Balance autonomy & physical/psychological security for older people leaving hospital says study

An interesting article in the Scandinavian Journal of Caring Sciences, at least judging by the abstract, and here was me saying earlier, don't trust the summaries go to the originals). It's from Australia. They studied the difference between older people's views of discharge planning before anything happened, their relatives and healthcare professionals, using a vignette of a frail older person in hospital.

The older people went for the safe option - the care home and so on - for the person in the vignette, but not themselves. The younger people balanced autonomy with security, provided the older person was mentally capable. Discharge planners are advised to stress balancing autonomy with security when working on the issue, look at the ethics of balancing physical with psychological security and help middle-aged people to plan in advance. Sounds like good advice, but I can only see the abstract - this isn't a journal I get.

Linley A. Denson, Helen R. Winefield, Justin J Beilby Discharge-planning for long-term care needs: the values and priorities of older people, their younger relatives and health professionals. Article first published online: 13 APR 2012 DOI: 10.1111/j.1471-6712.2012.00987.x

CQC report on healthcare in care homes: look at the figures underlying the summaries

 

I’ve been having a look at a special survey of healthcare services in care homes for older people was published last month by the Care Quality Commission, the regulator of all sorts of health and social care provision.

You can find it on the internet here (a summary, and you can click to get to complex or easy-read versions): CQC healthcare in care homes report March 2012

The difference between care homes and care homes with nursing

It looked at care homes and care homes with nursing. Duh, you say – what’s the diff, aren’t they all run by nurses? Well yes they (mostly) are, but care homes with nursing (what used to be called nursing homes) are supposed to be able to provide nursing care which substitutes for the kind of nursing you would get from the district nursing service in your own home and moves towards some of the nursing you might get in a hospital. Care homes are what used to be called ‘old people’s homes’. In reality, most of them are run by people with a nursing background, but the care they provide is supposed to be social care, which is help with the everyday requirements of living. So if you are so frail you can’t get up in the morning, get washed, do your own shopping, cook your own meals and so on, that’s care home business. But if you need treatment, such as bandaging, complicated medications, or your medical condition changes a lot and needs an experienced nurse to keep an eye on you, that’s care home with nursing business.

Some care home campuses provide both in different sections. Inevitably, they tend to merge into one another because older people who are admitted to a care home tend to become frailer and iller and are often not moved on into a CHN, and inevitably many of the needs met in a CHN are social care needs. Nursing homes cost more.

The summary is positive, but look at the figures underlying it

If you read the summary on the website, you might get a rosy view of the outcomes; even the document is presented in a fairly positive way. Part of the reason for this is they looked at care homes for people with learning disabilities alongside the homes for older people and the results are aggregated. However, the website also gives you access to the actual figures, and if you read these you might get a bit more worried. If you separate out the care homes and CHNs mainly for older people to get what interests this blog, some interesting facts emerge.

Your rights to a GP service – not

One of the interesting features of the results is the service these patients are getting from GPs.

The summary says:

Forty-four per cent of care homes indicated they received routine visits from GPs.

The report says (pp 5-6):

The review found some variability between care homes in the services provided by GPs and who pays for these services: 33% of homes said that GPs did not provide post-admission assessments for residents, 53% said they were provided and paid for by the PCT and 7% said  that they were provided but paid for by the care home. Managers at 44% of care homes indicated that GPs undertake scheduled surgeries or visits in the care home.

You have to ask what we are paying these GPs for – they get extra money for older people on their list and extra money again for people in residential care. These are probably the most frail and in need of their patients, yet two-third of the homes said GPs did not bother with regular assessment of their patients (I repeat that with emphasis THEIR patients) after admission. Well, you say probably the care home was so committed to the independence of their residents that they helped them to attend the GP surgery. No, I looked at the figures underneath the reports. Just over half (56%) of the homes supported people to attend their GP’s surgery and the case files reviewed by the CQC showed that just 25% of residents (remember, probably the most frail and in need patients) visited their GP’s surgery in the last year. The GPs didn’t do other things either. In more than half the homes they didn’t do Type 2 medication reviews (who knows what the burble means, but these are the less important reviews) and in 16% of homes they didn’t do Type 3 reviews either (that’s the more important reviews).

Finally, in 24% of the homes where GPs did post-admission assessments of THEIR most frail and in need patients, the home or someone else paid for it privately. Hey, hang on a minute, you say, it says 7% up there. Yes, but I’ve looked at the figures. The 7% refers to all the homes, in a third of which the GPs did nothing about it. Take out that third: in the homes where the GPs did these assessments, the home or someone else (you see there’s 3% missing from the report figures) paid. But GPs were already paid (extra remember) by the NHS to look after those patients – why is the home (relying on local authority payments or the fees paid by residents and their families) paying again?

Can you choose the sex of the person who wipes your bottom?

Many of the patients are incontinent more have difficulty getting to the toilet. The website summary says:

A quarter of residents did not feel they were offered a choice of male or female staff to help them use the toilet.

