Memorandum by British Geriatrics Society
(CC 19)
THE BRITISH
GERIATRICS SOCIETY
The British Geriatrics Society (BGS) is the
only professional association, in the United Kingdom, for doctors
practising geriatric medicine. The 2,200 members worldwide are
consultants in geriatric medicine, the psychiatry of old age,
public health medicine, general practitioners, and scientists
engaged in the research of age-related disease. The Society offers
specialist medical expertise in the whole range of health care
needs of older people, from acute hospital care to high quality
long-term care in the community.
GERIATRIC MEDICINE
Geriatric Medicine (Geriatrics) is that branch
of general medicine concerned with the clinical, preventive, remedial
and social aspects of illness of older people. Their high morbidity
rates, different patterns of disease presentation, slower response
to treatment and requirements for social support, call for special
medical skills. The purpose is to restore an ill and disabled
person to a level of maximum ability and, wherever possible, return
the person to an independent life at home.
The Society is delighted to be given the opportunity
to contribute to this debate and would comment as follows:
SUMMARY
The BGS recommends:
1. Regardless of the source of funding no
individual should enter a system of domiciliary or institutional
care without prior exposure to an effective system of specialist
and multidisciplinary assessment backed up by appropriate treatment
and rehabilitation.
2. Partnerships must be set up between,
district nursing, primary care, general practice, therapies, old
age psychiatry and geriatric medicine to recognise and meet the
needs of vulnerable older people receiving continuing care.
3. Older people in care homes need to be
recognised by practitioners as a discrete population and a case
management system set up to meet their needs.
4. Enhanced, appropriate education, training
and development must be in place for practitioners caring for
the most vulnerable older people in continuing care.
5. Clinical governance systems must be in
place for all providers of NHS continuing care.
1. THE WRITTEN
MINISTERIAL STATEMENT
ON NHS CONTINUING
CARE ISSUED
BY DR
STEPHEN LADYMAN
1.1 The BGS welcomes the development of
a national consistent approach to assessment for fully funded
NHS continuing care. The recent follow up report by the Ombudsman
in December 2004 identified the lack of national guidance as an
impediment to effective restitution for previous failures to grant
NHS continuing care status. (1)
2. HOW THE
CHANGES WILL
BUILD ON
THE WORK
ALREADY UNDERTAKEN
BY THE
STRATEGIC HEALTH
AUTHORITIES IN
REVIEWING CRITERIA
FOR NHS CONTINUING
CARE AND
DEVELOPING POLICIES
2.1 The considerable commitment shown by
the Strategic Health Authorities, Primary Care Trusts and local
authority partners to securing agreement to establish workable
arrangements should contribute to the implementation of national
guidance. We are of the opinion that the lack of national guidance
in England and Wales has resulted in hardship and injustice for
some individuals and that a fair and transparent system of funding
should operate across the country.
2.2 The BGS is in complete accord with the
statement issued by the Ombudsman in December 2004 where she recommended
the Department of Health should lead further work in six key areas
(1):
— "Establish clear, national minimum
eligibility criteria which are understandable to health professionals
and patients and carers alike.
— Develop a set of accredited assessment
tools and good practice to support the criteria.
— Clarify standards for record keeping
and documentation both by health care providers and those involved
in the review process.
— Support training and development
to expand local capacity and ensure that new continuing care cases
are assessed properly and promptly.
— Seek reassurance that the retrospective
reviews have covered all those who have been affected.
— Monitor the situation in relation
to retrospective reviews using the lessons learned to inform the
handling of continuing care assessment in the future."
3. WHAT FURTHER
DEVELOPMENTS ARE
REQUIRED TO
SUPPORT THE
IMPLEMENTATION OF
A NATIONAL
FRAMEWORK?
3.1 The BGS welcomed the Department of Health's
response Policy and guidance issued on Continuing Care Assessments
and Hospital Discharge in February 2004 which clarified the
assessment procedure and stressed the importance of communication
with families by professional members or clinicians (2). We were
pleased that the importance of the single assessment process,
involving the multidisciplinary team as well as the input of a
Consultant Geriatrician, was recognised. We see this as a way
of facilitating the implementation of effective comprehensive
geriatric assessment. However the BGS believes that these recent
changes will not bring about sufficient change to the care of
frail older people. Our opinion is that:
"Regardless of the source of funding no
individual should enter a system of domiciliary or institutional
care without prior exposure to an effective system of specialist
and multidisciplinary assessment backed up by appropriate treatment
and rehabilitation. By maximising an individual's health and functional
capacity their need for and usage of expensive prosthetic long
term care can be minimised. Comprehensive geriatric assessment
is the cornerstone of effective health and social care for older
people and has been identified as a major clinical advance that
systematically reduces the disability and institutionalisation
of older people." (3)
3.2 The BGS welcomed The Department of Health's
most recent guidance in 2004 stating that fully funded NHS continuing
care may be provided, subject to clinical advice, in a range of
settings: a nursing home, hospice, at home or in hospital (2).
