Jeremy Hunt, the health secretary, pledged earlier this year that his key priority for next year, beginning April 2014, would be to improve services and care for elderly patients, to help ease the growing pressure on hospital A&E departments and encourage them to remain independent at home where possible.
Mr Hunt said when he launched the public consultation that 'these proposals set out how to make improvements in primary care and urgent and emergency care. They also seek to establish ways for NHS and social care services to work together more effectively for the benefit of patients - in and out of hospital.'
The Department of Health began a public consultation in May 2013 to find out how health services could be best utilised to deal with the increasing demands of an ageing population and to manage long-term conditions. The consultation ended in September of this year, and the vulnerable older person's plan was expected in the autumn. At the time of writing, the Department of Health expected the plan to be issued in December. However, no date has been set.
Named GP
In the meantime, the BMA and NHS England have negotiated the 2013/2014 changes to the GP contract.
One of the changes that grabbed the headlines was Mr Hunt's announcement that 'We are bringing back named GPs for the vulnerable elderly. This means proper family doctors, able to focus on giving elderly people the care they need to prevent unnecessary trips to the hospital'.
All patients over 75, around four million in total, will be assigned a named GP who will oversee all of their health and create their care plans for them.
A hundred thousand of the frailest patients will be identified by GPs across the country. This will include those at the end of life, in care homes and those who are frequently admitted to hospital. The aim of this is to ensure that their needs are met quicker and that hospital visits are reduced.
An analysis by NHS England in autumn 2013 showed that much of the winter pressure on A&E comes from frail elderly patients needing help. As has been well documented, this winter is set to become the hardest ever faced by NHS in A&E departments. It is widely believed that older patients will be better served by being cared for by nurses in the community.
Professor Steve Iliffe, professor for primary care in older people from University College London said, 'having a named clinician for over 75s is a way of getting GPs to take clinical responsibility for patients and, in a way, this change is quite positive as someone has to [take responsibility] and it is clear that the majority of hospitals don't do it, or if they do it's because they have an on-site geriatrician.
'I can see why this was proposed but it will need good case management to work.'
Professor Iliffe also said that there needs to be a commitment to resources to support all patient groups, and this could start with investing in resources for the frail elderly. 'There will need to be a creation of case managers that can work across practices and that can function with community matrons.
'There needs to be a decision by GPs to care for the elderly and theywill also have to recruit nurses of a high calibre and that are experienced. CCGs can offer the funding for this, but there is a worry that it may deplete other forms of nursing. For example, some community matrons were experienced, high-level nurses that worked in district nursing teams. They were then moved into the community matron position, which disrupted a number of district nursing teams.'
Crystal Oldman, the chief executive of the Queen's Nursing Institute,(QNI) agrees with the importance of strong district nursing teams. 'District nurses are the experts in caring for older people in their own homes and communities. This is at the heart of their training and their core purpose. They prevent patients being admitted or readmitted to hospital and support early discharges wherever it is safe to do so. District nurses and their teams are ideally positioned and qualified to work with other professionals in the community to coordinate the care of older patients, including working with GPs, practice nurses and social care services.
To enable this excellent work to continue however, more district nurses need to be trained. They lead and manage the community teams, ensuring that care is given by the right nurse with the right skills.'
| Demographics of the UK's elderly population |
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Source: www.parliament.uk |
Piloted projects
A number of innovative projects already exist in order to integrate the care of the elderly across services. Professor Iliffe says that there is no problem with innovating for projects to improve the care of elderly, but that there are too many short-term, under planned projects occurring in the NHS.
One successful project was set up by a health visitor, Carolyn Lindsay, who still works with the elderly in Solihull, with funding from the QNI and support from staff from Age UK Solihull. Her project aimed to increase fluid intake among the vulnerable elderly, helping them maintain health and prevent dehydration, one of the key risk factors for patients being admitted to hospital. By talking to colleagues and gathering anecdotal evidence while meeting older people in the community, it became apparent to her that they tended to limit their fluid intake. This stemmed from a reluctance to go to the toilet, particularly among those with poor/reduced mobility, and not understanding the detrimental effects dehydration could can have on their health.