Let’s look at the figures. That’s a quarter of the residents in care homes. But it’s 30%, nearly a third, in care homes with nursing. Now add to that the proportions who said they were sometimes able to choose: that’s 11% in care homes and another whopping 25% in care homes with nursing. So in care homes less than half (40%) and in care homes with nursing (32%) less than a third always had the choice.

That’s not surprising when you look at some of the other figures. For example, only 37% (a bit more than a third) always or mostly organised their rotas to ensure that there was a choice.

Do not attempt resuscitation – who decides?

The report also looks at ‘do not resuscitate’ decisions (those are where if you die, they plan in advance not to try to get you breathing and your blood circulating again). Very often when you’re old and frail this is the right course to take, because the attempt to resuscitate you can be very painful and unpleasant and does not work so well on very frail and sick people anyway. The kind of action you see on the telly in Casualty is for people who are quite well but whose heart stops beating because of a sudden but curable heart problem. Even then, it’s not so successful as drama on the telly would have you believe.

The website summary says:

Thirty per cent of nursing homes did not have a 'do not attempt resuscitation' policy. Of those that did, just 37 per cent of staff had received training on it.

The report says:

30% of nursing homes included in the review did not have a ‘Do Not Attempt Resuscitation’ (DNAR) policy in place (in settings where having a DNAR policy was appropriate and required). Where DNAR policies were in place, most staff (76% of staff in nursing homes) were aware of the policy, although very few (37% of staff in nursing homes) had received formal training in the policy.

So nearly a quarter of staff didn’t know there was a policy and more than two-thirds had no training on a really rather complicated but also rather controversial issue at the end of people’s lives. But that's only the policy - what else does the report tell us?

Let’s look at the figures, which tell you a more complicated picture (although with a relatively small number of homes, so perhaps you cannot extrapolate to all homes too strongly). First of all, how many people had training? It tells you the nursing homes figure (37%), but it was even fewer in care homes (24%); they didn't tell us that. And the proportion of staff who knew there were DNAR decisions in place in their home (where this was the case): 52% in nursing homes, sorry, care homes with nursing; just about half, but that’s good compared with the care homes where only 20%, a fifth, knew. So the vast majority in those homes would not have known the right thing to do if one of their residents came to the point of needing resuscitation.

Now, who makes the decision? A lot of people think it’s the patient or the relative, but it’s not, it’s the doctor who decides, because only a doctor (or at least a very experienced nurse or other senior clinician) has all the evidence before them and can assess all the factors. But it’s generally regarded as good practice to consult the patient and other relatives too, so that they are not upset by unexpected action or inaction, and if they feel strongly, they can express their view.

So you would think that the DNAR policy would at least have been run past a clinician (for which in most cases read ‘doctor’). 45% of the policies showed evidence of having been developed with or tested on a clinician – less than half. This is a really delicate area of patient-professional communication. So how many policies provided for a clinician to coordinate the decision (they’re supposed to have a meeting to decide the best interests of the resident)? 72% (perhaps not surprisingly, since we know from what I’ve already said about the report that GPs are not heavily involved with their patients who are residents).

But that was just the policies. What happened in practice? For example, who was consulted? Point 1: only 42% of cases where a DNAR decision was on file were in accordance with the home’s policy. Point 2: only 16% had a signed agreement with the patient. Point 3: only 55% had a signed agreement from the patient’s carer. Point 4: only 52% had a signed agreement with the patient’s GP.

By this time the CQC staff must have been getting a bit desperate, because the next category of information didn’t look at the case files but asked how many homes involved ‘at least some relevant parties’ in the decision. Ah, success: that leaps to 72%. Oh dear, they lost out on the next question: how many homes sought to communicate the decision to relevant parties in appropriate ways? 46%. They were probably lucky that they hadn’t told their staff either (as we saw above) so the DNAR decision was unlikely to be enacted anyway. There were very few complaints. Does this show that no one knew about what was happening? Or that people behaved reasonably at the time? Or that relatives were appropraitely relieved when the end -of-life came peacefully?

There’s lots of other interesting and useful material in this report, and the CQC is doing right by looking into how healthcare for older people in care homes is being provided, and how people are being consulted and involved. Good on them, since they’re being much maligned at the moment.

But it’s a wonderful case study in how summaries and reports can conceal a complex and not terribly wonderful picture that is hidden in the more complex figures that most people will not look at.

So it does confirm what most people think about care homes. OKish, but not enough attention to detail to really be the place where you get helped to the best quality in your declining days. I’m going to try to keep out of them.

Transport access for all, not just for London at the Olympics

Channel 4 News has an item quoting Sir Philip Craven saying that it's not reasonable to expect all London underground stations to be accessible to disabled people in the period from winning the Olympics bid for 2012 and the Olympics taking place.

He's right to say that everyone wins from having more accessible transport, and that everyone particularly includes older people. You can get down to the station from the street at Sutton, where I live, but the gap still yawns between train and platform, terrifyingly if you're a child and pretty edgy even if you're a big-striding reasonably-fit nearly retiree.

So I hope it's not going to be just an effort for London and just for the time leading up to the Olympics, because access to transport is a real issue for older people and families with younger children. I saw a woman with a buggy slip down between the train and the platform trying to get off over a large gap recently and I don;t think that short of thing should be possible.

