Care institutions, whether they be acute institutions, such as hospitals, or non-acute such as nursing homes face an ever increasing pressure on services due to an increasing age demographic in the population as a whole. At the same time economic constraints place the NHS under considerable and increasing pressure.
The Care Quality Commission (CQC) has focused in recent years on looking at services for the elderly in its role as a quality service assessor on behalf of the National Health Service (NHS). The CQC is the independent regulator of all health and social care services in England & Wales and as part of that function it inspects, on both announced and unannounced bases, hospitals and other institutions to ensure they are meeting national standards. It has an increasing drive for transparency and to share its findings with the public. Their focus is to identify risks to the quality and safety of care, to act swiftly to eliminate poor care and to ensure care is centred on people’s needs and to protect their rights. There is a barely week goes by without the CQC being in the news in connection with a failing NHS Service. This week it’s Tameside who are under investigation for high death rates and whose Chief Executive has recently resigned, as has its medical director.
There has been a theme in the media in recent years that hospital provision, particularly following the Mid Staffordshire NHS Hospitals Trust crisis, is led in a business fashion i.e. financial efficiency takes precedence over clinical care. The public enquiry report that followed the Mid Staffordshire scandal reported that the NHS system was more focused on corporate self interest than on patient care. That is no doubt a culture that extends beyond Mid Staffordshire and that is a response to the perpetual problem that faces the NHS which is that it is, in my respectful submission, an under-funded resource. NHS management in recent decades has been dominated by non-medics, non-clinicians such as accountants and “bean counters” and financial efficiency has been a key feature for hospital managers. Indeed in the face of the NHS budget reduction of £20bn from 2009 and 2014, further significant job cuts and reduced services can be anticipated. One is hard pushed to criticise NHS managers for cutting services to improve financial efficiency against that economic and political backdrop. It seems to me that there is a perpetual conflict between the public’s demand for NHS services and the government’s economic demands to reduce the cost of providing those services, placing NHS managers in an invidious and unenviable position.
In 2011 the CQC reviewed 100 institutions in unannounced inspections. In 2012 this was followed by inspections of 50 institutions. In 2011 they targeted NHS acute hospital trusts and focussed their attention on standards of dignity and nutrition in the care of the older patient. Their findings were not encouraging. Whilst some hospitals were meeting the national standards they found 20% of hospitals in that cohort failed to do so. They have since, in 2012, implemented further inspections in care homes and in NHS Trusts this time including both mental health and acute trusts. The results of the 2012 enquiry showed no improvements on the 2011 one. In 2011, 88% of patients were given support and choice of meals and support in eating them. That fell in 2012 to 83%. In 2011 88% of hospitals treated patients with dignity and respect for their privacy and independence but by 2012 that figure had fallen to 82%.
It seems to me that the focus on issues concerning the elderly are in many respects a microcosm of issues concerning the NHS in general. It seems to me that it is an acknowledged fact amongst both patients and doctors that if you are in hospital and you have a difficulty eating you simply won’t get fed. The NHS, a symptom of its stretched resources, simply does not have the staff to assist patients with eating. Yet nutrition is a fundamental part of healthy living and accordingly key to recuperation from illness or surgery. It is especially important for the already vulnerable older patient. Yet is it frequently overlooked. During the 2012 cohort of inspections about a third of institutions failed to meet all standards for nutrition and dignity. In the care home sector just over 60% (316 out of 500 homes) met all standards. Aside from issues pertaining to nutrition and feeding, issues were highlighted relating to toileting issues and privacy issues associated with toileting and washing. These are significant issues for the elderly in care. From a personal perspective it must be deeply hurtful to have such intimate matters dealt with in an impersonal “production line” manner. Yet from a corporate perspective it is routine work suitable for delegation to the least trained staff to deal with in such a “process driven” manner. In budget terms this makes perfect sense but what is the world coming to when the provision of nursing service is administered in this fashion?
According to Wikipedia the definition of ‘Nursing’ is ‘a profession within the health care sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life’. It seems that that definition is inspirational in large portions of today’s NHS and social care provision.
The persistent and presently unanswered question is why are these issues being repeatedly highlighted in relation to the elderly? Is it a combination of factors, namely that the elderly have more medical needs, need more support by virtue of their unrelated but undeniable challenges to independent living and may spend more prolonged periods either acute or non-acute care? Set against a backlog of an increasingly aged and therefore increasingly vulnerable population, it is perhaps hardly any wonder that much of the media focus in recent years seems to have concerned the care of elderly patients.