Many clients enjoy tea and coffee, a very important element of their socialising, explains Ms Lindsay, but are unaware of the mild diuretic effect of caffeinated drinks or the need to drink water and other fluids as well. A number of older people she visited had already been advised by a health professional to drink more fluids but were unsure of what and how much to drink. They seemed unaware of the need for good hydration and the effects of dehydration, such as increasing their risks of constipation, urinary tract infections, effects on blood pressure, dizziness confusion and falls.
Ms Lindsay surveyed a group of older people living independently in private sheltered accommodation to discover some of the reasons why they limited fluids, and to identify some of the myths and beliefs. 'As a result of this, we were able to develop resources that would be influential, appropriate and effective in encouraging them to drink more fluids, especially water (unless otherwise advised by a health professional),' she explained.
Using what she discovered, she developed a six page booklet, 'Water for Wellbeing', which included a self-assessment tool. The booklet presented information on the effects of not drinking enough, hints and tips to improve drinking habits, how to boost fluid intake and a chart to help clients monitor how much they drank as well as a bookmark, featuring how urine colour indicates hydration status. Ms Lindsay's team also developed large laminated posters for the backs of toilet doors in community settings such as sheltered housing and the local hospital and clinics, with pull-up banners for National Falls Awareness week event held across the borough of Solihull.
The resources were then rolled out across a number of different community groups across the borough, including day clubs and exercise groups, with support from exercise staff, volunteers and other staff within Age UK Solihull. Hospital staff also used some of the resources to promote National Hydration and Nutrition Week on the wards.
A follow up questionnaire with 12 people attending an exercise group identified 67 per cent had increased their fluid intake as a result of receiving the leaflet and information. Following a brief discussion with the group, Ms Lindsay discovered they had all used the leaflet as a tool for monitoring fluid intake.
'Across the groups, 33 per cent stated they had reduced their caffeinated drinks and were drinking more water. They also reported benefits of improved sleeping, better appetite, reduced constipation and being less tired. Many participants said how useful the resources were and 58 per cent had shared information with relatives and friends,' Ms Lindsay explains.
'It is now becoming embedded in community nursing practice as part of all new patient assessments and across Intermediate Care Services.' Ms Lindsay hopes that in the future National Age UK will use the topic area as the focus for National Falls Awareness Week.
| Dementia |
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Source: www.alzheimers.org.uk/statistics |
Case management
While some projects and services focus on maintaining the health of the vulnerable elderly, others tackle better management of patients and care plans. Dr Kate Walters, a senior clinical lecturer in primary care at University College London (UCL) and a GP, piloted a software system that measures the needs of elderly patients in primary care. A team at UCL developed and modified software from a Swiss model. The system records the medical, social, physical and environmental needs of older people, then generates a personalised report, with feedback on the kind of interventions that may be required.
This was tested with a random sample of older people from five different GP practices, three in the London borough of Ealing and two in Hertfordshire. In four out of five of the practices it was the practice nurses who followed up the reports and addressed the different needs that were flagged up. The study was completed in August and since then the team has been evaluating the results, which will be available next year. The initial results appear to be that this would be a feasible system to implement but there are measures that could make the process better run and it does take time to carry out.
Dementia friendly
One area that is well-ahead of the pack in terms of elderly care and services is Crawley. Dementia was made a priority in 2006 when clinicians realised it was an area that was being neglected. Since receiving money to set up a dementia alliance group, 100 services and organisations signed up. Prioritising dementia aimed to create three change mechanisms - supportive networks, supportive communities and a supportive environment - so that everyone from families and friends of patients to organisations, local services and businesses are able to support people with dementia.
Dr Amit Bhargava, a GP in Crawley, says that nurses in practice and in the community are key to delivering proactive care to the community. 'They are all part of an integrated team to maintain the care of the elderly in the community.
'I think having a named GP is a good idea, as GPs need to be involved in the care of the most vulnerable. Community care needs to be aligned with GP services and they need to be accountable to each other.'
The imminent release of the vulnerable older person's plan, means that primary care professionals will need to continue to support the elderly to allow them to stay independent at home and cut down on unnecessary admissions to A&E.
Ms Oldman said: 'Nurses are experts in the promotion of self supported care and the creation of innovative solutions to meet rising demand. They recognise that with an increasingly older population, they need to work in partnership with patients and their carers. In particular, technology-assisted living and self-supported care will be a major part of how future services are delivered to older people with long-term conditions.'