quest for quality: bgs joint working party inquiry into the quality of healthcare support for older...
TRANSCRIPT
Quest for Quality: Quest for Quality:
BGS Joint working Party Inquiry into the Quality of BGS Joint working Party Inquiry into the Quality of HealthcareHealthcare Support for Older People in Care Homes: Support for Older People in Care Homes:
A Call for Leadership, Partnership and Quality A Call for Leadership, Partnership and Quality ImprovementImprovement
Incorporating interviews:Incorporating interviews:The contribution of health The contribution of health
professional expertiseprofessional expertise
Hazel HeathHazel HeathIndependent Nurse Consultant for Older People, Honorary Senior Research Fellow Independent Nurse Consultant for Older People, Honorary Senior Research Fellow City University London, Consultant Editor: Journal of Dementia Care, Chair RCN City University London, Consultant Editor: Journal of Dementia Care, Chair RCN
Older People Forum.Older People Forum.
16th September 201116th September 2011
BGS Joint Working Party BGS Joint Working Party ReportReport
Describes:Describes: Current NHS support for care homesCurrent NHS support for care homes What should and could be doneWhat should and could be done
Highlights:Highlights: The need to build joint professional leadership from the The need to build joint professional leadership from the
health, social and care home sectors, statutory regulators health, social and care home sectors, statutory regulators and patient advocacy groups for find the solutions that and patient advocacy groups for find the solutions that none of these can achieve along.none of these can achieve along.
Calls for:Calls for: National action by governmentNational action by government Local action by NHS commissioners, planners and clinical Local action by NHS commissioners, planners and clinical
servicesservices
MethodsMethods Working with a range of stakeholdersWorking with a range of stakeholders In-depth interviews In-depth interviews (21 health professionals (21 health professionals
working into care homes)working into care homes) Focus groups Focus groups (BGS Consultant Nurses, BGS OP (BGS Consultant Nurses, BGS OP
Specialist Forum, Care Homes, Commissioners)Specialist Forum, Care Homes, Commissioners) Review of contemporary surveys Review of contemporary surveys (GPs, (GPs,
Geriatricians)Geriatricians) Collating and evaluating the published Collating and evaluating the published
evidence and systematic reviewsevidence and systematic reviews Synthesis of guidance on the management Synthesis of guidance on the management
of long-term conditions adapted for use in of long-term conditions adapted for use in care home settingscare home settings
Focus of the interviews:Focus of the interviews:
The expertise and distinct contribution of The expertise and distinct contribution of health professionals. health professionals.
How health professionals are working in How health professionals are working in different localities.different localities.
Common situations in which health Common situations in which health professionals are consulted.professionals are consulted.
The issues that clinical experts want to The issues that clinical experts want to signpost; ‘pieces of wisdom’ they want to signpost; ‘pieces of wisdom’ they want to share with others less familiar with share with others less familiar with healthcare work in care homes.healthcare work in care homes.
How can we do things better?How can we do things better?
Twenty one interviews have been undertaken with:Twenty one interviews have been undertaken with:
Six GeriatriciansSix Geriatricians
Two Old Age PsychiatristsTwo Old Age Psychiatrists
Five GPs (two in General Practice, two with Special Five GPs (two in General Practice, two with Special Interest, two working in Nursing Home Medical Practices)Interest, two working in Nursing Home Medical Practices)
Two Older People Specialist Nurses Two Older People Specialist Nurses
Two OPSN Mental Health Two OPSN Mental Health
Two Community MatronsTwo Community Matrons
Two other (care home manager and researcher).Two other (care home manager and researcher).
Eighteen around England, two in Scotland, one in Wales. Eighteen around England, two in Scotland, one in Wales.
Health care: service modelsHealth care: service models
Wide variety around the country. Each Wide variety around the country. Each interviewee working to different model.interviewee working to different model.
Services influenced by:Services influenced by: Local responses to national prioritiesLocal responses to national priorities Local responses to perceived patient needLocal responses to perceived patient need Funding sources and prioritiesFunding sources and priorities Individual professional priorities, local Individual professional priorities, local
‘talents’ and influential leaders‘talents’ and influential leaders Commitment and perseverance !Commitment and perseverance !
Referral patterns: all professionalsReferral patterns: all professionals
Schedule visits, meetings and Schedule visits, meetings and reviews.reviews.
Individual referrals, requests and Individual referrals, requests and consultations.consultations.
