirmary in Glasgow. He is also President of the British Geriatrics Society.
The Westminster Government’s response to the second Francis Report was published as I was preparing to go to Harrogate for the BGS biannual conference and co-incidentally where I was due to speak on what the BGS had done and would do “After Francis”. So it wasn’t until a few days later that I managed to read in detail “Hard Truths. The Journey to Putting Patients First”.
The BGS response to Francis has been to try to influence policy makers and regulators by partnering with likeminded organisations that might give clarity and volume to the patient voice viz. Age UK, National Voices and the Picker Institute; campaigning for more and better training for health and social care professionals so that they are prepared for the challenges and complex needs of an ageing population; supporting our members through enhancing members’ capacity for leadership and providing them with guidance on how to improve their services to older people.
So how does “Hard Truths” measure up?
My first approach to a document that is 137 pages long is to do 3 things. 1) Put all the text into a Wordle and see what pops up 2) Search for older people as a phrase in the text and 3) Read the Executive summary.
The Wordle approach was a bit depressing with older people not appearing at all but education and leadership featuring in the smaller print stuff. The phrase “older people” is mentioned on 24 occasions although one of these is describing Kate Granger and her “my name is” campaign. The executive summary runs to 12 pages and has 73 bullet points that cover the meat of the document and while there are a number of initiatives that the BGS would support there are areas where opportunities have been missed.
“Hard Truths” emphasises the need for health care professionals to listen to what the patients and their carers say and suggests a number of structural ways in which that might be improved. This is not specifically for older people but they are often the ones who are least heard. Working with our partners we are looking at innovative ways in which we might gain insight into what frailty means to individuals and how we might use this insight in improving our services.
The BGS would strongly support the suggested career path and postgraduate qualification for nurses involved in the care of older people. We are meeting with Health Education England (HEE) and NHS Education for Scotland to see how we as an organisation can help. We will also be speaking to workforce leads in Wales and Northern Ireland along similar lines. We would also support the aspiration to create a care certificate qualification for health care assistants and social care support workers. I would agree with the desire to require HEE to implement changes in GP training to include more emphasis on the care of older people and this perhaps sits nicely with the extension of the GP training programme to 4 years. Geriatricians should be involved with this training but will need to be more imaginative than just having GP trainees acting as latter day SHO’s on wards. At present there is some evidence to suggest that less than half of GP Trainees in some programmes will have exposure to training under the supervision of a geriatrician. I am not sure why the educational initiatives stopped there. In terms of doctors, our discussions with the GMC would suggest that they agree with us that there should be more emphasis in the undergraduate curriculum on geriatric medicine and they are willing for us to work with them to make that happen. Similarly, they see a need for those basics in geriatric medicine to be re-emphasised in foundation training and for those involved in acute medical take to have a higher level of competence taught and tested whilst recognising the need for the retention of specialist training for the very complex cases. We will continue to press that case with the GMC, the Medical Royal Colleges and Medical Schools. However, health care includes more than just doctors and nurses and there is a requirement to give this type of training greater emphasis in allied health professions as well.
Quality Improvement and Patient Safety:
We would support the drive for more clinicians to be involved in leadership as the evidence is that this improves both quality and safety. We have started in our own small way to utilise the talent within our own ranks and pass it on to the next generation. But, to make this meaningful I suspect we will need to engage with the Faculty of Medical Leadership and Management in a more structured fashion.
There is almost nothing about specific initiatives to improve health care quality for older people as a group, just recognition that they are core business and that (in the words of Bernard Isaacs) if we get it right for them then it is likely to be right for the rest. However, I was pleased to see that the Malnutrition Task Force (of which I was a member for the BGS) has been given a £1 million grant to pilot methods of improving nutrition in older people in a range of settings. We will continue to work on specific tools for our members to use in their endeavours and make them widely and freely available. FRAILSAFE would be an example.
We will shortly meet with the Care Quality Commission about their inspection regimen and how the BGS might help make it particularly responsive to the needs of older people as opposed to some nebulous score card. However, I would worry that the regimen, as I understand it at present, may be more about blame than quality improvement and support.
The government makes much of what they have published thus far such as the initiatives for named clinicians and vulnerable adult care but levels of safe staffing is new. They have stopped short of saying what that is other than to say that NICE will publish guidance. This could be a double edged sword as I suspect that the guidance could quickly become a maximum rather than a minimum. I also suspect that this will be for nursing staff only when we know that in our work the whole team including medics and rehabilitation professionals is essential for the provision of comprehensive geriatric assessment.
Thus, on the whole, there are a number of themes that resonate with BGS strategy and although this is a document for NHS England it will get picked up in the devolved nations. For example HEE can’t change GP training without the agreement of the other nations. There is sufficient agenda here for us to get our teeth into and some missing bits for us to campaign on. It will be an ambitious programme for us to try and achieve all our aims but, if not us then who, if not now then when would be a better time and if this isn’t the correct agenda I would like to know a better one.