Older people are getting good acute care in Scottish hospitals but many are being admitted who do not need to be there, a national review of services has concluded.
Acute hospital care improving for older people but avoidable admissions need to be prevented.
Older people are getting good acute care in Scottish hospitals but many are being admitted who do not need to be there, a national review of services has concluded. It says there is a need to expand services that can look after people in their own community.
As Scotland’s population ages, care of older people has become one of the main priorities of the NHS. The report from NHS Quality Improvement Scotland found that the acute care provided to older patients by Scottish hospitals is improving but more needs to be done to extend high quality care across the country.
The report recognises that the health service has adapted too slowly to the needs of a growing number of older people over the past 30-40 years. However it says that all Trusts are now working on developing and improving services for older people with the aim of getting them better and keeping them well. It emphasises the importance of good community services to allow older people to remain safely at home and better rehabilitation to help those in hospital make a quicker recovery and return home, often with increased support and continuing rehabilitation.
The report is based on visits that have taken place across Scotland to assess the performance of local health services against standards for the acute care of older people. It looked in detail at arrangements throughout the “journey of care”: in accident and emergency departments and through hospital admission, rehabilitation and discharge. The review teams, which included members of the public, also examined the care of patients with hip fracture. This is a common and serious injury with a complex journey of care and was therefore chosen as a tracer condition to test the treatment and care given to a specific group of older patients.
The review visits found that the physical care offered to older patients who are admitted to hospital is good but, once in hospital, their journey of care can sometimes go wrong. Patients may find they are moved from ward to ward to make room for other patients and can suffer from having their discharge delayed. This highlights the importance of preventing avoidable admissions, particularly for frail people. They are especially at risk of immobility, infections and delayed discharge once admitted.
The report found many examples of high quality services for older people in Scotland. However it adds: “Services are uneven throughout Scotland and there is certainly scope for change and improvement in the process of acute care by building on the examples of good practice that were found.”
There is praise for the development of multi-agency teams which provide help for people at home and prevent the need for admission to hospital. The report says such services have resulted in “tremendous improvements in the care of older people at home and are valued by those who use them.” However, the majority of these services are only available during the day, 5 days a week. They would be far more effective as a 7 day service. The report recommends that a review takes place of such services to make them more available and flexible.
Fewer than a quarter of trusts were able to show that they are achieving the standard of admitting older patients within 2 hours of them being seen in A&E units. Where patients were waiting for admission, this was often because staff were making sure they had the right tests and were admitted to the right place The report says that improvements in emergency care mean that patients are more likely to receive thorough assessment and, in most cases, begin treatment before leaving A&E.
Most Trusts are providing rehabilitation services to help older people recover as quickly as possible. The report found there are problems with the availability of physiotherapy and occupational therapy staff outside normal working hours. It also stresses the importance of setting rehabilitation goals for each patient and monitoring these to ensure the goals are met.
Planning for discharging patients should begin as soon as they are admitted and needs to involve all members of staff, the patient and carers. The report found discharge planning in many areas to be fragmented and poorly co-ordinated. As part of the discharge process faster provision of aids such as grab rails would allow older patients to return home more quickly.
High standards of care were found across the country in treating patients with hip fracture. However, only seven out of 36 Trusts met the standard of operating on hip fracture patients within 24 hours of admission. The report recommends that Trusts should ensure that sufficient daytime operating sessions are available 7 days a week to be able to offer prompt surgery to hip fracture patients.
It also says that Trusts need to work harder to involve older people in the design and development of services and in their own care. It recommends that this should include taking a sensitive account of the needs and views of patients and carers when a care home they want to move into is not immediately available. Particular attention needs to be paid to the assessment and care of confused patients. Ensuring that their needs are met requires skill, time and experience and more staff training is needed to help improve the management of this important group of patients.