Focus, approach, ways of working:Focus, approach, ways of working:
Uniquely individual.Uniquely individual.
Focusing on specific problems, clinical issues, Focusing on specific problems, clinical issues, patient and family issues, ethical issues.patient and family issues, ethical issues.
Focusing on patients within situations, then Focusing on patients within situations, then ‘stepping back’ and investigating to establish a ‘stepping back’ and investigating to establish a broader picture. broader picture.
Experience: Clinical and in Care Homes
AuthorityPower
Autonomy
CommitmentEnthusiasm
Stamina Confidence
Team working
Skills: Teaching; Supporting
Others
Skills: Clinical; Inter-personal
Knowledge: Health Care and
Clinical
HEALTH CARE / CLINICAL
EXPERTISE
GPsGPs ‘‘General medical services’, specific General medical services’, specific
medical interventions, acute medical interventions, acute interventions, chronic illness, family interventions, chronic illness, family practicepractice
Some practices ‘adopt’ care homesSome practices ‘adopt’ care homes Some work alongside other practices Some work alongside other practices
into care homesinto care homes Some care home residents retain their Some care home residents retain their
own GPs.own GPs.
GPs with Special InterestGPs with Special Interest
GPs with special interest in older GPs with special interest in older people: additional training and people: additional training and experience. Work in ways similar to experience. Work in ways similar to geriatricians.geriatricians.
GPs with special interest in, e.g. GPs with special interest in, e.g. medications or palliative care.medications or palliative care.
Some GPSIs ‘adopt’ care homes, Some GPSIs ‘adopt’ care homes, others work into care homes.others work into care homes.
GeriatriciansGeriatricians Complex medical problems in older people; multiple Complex medical problems in older people; multiple
co-morbidities; frailty; geriatric syndromes; co-morbidities; frailty; geriatric syndromes; ‘textbook geriatric medicine’.‘textbook geriatric medicine’.
Complex conditions combining physical, Complex conditions combining physical, psychological, psychiatric, social etc dimensions in psychological, psychiatric, social etc dimensions in older age.older age.
Medication use in older people and people with Medication use in older people and people with frailty; multiple medication use and interactions; frailty; multiple medication use and interactions; optimum medication use.optimum medication use.
Rehabilitative and reablement approaches.Rehabilitative and reablement approaches. End of life care; decisions on timing end of life care; End of life care; decisions on timing end of life care;
palliative care; end stage condition management; palliative care; end stage condition management; advanced care planning; ethical dilemmas around advanced care planning; ethical dilemmas around end of life. end of life.
Working with older individuals and families.Working with older individuals and families. Multi-professional team working.Multi-professional team working.
Old Age PsychiatristsOld Age PsychiatristsMental health in later life in all its complexities, for Mental health in later life in all its complexities, for
example:example: Depression, any psychotic illness, bipolar Depression, any psychotic illness, bipolar
disorder, someone trying to self harm.disorder, someone trying to self harm. Non-pharmacological issues related to mental Non-pharmacological issues related to mental
healthhealth Complicated behavioural issues, someone with Complicated behavioural issues, someone with
dementia hitting out or hypersexual.dementia hitting out or hypersexual. Issues of capacity which are not straightforward, Issues of capacity which are not straightforward,
e.g. with family dynamicse.g. with family dynamics Anything to do with antipsychoticsAnything to do with antipsychotics Terminal agitationTerminal agitation
Nurses: Types of Nurses: Types of interventionintervention
District Nurses – specific interventionsDistrict Nurses – specific interventions Community Matrons – some have Community Matrons – some have
remit for specific interventions, others remit for specific interventions, others for specific types of support including for specific types of support including individual referralindividual referral
Older People Specialist Nurses – Older People Specialist Nurses – scheduled intervention and individual scheduled intervention and individual referralreferral
Nursing expertiseNursing expertise Working holistically with individuals and families.Working holistically with individuals and families. Working alongside individuals and families.Working alongside individuals and families. Seeing the broad picture and person’s ‘journey’.Seeing the broad picture and person’s ‘journey’. Older people’s care; complexities (multiple co-morbidities Older people’s care; complexities (multiple co-morbidities
etc) transitions, looking beyond the obvious and unpicking etc) transitions, looking beyond the obvious and unpicking complex situations.complex situations.
