Frailty Care a matter of national social injustice

Transcription

1 Frailty Care a matter of national social injustice Authors: Dr Steve Feast, Managing Director, Eastern Academic Health Science Network, steve.feast@eahsn.org Professor David Hewson, Professor of Health & Ageing, University of Bedfordshire, david.hewson@beds.ac.uk Professor Gurch Randhawa, Director, Institute for Health Research, University of Bedfordshire, gurch.randhawa@beds.ac.uk

2 Frailty Care a matter of national social justice The budget response highlights that one of society s greatest challenges is how we best support older and frail people to remain self-caring and independent at home. Numbers of older and frail people are increasing as NHS and social care services face their greatest financial challenge. Constrained social care budgets are making it harder to discharge people back to supported environments. Acute care settings are challenging places for older and frail people to retain their personal sense of self-esteem, respect and dignity Current service provision can reinforce a culture of stigmatisation and disregard of older people s recovery needs. Once medically stable, vulnerable and frail people are declared fit for discharge or characterised as bed blockers. These issues have been brought to the fore by the Kings Fund and Nuffield Trust (Humphries et al, 2016) and the NHS Confederations Commission on Improving Urgent Care for Older People (NHS ConFed 2015). Both set out the scale of the challenge in both human and financial terms. Prolongation of hospital stay after patients are fit for discharge can increase morbidity and mortality (Rosman et al, 2015). Emergency department overcrowding is associated with increasing risk of death and subsequent hospital readmission (Guttman et al, 2011). Up to one third of deaths in hospital can be attributed to medical errors (James, 2013). Delays in door to team and team to ward times have been shown to be independent predictors of death within 30 days (Plunkett et al, 2011). Complex care settings may increase the risk of harm rather than improve chances of recovery and return to home. Many health professional s response when elderly relatives are admitted to hospitals is to try and help get them away from harm and back home as soon as possible. The CQC report, Building bridges, breaking barriers: Integrated care for older people (CQC, 2016) found many organisational barriers that make it difficult for services to identify older people who were at risk of deterioration or an unplanned emergency admission to hospital. The lack of connection between services often results in older people and their families or carers needing to take responsibility for navigating complex local services. This could result in people 'falling through the gaps' and only being identified in response to a crisis. This evidence and experiences echoes the drivers that led to the foundation of the Mental Health Movement in the last century. From the mental health movement grew community psychiatry. Is now therefore the time learn from this movement and reframe how we see, report, care for and value frail older people? The last fifty years witnessed four key phases of mental health reform - That society was detaining those with chronic and enduring mental illness in asylums became a matter of significant social injustice with the realisation of the consequence of institutionalisation. Hospitals were closed. - Advances in psychopharmacology led to new medicines that could better treat symptoms. Excessive use of these medicines helped people be symptom free but often at the expense of their wider health. Side effects and obtunded affect rendered people incapable of engaging with society, work and the right to a full and enriching life. There was a shift to an approach characterised by the minimum amount of medication that helps people remain independent whilst not distressed by symptoms. - After the closure of asylums little infrastructure existed to support people in the community. Less beds to admit to stimulated a need for cohesive and coherent community services. Following the National Service Framework for Mental Health (DH, 1999) crisis intervention,

3 assertive outreach, early intervention in psychosis and continuing care and rehabilitation services were invested in. This supported a further revolution in mental health care and a consequent further reduction in inpatient beds. - Poor mental health or an acute mental illness was seen by society and employers as an illness for life. The Recovery movement reframed this by highlighting that recovery is about staying in control of lives despite experiencing a mental health problem. Care refocussed on not just on treating or managing symptoms. Older and frail people are experiencing the same set of challenges. Politicians, NHS decision makers and wider society should look and learn from mental health reforms. A risk adverse society is frequently admitting older and frail people at the convenience of services rather than investing in their continued independence at home. A UCLP survey of admissions age 75 or over found that the decision to call an ambulance was mostly made by someone other than the patient. Upon arrival at an assessment unit older people are undressed and wait for long periods. Many are not dressed during their stay on wards. Hospitalisation can lead to loss of self-esteem and dignity. After admission people see specialists, nurses or allied health professionals. Each will seek to optimise the treatment of their relevant expertise. Polypharmacy and side effects increase after admission (Nobili et al, 2011). Patients experience in hospital clinical adverse events. We should learn from mental health prescribing as to what is the minimum amount of medication that a person needs to remain independent and able to remain mobile, alert, and return to home. Discharge can result in older and frail people being dropped in to disconnected and fragmented services. Overburdened GP practices no longer routinely provide home visiting and care coordination. Community staff may be the patient and carers only regular contact. Access to community staff is very variable (Ball et al, 2014). We must shift scarce resources from inpatient in to community provision. If through STP implementation less beds are available then we must reset the paradigm in favour of better resourced community care. Finally, there is a need to shift the debate towards recovery. The British Geriatric Society Fit for Frailty (Fit for Frailty Campaign British Geriatrics Society 2014) report highlights It is important to remember however, that Frailty varies in severity (individuals should not be labelled as being frail or not frail but simply that they have frailty). The frailty state for an individual is not static; it can be made better and worse Greater attention needs to be paid to preadmission condition and how a person can be supported to regain that. Busy units task health and care workers to find a placement in the first available care or nursing home. Older and frail patients when ill are not on some inevitable decline to incapacity. There is evidence that encouraging frail older patients to engage in regular physical activity is safe, and can delay functional decline (McPhee et al, 2016). An integrated care approach for frail older people has been proposed however positive results, particularly related to the cost-effectiveness of the interventions are lacking. For instance, results from trials of the Dutch National Care for the Elderly Programme show limited evidence of success (Hoogendijk, 2016). Further work is needed. Optimising services to enable frail older people to live independently is also necessary (Metzelthin, van Rossum et al. 2015).

4 Conclusion It is time to transform how we treat older and frail people. Society and government need to reframe a growing problem in to a solution. As a matter of social justice, we must optimise people s opportunities to be activated and engaged in their care. Supported on their terms to be treated and remain in their own homes or care settings. We can learn from transformations in mental health care and design solutions that minimises risks of treatment and care, understanding the risks that independence may bring. A greater focus and respect for the dignified ways in which individuals recover is better than a response that focusses on flows and efficiency. This approach values citizens as contributors to society regardless of their age, and potentially offers some optimism to the human and financial challenges that the UK is currently facing. Activated engaged frail and older citizens can help us design solutions that work best for society and the vulnerable.

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