The issue of the ‘lost tribe’ of care home residents has been the focus of two workshops jointly facilitated by the Cerebral Ageing and Mental Health and Primary and Continuing Care SIGs in conjunction with the Faculty of Old Age Psychiatry.

We report here the conclusions of these workshops, to stimulate both debate and interest in this important area of caring for older people.

Psychiatry and geriatrics
Old age psychiatry teams have developed a culture of community based care whereas geriatricians have progressively retreated into the acute sector. Thus the scenarios may be very different for the current management of behavioural and psychological symptoms of dementia (BPSD) in care homes, as compared to the management of other chronic diseases such as continence, falls, Parkinson’s, diabetes, cardiac failure and palliative care.

The failure to provide a system of chronic disease surveillance for care home residents, both by primary and secondary care providers, frequently leads to inadequate care or crisis management in A&E or MAU. Fear of being accused of negligent care has led many homes to want to be seen to do something. We would suggest that the fault lies in lack of systems to avert such crises, or in not having a plan of care should a crisis occur, e.g. advance directives. This is not an ideal way of providing a service to the most vulnerable sick and dying.

In future, services should be proactive, not just reactive. This will require established liaison services to be available to care homes. Continuity of care should be provided to both the residents and the care homes to establish good relationships between the home and primary and secondary care providers. One model of service will not fit all, but the underlying principles can be agreed and standardised.

It is possible that in the future secondary services may need to bid for their services to the care home providers. There was unanimous agreement that there should be studies to evaluate the best method of providing primary and secondary care to the care home sector.

Educating carers and medical staff (GPs)
Despite its importance, care homes rarely have a formalised educational or training programme. At present there is limited evidence for effective educational interventions in care homes from health care professionals. Traditionally training is provided by the industry to the staff, based on the requirements of the Care Standards Commission and NVQ guidelines. Although care homes are responsible for the care of the most frail of our aged population, who use a significant part of our acute services, the health component is relatively neglected, with the social care model predominating. The importance of teaching skills were recognised by the workshop participants.

Delegates believed that good and effective training should be multidisciplinary/multi-professional. In recognition of the constraints on staff time and the profit driven private sector, homes and GPs may need to be given incentives to acquire the knowledge and skills required to provide high quality care to frail older people.

• Managing depression
• Medication review
• The use of neuroleptics
• Advance directives
• Palliative care in older people with dementia
• Abuse of older people
• Prevention of falls
• Behavioural problems
• Nutrition
• Bowel care
• Promoting continence
• Preventing and treating pressure sores

The following areas were also discussed, as a means of developing training programmes:

• Dementia care mapping in homes
• A regular cycle of specialist training for staff caring for patients from ethnic minorities
• The recognition of abuse and neglect
• The importance of regular updates
• Primary and secondary prevention e.g. exercise, hip protectors and calcium plus vitamin D
• Advance directives
• Mental Capacity bill

How to direct policy and research at a local and national level?
There needs to be effective local and national planning for the future, if acute services are not to continue to be overwhelmed by the needs of frail older people with dementia on the cusp of needing placement in a care home. This is true too, of those care home residents who are frequent, often inappropriate users of acute services. The single assessment process will not provide all the answers and these issues are not addressed in the National Service Framework for Older People. Traditionally, advances in care for older people have been driven by charismatic visionary, local and national medical leaders, as well as by vocal carer groups. Collaborating with voluntary organisations may be the most effective way forward in the future.

The new Commission for Care Standards Inspection established in April 2004 will be responsible for inspecting care homes, but will not have a health component or contribution. There is evidence that secondary health providers have at least partially disengaged from the care home sector. A way forward may be for the new commission to ask questions around the level of secondary health care involvement, as well as the level of GP involvement.

Delegates suggested that studies should be set up to explore which model of secondary care support works best (CPN, consultant, team, geriatrician). The concept of a nursing home physician was discussed as an alternative solution to the need to provide expertise.

In conclusion the workshops formed the opinion that there is a need to work with voluntary organisations such as Help the Aged and Age Concern, to lobby to improve provision and quality of continuing health care. There is also a need to establish whether standards of continuing health care provision should be driven locally or through national policy, or both. There was a general assumption that at present doctors have been disempowered and that these services are planned in a fragmented fashion as opposed to from a holistic or comprehensive perspective. Moreover, some of the recent innovations exclude older people with mental health problems.

Future local and national policy developments need to be evaluated.

Jackie Morris
Chair Primary Care & Continuing Care SIG
Duncan Forsyth
Chair Cerebral Ageing & Mental Health SIG