David Oliver: Older people in nursing homes—from “hard hitting exposés” to constructive solutions

david_oliverLast night BBC One’s Panorama: Behind Closed Doors was the latest in its series of programmes on appalling care for frail older people. For someone like me, who works day in day out in frontline services, it was disturbing viewing and a hard watch. The producers picked three care homes identified as problematic by whistleblowers, residents’ families, and earlier inspections. They used a combination of covert filming and undercover reporters working numerous shifts as care assistants. The care depicted for some vulnerable residents, who had moved to what they and their families would have hoped to be a place of safe, compassionate care when they could no longer stay at home, was neglectful and indifferent at best and abusive at worst.

As the programme makers noted, 1260 English care homes were placed in special measures in 2011, with around one third still failing to meet minimum standards (yet allowed to continue operating).

While we must never defend the indefensible, I should point out that, with around 400 000 people in thousands of care homes across the UK, there are many well led facilities and many residents receiving good care in what is of course their home—generally their final one. But we know that “good news is no news,” and these stories are seldom reported.

Given the collective denial and squeamishness around frailty, dementia, and extreme old age in society and in the media (and the kind of terminology used all too often: “grey tsunami,” “ticking demographic time bomb,” “burden,” or, by doctors themselves, “acopic,” “bed blocking,” “social admission”) it seems only scandal and sensation make it to our screens.

On the other hand, the undercover reporter received only three days on the job training before starting as a care assistant, despite the complexity and challenge of the role. There were staff on £7.60 an hour for this work—with hours and numbers being cut during filming. The lack of knowledge or competence was evident in the total lack of understanding in some staff about how to communicate with demented residents. They also seemed to have no awareness of basic management of incontinence; with some of the carers filmed not even realising that one old lady required hoisting, and could not just “walk” to the toilet, before encouraging her to “use your pad.” Nor were senior managers in the homes aware of some of the staff in their organisation who were actively hostile to vulnerable older people.

Big picture national politics also play a part here. Social care spending is dwarfed by that on hospitals, even though there are three times as many people in long term care as in acute beds. It remains means tested, with many people having to use savings and assets to pay at a time when they are already under great emotional stress. In turn, the money received by nursing and residential homes leaves them frequently short staffed, with high turnover, and workers who’ve experienced poor training or supervision. Remember, many residents have complex comorbidities, disabilities, or cognitive impairment—often compounded by problems with nutrition, continence, and inappropriate polypharmacy. This is set out clearly in the BGS “Quest for Quality” report. Furthermore, when nearing the end of life, many require skilled care planning and palliative care support.

In short, caring for them requires high levels of training, skill, and adequate staff to resident ratios. Sadly, this is not always what we offer. Also, while the national regulator (in this case the Care Quality Commission) may be able to inspect a couple of hundred hospitals fairly swiftly, getting round thousands of facilities—some part of major chains, others standalone institutions, some council run, some for profit, and some charitable—is a nigh impossible job. In many, the quality may vary drastically between inspection visits. The CQC admits that we can’t merely inspect and regulate quality into the system, so whose job is quality improvement?

Local politics and service leadership also count. There is an eightfold variation in council funded placements across England, and a sixfold variation in placements into long term care straight from hospital beds. There is even bigger variation in the provision of rehabilitation, reablement, and intermediate care services outside of hospital—all of which are services that can have a key role in reducing older peoples’ long term dependency.

We don’t have anywhere near enough emphasis on age friendly housing, extra care support, or adaptations to help people stay in their own homes. Let alone a realistic dialogue with our ageing population to help them consider such options before their frailty puts them at risk of rapid decompensation.

With this blog being aimed predominantly at clinicians, I have to mention what we as doctors need to do better.

Firstly, we need to ensure that older people admitted acutely to hospital, or beginning to struggle at home and at high risk of decompensation, are known to clinical teams. Their appearance should not be a surprise to be dealt with only in a crisis and they require skilled comprehensive geriatric assessment (CGA). This involves a holistic review, not only of various medical conditions, but of activities of daily living, social support, mental health, cognition, sensory impairment, carers, and harmful polypharmacy. We know that applying CGA both at home and in hospital can significantly increase your chances of remaining at home and retaining independence.

Secondly, we need to make post acute rehabilitation and discharge planning “core business.” Frail older people lose function rapidly in the face of acute illness, and we need to do all we can to ensure that we avoid hospitalisation or post discharge care leading to long term dependency. This in turn means that clinicians commissioning and providing care for older people need to ensure that there is an adequate capacity in intermediate care services outside of hospital.

Thirdly, we know from reports such as “Failing the Frail” that the provision of primary care and mental health services, medication reviews, end of life planning, palliative care support, and access to rehabilitation or support from professionals is very patchy for people in homes—despite the residents being on GP practice lists and having a statutory entitlement to healthcare. So we need to ensure provision of a full range of healthcare services to residents. The core elements are set out in the BGS Care Home Commissioning Guidance. They include proactive comprehensive assessment and care planning on admission and discharge from hospital, a real focus on medicines management, a focus on admission prevention, and on improving end of life care.

Sadly, we are not stepping up to the plate at the moment. There are some great examples of local service leadership and innovation, driven, for example, by GPs with a special interest, community geriatrics, mental health services, or AHPS. But these are too few and far between.

Some of those older people portrayed in Panorama might not have required so much assistance with continence or mobility, or might not have had such “challenging” behaviour if local clinicians or clinical leaders had done their jobs properly. Some might still have been at home. And doctors visiting care homes could be a useful pair of eyes and ears to spot problems earlier and could be involved far more in staff training. Look no further than multi agency quality improvement programmes such as “My Home Life” to see what can be done to share best practice and to help staff improve.

Competing interests: None declared.

David Oliver is a consultant geriatrician, visiting fellow at The King’s Fund, professor of medicine for older people at City University London, and president elect of the British Geriatrics Society.