We should be making the accessibility effort for everyone, not just people who have a recognised disability, and for all time, not just for the Olympics, and for all the country, not just London.

Citizenship Social Work - nice review

An encouraging review of my 'Citizenship Social Work with Older People' in one of my favourite American journals, the Journal of Sociology and Social Welfare.

'A welcome addition to the literature on aging...The author brings a wealth of scholarship to this book...This gives the book a richness and range...this book is written in the best tradition of C.Wright Mills...'

'...citizenship social work with older adults...can serve as a useful model for social workers to use in their practice to enable older adults to live well with their aging and to help society to accept responsibility for the life that older people live. This book would be edifying reading for anyone interested in aging and how to maintain the dignity and participation of the aged in society.'

Nice to be compared with C. Wright Mills.

A fall - now and in the future

Fell up the kerb and scraped my skin. Looking like a victim of domestic violence, although the only violence was a lack of sympathy - 'you should look where you're going'.

Still, its a reminder that I shall have to be increasingly careful since skin and bones are frailer as you get older, and in twenty, even tne, years I won't  be so little affected.

Institutional ageism is the main pressure against good social work with older people

Yesterday, I asked, following up on a recent publication of government statistics: ‘Do social workers have nothing to offer older people?’ and on Twitter, various social workers commented in their tweets, that they certainly do have something to offer, but that a variety of constraints prevent them. To sum these up, there are:

• Costs, inadequate resources
• Practitioners’ time (this is part of the resources, but I’ll put it separately)
• Institutional ageism
• The dominant medical discourse
• Unimaginative local authority practice and policy.

An American social worker comments that in the US, social workers do provide more personal support. The implication of this point is that good interpersonal social work with older people and their carers is perfectly consonant with social work theory and practice. Absolutely true, and the Twitter commentary at the same time about my latest book Citizenship Social Work with Older People offering ‘a great human rights perspective on social work and ageing’ reflects the priority I give to using social work skills in that way. The publishers' pages for Citizenship SW...UK: Policy Press; US: Lyceum Books

I think institutional ageism is the most important of these, because I think all the others, poor resource, poor local authority practice and policy and lack of time for social workers to do what social workers could do are more connected with institutional ageism than anything else. Although there are pressures (of course – I lived through the Seebohm reorganisation of social services in the early 1970s and remember being in tears about not being able to cope with my workload), money has been found for child safeguarding and people like Eileen Munro have begun saying that we have to let social workers use their skills in that field of practice.

It’s also true for social work with older people. And we can manage our time to do good interpersonal social work with some older people and their families who really need the best kind of practice: I know some social workers manage to do this because I meet people in the Hospice where I work singing the praises of their social worker. And we cover some of the poorest parts of London. It’s about making the right priorities in our workloads.

But our American colleague’s comment also makes an important point: unless we have the chance to practise to the full extent of social work at least some of the time, we will not retain the skills to do the best job. And that means that the medical discourse is always going to reject our value, because they don’t always see the best of which we are capable. We have to be able to demonstrate to sceptical colleagues how good we really are.

These are the tweets, in order of arrival:

Ermintrude ‏ @Ermintrude2

Really interesting post. I think answers lie in cost and institutional ageism.

Orpheus ‏ @lavinialady

Sadly, in my [local authority] they do 'zap in routine services' due to case load pressure, [under-resourcing] etc. [There is] little time to offer real support.

Cuskellk ‏ @cuskellk

As a mental health social worker with older persons I say we do! More so, [it’s the] dominant medical discourse that constrains us.

Louise ‏ @Lou15eb

We have lots to offer but [it’s] difficult due to budgetary constraints and [the] reluctance of local authorities to think outside the box.

michelle griggs ‏ @michelleg1976

Can I say we can only do good with what limited resources there are?

Kelsey Kelsey ‏ @kelseyterp

Interesting. I wonder if [the] statistics are similar in the US. I work with older adults and I find the support is there from social workers.

(Because Twitter limits how people can write, I have filled out the abbreviations and shorthand in these tweets, indicated in the square brackets.)

Do social workers have nothing to offer older people?

Here is an interesting table, taken from a Commons Library Standard Note: you can find it here:

Social Care indicators

Citation:  Harker, R. (2012) Community care: Social Indicators page. SN/SG/2643. London: House of Commons Library.

In the press, it is often taken for granted that community care is largely for older people. If you look at home care, equipment and adaptations and meals it is. And most other things are half and half. But if you look at professional support you will see that older people get much less than half. Yet they are a very big proportion of the clients of adult social care departments compared with physically and mentally ill and disabled people and people with learning disabilities. So why do these other groups get half or more of these services and lots more professional support?

Do older people and their families get a raw deal from adult social care in receiving professional support from social workers and others? Considering they are such a big proportion of adult social care clients - why?

Could it be that older people and their families are not interesting to social workers? Or that local authorities think social workers have nothing to offer them? Or that local authorities are not bothering with the more complex support needs of older people - just zap in the routine services and ignore their personal cares and concerns.