Working in multi-professional teams.Working in multi-professional teams. Rehabilitative and reablement approaches.Rehabilitative and reablement approaches. Individual expertise.Individual expertise. Broad range of knowledge, skill and experience.Broad range of knowledge, skill and experience. ‘‘Reading situations’; instinct and intuition; anticipation and Reading situations’; instinct and intuition; anticipation and
being able to predict.being able to predict.
The concept of ‘real’ nurses and ‘real’ geriatriciansThe concept of ‘real’ nurses and ‘real’ geriatricians
FINDINGSFINDINGS
The problemsThe problems Residents have complex healthcare needs, long-term conditions, Residents have complex healthcare needs, long-term conditions,
significant disability, frailtysignificant disability, frailty The social care model is central but insufficient to meet healthcare The social care model is central but insufficient to meet healthcare
needsneeds The NHS has gradually withdrawn its expertise and support. Most The NHS has gradually withdrawn its expertise and support. Most
geriatricians and Old Age Psychiatrists play no part.geriatricians and Old Age Psychiatrists play no part. Regulation can highlight problems and promote improvement but Regulation can highlight problems and promote improvement but
providers cannot achieve this without necessary support.providers cannot achieve this without necessary support. No model of co-ordinated healthcare to meet needs of care home No model of co-ordinated healthcare to meet needs of care home
residents. Traditional GP in many areas ill equipped.residents. Traditional GP in many areas ill equipped. Many residents are denied equitable access to suitable NHS primary Many residents are denied equitable access to suitable NHS primary
and secondary healthcare. Low priority and secondary healthcare. Low priority inappropriate hospital inappropriate hospital admissions.admissions.
Care homes will continue to be an important component of care for Care homes will continue to be an important component of care for frail older people but healthcare remains a Cinderella service in the frail older people but healthcare remains a Cinderella service in the NHS.NHS.
What is neededWhat is needed
A health service suitable for the A health service suitable for the specific needs of this populationspecific needs of this population
The residents and their relatives must The residents and their relatives must be at the centre of decisions about be at the centre of decisions about carecare
A multi-disciplinary approachA multi-disciplinary approach A partnership approach with care A partnership approach with care
homes and social care professionals.homes and social care professionals.
RECOMMENDATIONSRECOMMENDATIONS1.1. Local NHS planners/commissioners should ensure that clear and specific Local NHS planners/commissioners should ensure that clear and specific
service specifications are agreed with local NHS providers.service specifications are agreed with local NHS providers.2.2. Care home residents should be at the centre of decisions about their Care home residents should be at the centre of decisions about their
care. An integrated social and clinical approach should support care. An integrated social and clinical approach should support anticipatory care planning, encompassing preferred place of care and anticipatory care planning, encompassing preferred place of care and end of life plans.end of life plans.
3.3. Service specification for providing healthcare support to care homes Service specification for providing healthcare support to care homes should guarantee a holistic review for any individual within a set period 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 from their move into a care home, leading to healthcare plans with clear goals. This will guide medication reviews, modifications and clinical goals. This will guide medication reviews, modifications and clinical interventions both in and out of hours.interventions both in and out of hours.
4.4. Healthcare services to support the achievement of 3 should be Healthcare services to support the achievement of 3 should be integrated, combine enhanced primary medical and nursing care with integrated, combine enhanced primary medical and nursing care with dedicated input from departments of old age medicine, MH and other dedicated input from departments of old age medicine, MH and other specialisms – palliative care, rehab medicine.specialisms – palliative care, rehab medicine.
5.5. UK nations health departments should clarify NHS obligations for NHS UK nations health departments should clarify NHS obligations for NHS care to care home residents.care to care home residents.
6.6. Statutory regulators should include in their scrutiny the provision of NHS Statutory regulators should include in their scrutiny the provision of NHS support to care homes and the achievement of quality standards.support to care homes and the achievement of quality standards.
7.7. Multi-agency and multi=professional national leadership should be Multi-agency and multi=professional national leadership should be promoted to support development and dissemination of good healthcare promoted to support development and dissemination of good healthcare practice in care homes, supported by clinical guidance and quality practice in care homes, supported by clinical guidance and quality standards.standards.
The report marks the start of a process The report marks the start of a process of partnership to develop impetus, of partnership to develop impetus,
resources and clinical guidance that resources and clinical guidance that will support the NHS to play its part in will support the NHS to play its part in
improving the experience and the improving the experience and the quality of life of residents in care quality of life of residents in care
homeshomes..