It has considerable reservations about the ability of primary
and community health care to meet the needs of these extremely
vulnerable patients without systems, setting up partnerships between,
district nursing, primary care, general practice, therapies and
geriatric medicine.
3.3 Older people designated as requiring
Social Service funded care in homes often have very similar and
overlapping needs as the patients requiring NHS continuing care.
A significant majority of older people in care homes suffer from
chronic neuro-degenerative diseases such as Dementia, Parkinson's
disease and Cerebro-vascular disease (Strokes). It is thought
that at least 60% of care home residents suffer from Dementia.
The BGS in a joint publication with The Royal College of Physicians
and The Royal College of Nursing argued in 2000 that unless older
people in care homes are recognised by practitioners as a discrete
population their health needs will be over-looked (4). Enhanced,
appropriate training and development must be in place for practitioners
caring for the most vulnerable older people in continuing care.
3.4 The National Minimum Standards for Care
Homes made the NHS responsible for meeting the nursing, medical
and rehabilitation needs of residents and in addition requires
the NHS to provide other services including chiropody, dentistry
and audio logy and optician services. (5) Despite this a recent
national study demonstrated the difficulty care homes experience
accessing expert advice from specialist old age psychiatry, geriatric
medicine, speech and language therapy, physiotherapy, pharmacy
and rehabilitation services, podiatry, dietetics, district nursing,
and general practice. The study demonstrated variations in the
range of services offered by GPs, as well as marked regional variations
in the availability of NHS services. Only 83% of homes could contact
a geriatrician when needed, usually via a GP, and only 6% could
contact one directly. Charges were made for occupational therapy
in 38% of homes, physiotherapy in 39% of homes and speech and
language therapy in 29% of homes. These people have equal rights
to health care and the survey demonstrates inequity of care as
the most vulnerable have become the most excluded (6). Clinical
governance systems should be set up to ensure equal access of
care.
3.5 General practitioners are unhappy about
taking on what was an extra and complex addition to their already
busy workload. Frail older people who were once the care of geriatricians
became the responsibility of GPs and the already over stretched
community and rehabilitations services. They found the increasing
workload from care homes difficult to manage. For successful NHS
continuing care and health care in care homes the recommendations
made by the joint report in 2000 must be implemented (6).
3.6 The recommendations are as follows:
— "To introduce a specialist gerontological
nurse specialist for homes.
— To introduce a General Practitioner
with a special interest.
— To include a specialist pharmacist
for homes.
— To increase inputs from professionals
allied to medicine.
— To introduce regular multi-disciplinary
consultant sessions and consultant visits to homes.
— To improve care planning through
the introduction of formal approaches.
— To develop teaching nursing homes
in each region."
3.7 The recent Department of Health's publications
on the management of long term conditions and case management
(7), (8), (9) provides the Primary Care Trusts with an opportunity
to review and recognise the needs of this vulnerable, not homogenous
population with long term conditions resident in care homes. They
are uniformly old and the vast majority have cognitive impairment.
The BGS recommends that residents of care homes could benefit
from a case management system which has been demonstrated to be
effective in Care Homes in the USA (9). This would improve care
planning with end of life care a particular priority in nursing
homes.
3.8 These methods of providing care to our
most vulnerable and frail older people could not fail to raise
the quality of NHS continuing care. National guidance from the
Department of Health recommending and supporting these developments
would reduce the geographic variation in the provision of NHS
continuing care as well as the ability of those older people to
access appropriate health intervention wherever they are living.
The Society would welcome the opportunity to
give oral evidence.
REFERENCES
(1) The Parliamentary and Health Service Ombudsman.
NHS Funding for long term care: follow up report. 2004.
(2) Department of Health Continuing Care assessments
and hospital discharge London DoH 2004.
(3) Lubel, D et al: British Geriatrics
Society Submission of Evidence to The Royal Commission on Long
term Care for the Elderly. BGS; London 1999. www.bgs.org.uk.
(4) Royal College of Physicians. The health
and care of older people in care homes. Report of a joint working
party of the Royal College of Physicians, the Royal College of
Nursing and the British Geriatrics Society. London: RCP 2000.
(5) Department of Health. Care Homes for Older
People. National Minimum Standards. London: The Stationery Office
2002.
(6) Jacobs S , Alborz A, Glendinning C, et
al. Health Services for Homes; A survey of access to NHS services
in nursing and residential homes for older people in England.
NPCRDC: 2001.
(7) Department of Health. Supporting people
with Long Term Conditions. An NHS and Social Care Model to support
local innovation and integration. London DoH. 2005.
(8) Department of Health. NHS Improvement Plan:
Putting people at the heart pf public services. London DoH 2004.
(9) Kane, R L, Keckhafer, G, Flood, S, et
al (2003) The Effect of Evercare on Hospital Use. Journal
of the American Geriatrics Society 51 (10), 1427-1434.
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