Not only has there been a lack of care there have been reports, by the health secretary that are far more worrying, reports of cruelty becoming normality in some health and social care settings. There are 25,000 reports of abuse of the over 65’s in 2011 and that was abuse allegedly perpetrated by carers or health workers. It seems that there is a growing awareness in society and government institutions and patient groups of the needs of the elderly and that is probably contributed to increased reporting of incidents of concern. It may be that the incidents of alleged abuse are no higher than they used to be but owing to increased reporting it has been highlighted more frequently.
In 2012 the Department of Health introduced an age discrimination ban to try and change behaviours and perceptions. It seems however that the rate of improvement is slow.
In 1993 the charity Action on Elder Abuse established a definition of elder abuse which has been subsequently adopted by the World Health Organisation and promoted by the international network for the prevention of elder abuse. The definition is “a single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress or an older person”. It is key that at the heart of the definition is a trust relationship. Any patient must trust their carers hence when that trust is violated there has been a perceived abuse. In 2007 Action on Elder Abuse undertook a prevalence study which indicated that at least 4% of older people of both genders experienced abuse in their own homes. When that figure was increased to abuse in any environment the percentage figure rose to 8.6%. That study included non NHS instances because it involved family in the abuse i.e. care in the domestic setting. It is however Action on Elder Abuse’s view that in some settings abuse may be a symptom of a poorly run establishment which can be in turn a symptom of inadequate funding of care provision by both local authorities and health commissioners.
The Patients Association, a charity, have four times reported on poor care although the focus of those reports is not exclusively pertaining to the elderly. There has been some suggestion that in these times of economic pressure an elderly patient may be regarded as a “blocking” influence by taking up an acute bed in circumstances that perhaps acute beds were not intended for. A study by the Kinds Fund criticised the attitudes and language of NHS staff particularly doctors and highlighted the use of the phrase “bed blocker”. Elderly patients it said make up two thirds of admissions and it opined “that the health and social care system has failed to keep pace with changing health needs”. Perhaps, in fact, the health and social care system have failed to keep pace with changing health demographics?
An elderly patient who is acutely unwell will be admitted to an acute ward but it may then be identified that they need to be transferred to a non-acute service and that takes time to arrange in terms of logistics and funding. Hence, frustration for medical staff unable to help other acutely ill patients owing to lack of beds is understandable. Again it is a symptom of the conflict between the demands upon the NHS service and the sources it has to supply those demands.
It seems to me, having dealt with a number of claims for badly treated elderly clients that a lack of attention to detail at basic levels can cause significant problems. This lack of attention to basic issues appears embedded in a culture of ignorance and carelessness. This stems the acute / non acute divide & the hospital / community divide. In other words it is a shameful but endemic. And the statistics about abuse to the elderly in their homes suggests it is not limited to commercial care settings. What does appears key is that the elderly patient is a vulnerable patient & failure to follow basic hygiene & comfort issues can cause significant injury and even death. Pressure sores are a perfect example. They are largely preventable yet I am frequently referred cases of elderly patients who have not been nursed in accordance with best practice relating to mattresses, turning and inspection of vulnerable sites. Poor wound hygiene then invites infection & risk of cellulites & septis. Once contracted the NHS bill for care increases significantly – costs that could have been saved by an earlier investment in staff, staff training & good management.
With £20bn to be cut from the NHS budget between 2009 & 2014 it seems impossible for the healthcare providers to improve services since significant workforce reduction is required. Without staff on the wards how can the patient experience improve? Similar economic pressures exist in nursing homes where, as a result, trained nursing staff are in the minority and the staff to patient ratio is inadequate. This explains why bed sores are reported to be twice as prevalent in nursing homes as hospitals. De-skilling is a common business tactic to reduce costs, but at what cost to both quality & quantity of life? When will it be accepted that cost cuts cost lives? Against this backdrop the story of the 100 year old who died in hospital due to dehydration when her drip was removed & she was declined access to water to drink is not an isolated incident.
The care minister has indicated that swift action is required to provide better quality services. It is acknowledged that much work is required. My question remains. Given the conflict between demand and resource how can those improvements be made? It is easy for politicians and ministers to give reassuring statements but how can the NHS managers provide the results required when faced with the economic constraints that they are placed under? It seems to me that little has been learned from the Mid Staffordshire enquiry and accordingly hospitals administrations will continue to be driven by corporate self interest as they are required to do by the economic constraints placed upon them by government. In other words, the senior managers are the government’s scapegoats. Until that changes and we revert to a caring culture we will continue to hear horror stories of neglect of the elderly that may even amount to cruelty.