Alternatives to hospital for older people must be found, says NHS chief
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f453 (Published 22 January 2013) Cite this as: BMJ 2013;346:f453
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SO MAKE HOSPITALS GOOD FOR OLD PEOPLE
"Hospitals are very bad places for old, frail people" asserts David Nicholson, chief executive of the NHS Commissioning Board, and suggests alternatives to hospital must be found (1). Following this logic perhaps the solution to the lack of compassion in nurses to which he also refers might equally well be solved by admitting to hospital only patients who are not in need of compassion?
Here is a radical suggestion - make hospitals good places for old people. Few national providers would make such a blatantly ageist inference that its "core business" (2) was too tricky to manage, and propose to solve "the problem" by ceasing to attempt to deal with it. The greatest burden of ill health falls on older people, making them the group encountered most commonly in clinical practice. But is appears that the impertinence of our older population in actually becoming unwell, and so requiring care, will no longer be tolerated in hospitals. The acute care of older people has progressed through being an inconvenience to being an anathema.
Hospitals are still organised around the care of younger, fit adults presenting with a single acute medical problem. Yet this is no longer the population requiring care. Barnett and colleagues report that 23% of patients in general practice have 2 or more chronic conditions, a figure which rises steeply with age (3). The problem is not with our patients, the problem is with our health systems. Let's fix our health care system to make it responsive to the needs of the patients who require it. Let's change training and education to ensure that its staff possess the skills to manage people with multimorbidity, including older people. Let's enable prompt diagnosis and invest more in downstream systems designed to allow old people to leave hospital when ready to do so. Let's have equity of access for all patients who require it, and begin the overhaul of the NHS to make it fit for the 21st century.
(1) BMJ 2013;344:f453.
(2) Adding Life to Years. Report of the Expert Group on Healthcare of Older People, 2006. Scottish Government.
(3) Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012;380:37-43.
Competing interests: No competing interests
How deeply sad to read such ageist and ill-informed views of the medical needs of frail older people from the top of the NHS, apparently also supported by the main advocacy group for those with dementia.
Do we seriously believe that their fractured hips, heart attacks and strokes should not benefit from orthopaedic surgery, cardiac assessment and stroke unit care?
While it is clear that hospitals need to be better attuned to the needs of frail older people, as well as of those with dementia, these groups are more likely than younger patients to present with conditions that require the complex assessment treatment and management options that hospitals provide.
Their stay should be as short as possible, with staff trained in gerontology and dementia care as a core element of the training of all adult specialities across all disciplines, and with appropriate comprehensive assessment and planned and supported discharge.
That the the NHS, along with many other healthcare systems, has not yet sufficiently age-attuned its health services and hospitals in line with modern evidence-based research, should not lead to seeking to exclude older people from hospital.
The hallmark of ageing is complexity, and to seek to define an artificial dichotomy of 'hospital bad/community good' is to oversimplify and underestimate the more diverse care needs of this group.
Competing interests: No competing interests
Re: Alternatives to hospital for older people must be found, says NHS chief
ALTERNATIVES TO HOSPITAL FOR OLDER PEOPLE MUST BE FOUND?
David Nicholson's views on the use of hospitals by frail older people (1) suggest disturbing ignorance. Frail older people, including those with dementia, may well benefit from diagnosis and treatment in hospital and are likely to need these because of their multiple diseases. A minority of admissions could be prevented by anticipatory care (especially of people with progressive conditions such as dementia), hospital at home schemes, palliative care in nursing homes, a greater acceptance of risk or rapid social care (where the social crisis is not a manifestation of acute illness) – but most cannot.
The problem is more one of excess stay than inappropriate admission . In part, this is of hospitals' own making, with disabling nursing regimes and a lack of interest in restoring function to enable people to return home. The expectation that future care should be arranged while the patient is still in hospital, rather than be assessed for and arranged on discharge, contributes.. Delays in social care, which the Care and Support Bill will do little to address, add to the problem.
The Royal College of Physicians (2) has rightly called on hospitals to adapt to the needs of those most likely to need them: this is likely to be a much more productive approach than believing that alternatives to hospital care will solve the problem.
References
1.Alternatives to hospital for older people must be found, says NHS chief. BMJ 2013;346:f453
2.www.rcplondon.ac.uk/projects/future-hospital-patients-and-compassion. Accessed 27/1/2013
Competing interests: No competing interests