Challenging anecdote-based practice for frail elderly

This report from the HSJ Commission on Hospital Care for Frail Older People is generating interest not only because it is addressing what will be a priority for many commissioners but because it is challenging some of the myths which are present in current policy and thinking.

Care of the frail elderly is an area where there is significant variation across the country and we’re all familiar with high-profile examples where care has fallen short of standards and expectations.

There have been a number of reports, from notable organisations such as the Royal Colleges, NHS Confederation, British Geriatrics Society, offering evidence, guidance and opinion, in recent years – and this report attempts to build on this earlier work.

Key findings of the Commission

The report notes that hospital may not be the best place for frail elderly patients, due to the risk of iatrogenic harm. However, it challenges the assumption that community-based care and more integrated care will lead to reduced demand in the acute setting – and that savings will be generated. The report aims to present an evidence-based and realistic viewpoint to set out the challenges in improving care for the frail elderly. Increasing demand in a harsh financial climate is impacting on quality and the report acknowledges that difficult decisions will be needed to prioritise investment.

The report aims to challenge long standing myths around opportunities and savings.

From a commissioning perspective, the report notes the need for more responsive services in the community and more provision of step-up and step-down beds to manage delayed transfers of care.

From a provider perspective, the role of geriatricians and comprehensive geriatric assessment are highlighted. A key point is that sometimes admissions will be necessary so we shouldn’t over-generalise that an admission is a failure of the system. Continuity of care and the quality of patient-professional relationships are important priorities from a patient perspective, but perhaps not given the attention they deserve in service redesign.

The report authors are keen to note that there is no “silver bullet” solution to providing high quality care for the frail elderly – health and care needs are complex often due to co-morbidities and service provision involves different professions, agencies and providers. I felt the report missed an opportunity to address this complexity in more detail, with its focus on hospital-based care; service transformation is needed at a system-wide level and I feel the Commission would have benefited from a wider remit and inclusion of panel members from social care, commissioning, community services and importantly, the patient/public perspective.

Continuity of care and quality of relationships are important to patients

A series of case studies shares results from a number of initiatives:

A rehabilitation and enablement programme in Lanarkshire which resulted in a 20% reduction in falls
The introduction of discharge-to-assess pathways in South Warwickshire which led to bed closures and savings
Regular meetings between health and social care to improve patient flow and a streamlined discharge assessment in Sheffield
Screening admissions for frailty using a pragmatic tool in Derby
Embedding comprehensive geriatric assessment in the emergency department in Leicester, reducing admissions by 10%

Methods

The Commission’s findings are based on a review of evidence and a call for evidence and good practice. The Commission panel comprised 7 senior leaders and was led by Dame Julie Moore from the University Hospitals Birmingham Foundation Trust.

Key questions for commissioners

Commissioners may wish to consider:

What pathways are in place for frail elderly patients?
How these pathways are monitored?
How are processes/outcomes measured?
Are the pathways and measures based on evidence or anecdote?
What methods are in place to understand the needs, preferences and expectations of their frail elderly population?