Consultant geriatrician, Dr Colin Currie, who chaired the project group, said:
“We found evidence in many areas of high quality care and more focused attention on the needs of older people. This is very much to be welcomed and needs to be built upon. However, there is still much variation across the country, and what we have to do now is extend the best of what the NHS does to the rest of the NHS. We also need to provide services far beyond the 5-day standard working week. Responsive services providing evening and weekend care would make a great difference.
“Providing good care for older people will work out cheaper in the long run than providing bad care. Better services to look after people at home, better rehabilitation and discharge management to shorten length of stay, and successful action on delayed discharge will all reduce costs. But far more important than that, it will mean better care for the patients concerned.“
The chairman of NHS Quality Improvement Scotland, Lord Naren Patel said: "The need for health services increases as people get older. Care of older people accounts for 40% of the health service budget and it is important that services meet their needs. This report details many examples of good practice but it also shows that there is too much variability in the quality of services across the country.
"This report shows where we are today and it identifies the changes that need to take place to improve services for older people. It is an important step forward. We will continue to monitor the situation to ensure that the standard of services improves further across Scotland and that older people get the care that they deserve."
Visit our Publications section and select either ‘National Overview’, ‘Local Reports’, or ‘Standards’ from the drop-down Publications menu in our Publications section. Alternatively, use the Publications search facility by typing in 'older people'.
The reports cover the following Standards and Criteria:
SECTION 1 – ACUTE CARE
Standard 1 – The Option to Remain at Home
Standard 2 – Assessment of Older People Being Admitted Briefly
Standard 3 – Older People Admitted for In-patient Acute Care
Standard 4 – Rehabilitation in Acute Care Wards
SECTION 2 – PLANNING A SAFE DISCHARGE HOME, SUPPORTING PEOPLE AT HOME AFTER THEIR DISCHARGE
Standard 5 – Discharge Management
Standard 6 – Equipment and Adaptations
SECTION 3 – HIP FRACTURE – A ‘TRACER CONDITION’ FOR OLDER PEOPLE IN ACUTE CARE
Standard 7 – Hip Fracture
SECTION 4 – COMMUNICATION
Standard 8 – Communication Between the Trust and Older People
Standard 9 – Communication Between the Trust and Other Agencies
that Provide Care for Older People
NHS QIS Remit:
NHS Quality Improvement Scotland (NHS QIS) has been established to improve the quality of healthcare in Scotland. To do this, it will set standards and monitor performance, and provide NHSScotland with advice, guidance and support on effective clinical practice and service improvements.
The clinical standards it develops, defined in partnership with members of the public and healthcare professionals, follow the ‘patient journey’ as they move through different parts of the NHS. This NHS QIS system of assuring quality is designed to complement the duty that has been laid upon the board of each NHS body by the Health Act 1999 to monitor and improve the quality of healthcare which it provides to individuals (clinical governance).
NHS QIS is independent from government. Although it is accountable to the Scottish Executive for delivering its work programme and for the public money it spends, NHS QIS reaches its own conclusions on the quality of services being provided by the NHS, and publishes its findings.
Background:
Established on 1 January 2003, NHS Quality Improvement Scotland is a Special Health Board, built on the expertise developed within the:
• Clinical Standards Board for Scotland
• Clinical Resource and Audit Group
• Health Technology Board for Scotland
• Nursing and Midwifery Practice Development Unit
• the Scottish Health Advisory Service.
Chaired by Lord Patel, the Board has a broad membership that includes NHS staff and members of the public. Dr David Steel is Chief Executive.
NHS Quality Improvement Scotland Chairman Lord Patel, Chief Executive Dr David Steel, Chairman of the Older People in Acute Care Project Group, Dr Colin Currie, Advisor – Older People, Alison Blakely, and Interim Director for Standards and Reviews Jan Warner, are available for interview. To arrange an interview, please contact:
Patrick Maitland-Cullen, Communications Section, NHS Quality Improvement Scotland, Tel: 0131 623 4297 (dl) or 07968 494 164 (mobile – on morning of 23 February).
ENDS