Transcript draft

Quest for Quality:
BGS Joint working Party Inquiry into the Quality of
Healthcare Support for Older People in Care Homes:
A Call for Leadership, Partnership and Quality
Improvement
Incorporating interviews:
The contribution of health
professional expertise
Hazel Heath
Independent Nurse Consultant for Older People, Honorary Senior Research Fellow
City University London, Consultant Editor: Journal of Dementia Care, Chair RCN
Older People Forum.
16th September 2011
BGS Joint Working Party Report
Describes:

Current NHS support for care homes

What should and could be done
Highlights:

The need to build joint professional leadership from the health,
social and care home sectors, statutory regulators and patient
advocacy groups for find the solutions that none of these can
achieve along.
Calls for:

National action by government

Local action by NHS commissioners, planners and clinical services
Methods






Working with a range of stakeholders
In-depth interviews (21 health professionals working
into care homes)
Focus groups (BGS Consultant Nurses, BGS OP
Specialist Forum, Care Homes, Commissioners)
Review of contemporary surveys (GPs, Geriatricians)
Collating and evaluating the published evidence
and systematic reviews
Synthesis of guidance on the management of
long-term conditions adapted for use in care
home settings
Focus of the interviews:





The expertise and distinct contribution of health
professionals.
How health professionals are working in
different localities.
Common situations in which health professionals
are consulted.
The issues that clinical experts want to signpost;
‘pieces of wisdom’ they want to share with
others less familiar with healthcare work in care
homes.
How can we do things better?
Twenty one interviews have been undertaken with:

Six Geriatricians

Two Old Age Psychiatrists

Five GPs (two in General Practice, two with Special Interest, two
working in Nursing Home Medical Practices)

Two Older People Specialist Nurses

Two OPSN Mental Health

Two Community Matrons

Two other (care home manager and researcher).
Eighteen around England, two in Scotland, one in Wales.
Health care: service models
Wide variety around the country. Each interviewee
working to different model.
Services influenced by:
 Local responses to national priorities
 Local responses to perceived patient need
 Funding sources and priorities
 Individual professional priorities, local ‘talents’
and influential leaders
 Commitment and perseverance !
Referral patterns: all professionals


Schedule visits, meetings and reviews.
Individual referrals, requests and
consultations.
Focus, approach, ways of working:



Uniquely individual.
Focusing on specific problems, clinical issues, patient
and family issues, ethical issues.
Focusing on patients within situations, then ‘stepping
back’ and investigating to establish a broader picture.
Knowledge:
Health Care and
Clinical
Experience:
Clinical and in
Care Homes
Authority
Power
Skills: Clinical;
Inter-personal
Skills: Teaching;
Supporting
Others
HEALTH CARE /
CLINICAL
EXPERTISE
Team working
Autonomy
Commitment
Enthusiasm
Stamina
Confidence
GPs




‘General medical services’, specific medical
interventions, acute interventions, chronic
illness, family practice
Some practices ‘adopt’ care homes
Some work alongside other practices into
care homes
Some care home residents retain their
own GPs.
GPs with Special Interest



GPs with special interest in older people:
additional training and experience. Work in
ways similar to geriatricians.
GPs with special interest in, e.g.
medications or palliative care.
Some GPSIs ‘adopt’ care homes, others
work into care homes.
Geriatricians







Complex medical problems in older people; multiple comorbidities; frailty; geriatric syndromes; ‘textbook
geriatric medicine’.
Complex conditions combining physical, psychological,
psychiatric, social etc dimensions in older age.
Medication use in older people and people with frailty;
multiple medication use and interactions; optimum
medication use.
Rehabilitative and reablement approaches.
End of life care; decisions on timing end of life care;
palliative care; end stage condition management;
advanced care planning; ethical dilemmas around end of
life.
Working with older individuals and families.
Multi-professional team working.
Old Age Psychiatrists
Mental health in later life in all its complexities, for
example:
 Depression, any psychotic illness, bipolar disorder,
someone trying to self harm.
 Non-pharmacological issues related to mental health
 Complicated behavioural issues, someone with dementia
hitting out or hypersexual.
 Issues of capacity which are not straightforward, e.g.
with family dynamics
 Anything to do with antipsychotics
 Terminal agitation
Nurses: Types of intervention



District Nurses – specific interventions
Community Matrons – some have remit for
specific interventions, others for specific
types of support including individual
referral
Older People Specialist Nurses – scheduled
intervention and individual referral
Nursing expertise










Working holistically with individuals and families.
Working alongside individuals and families.
Seeing the broad picture and person’s ‘journey’.
Older people’s care; complexities (multiple co-morbidities etc)
transitions, looking beyond the obvious and unpicking complex
situations.
Working in multi-professional teams.
Rehabilitative and reablement approaches.
Individual expertise.
Broad range of knowledge, skill and experience.
‘Reading situations’; instinct and intuition; anticipation and being
able to predict.
The concept of ‘real’ nurses and ‘real’ geriatricians
FINDINGS
The problems







Residents have complex healthcare needs, long-term conditions, significant
disability, frailty
The social care model is central but insufficient to meet healthcare needs
The NHS has gradually withdrawn its expertise and support. Most
geriatricians and Old Age Psychiatrists play no part.
Regulation can highlight problems and promote improvement but providers
cannot achieve this without necessary support.
No model of co-ordinated healthcare to meet needs of care home residents.
Traditional GP in many areas ill equipped.
Many residents are denied equitable access to suitable NHS primary and
secondary healthcare. Low priority  inappropriate hospital admissions.
Care homes will continue to be an important component of care for frail
older people but healthcare remains a Cinderella service in the NHS.
What is needed




A health service suitable for the specific
needs of this population
The residents and their relatives must be
at the centre of decisions about care
A multi-disciplinary approach
A partnership approach with care homes
and social care professionals.
RECOMMENDATIONS
1.
2.
3.
4.
5.
6.
7.
Local NHS planners/commissioners should ensure that clear and specific service
specifications are agreed with local NHS providers.
Care home residents should be at the centre of decisions about their care. An
integrated social and clinical approach should support anticipatory care planning,
encompassing preferred place of care and end of life plans.
Service specification for providing healthcare support to care homes should
guarantee a holistic review for any individual within a set period from their move
into a care home, leading to healthcare plans with clear goals. This will guide
medication reviews, modifications and clinical interventions both in and out of
hours.
Healthcare services to support the achievement of 3 should be integrated,
combine enhanced primary medical and nursing care with dedicated input from
departments of old age medicine, MH and other specialisms – palliative care,
rehab medicine.
UK nations health departments should clarify NHS obligations for NHS care to care
home residents.
Statutory regulators should include in their scrutiny the provision of NHS support
to care homes and the achievement of quality standards.
Multi-agency and multi=professional national leadership should be promoted to
support development and dissemination of good healthcare practice in care
homes, supported by clinical guidance and quality standards.
The report marks the start of a process of
partnership to develop impetus, resources
and clinical guidance that will support the
NHS to play its part in improving the
experience and the quality of life of
residents in care homes.
Hazel Heath
[email protected]