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| The NSF Wales has the NSF had any effect on the culture of elderly care? |
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| Email your comments Introduction It stated that, ‘older people are a high priority for the Welsh Assembly Government…National Service Framework (NSF) for Older People in Wales… through the setting of national, evidence based standards, it aims to improve health and social care services and equity of access for older people across Wales.’
In furtherance of this 10 key standards have been laid down:
There has been progress but not at the same rate in all areas. This article concentrates on those areas where consultants in old age medicine in Wales have made particular contributions or feel that the most progress has been made. Intermediate Care The NSF standards have emphasised the need for integration across primary and secondary care. The Gwent Clinical Futures Programme is Gwent health community’s response. Gwent has been able to reduce the number of community beds without compromising quality of care or clinical outcomes. Developing a aealth and social care pathway for the frail elderly requires the integration of intermediate care services in order to provide an easily accessed, seamless service that is needs led and evidence based. The model provides four key elements:
Implementation of the model requires a structure that ensures executive support and formal arrangements to manage day-to-day barriers to partnership working. The proposed model has a single pan-Gwent executive board to steer the strategic objectives and to ensure the model delivers the underpinning principles. Under this sits a Steering Board for each locality made up of Trust, LHB, LA and voluntary sector partners. An operational team (consultant physician, consultant nurse, senior social worker and a consultant rehabilitationist) is responsible for the day to day running of the service. One of these will be the clinical manager, but not necessarily the doctor. The principles for the operation of the team are:
In conclusion, there has been good progress on developing this Gwent wide service model to date. The challenges ahead will be around changing the culture, expectations and behaviours of the population and wider workforce to ensurethat they stop thinking about bricks and mortar and identify healthcare with self-care and local support. Hospital Care - Older Person’s Acute Liaison This change in the management of older people needing acute (emergency) hospital admissions is underpinned by hospital care and person-centred care standards of NSF for Older People in Wales. The model is based on the seminal work published by Harari et al in Age and Ageing (2007, 36(6):670-675). It is currently being practised as a pilot in a semi-urban acute DGH in South Wales (Princess of Wales Hospital, ABM University NHS Trust). The key driver behind the model is comprehensive geriatric assessment and screening for frailty markers in older people needing acute hospital admissions. All acute medical admission patients who are 65 years or older are probed for frailty markers in the admission unit by an acute liaison team (consultant geriatrician and a specialist nurse practitioner) within 24 to 48 hours of admission during weekdays. Frailty markers include: mobility problems, falls, incontinence, urinary tract infections, or confusion/delirium. Older people with any two of the following conditions are also included in this liaison service model: unmet social need, person living alone or from residential homes, polypharmacy (on 4 or more medications), presence of three or more co-morbidities, malnutrition, sensory impairment, 28-day readmission from rehabilitation ward. Patients who fit these criteria are transferred directly to an elderly care assessment and rehabilitation ward so that a comprehensive assessment takes place early during his/her journey through the acute hospital system. Older Person’s Acute Liaison is a kind of ‘whole system approach’ where assessment, management, rehabilitation and discharge planning for frail older people needing acute hospital admission are co-ordinated by a specialist geriatric team. The outcome of the initial pilot evaluation showed a reduction in total length of stay by 55% in patients who had an acute hospital admission and were subsequently managed by Older Persons Acute Liaison. It also reduced the length of stay in a rehabilitation ward by 30% , perhaps due to elimination of ‘catch-up’ rehabilitation time had the patient spent some of their time in a medical ward. The length of stay for all patients in a rehabilitation (geriatric) ward, where the case mix is a combination of transfers from medical, orthopaedic and surgical wards for rehabilitation, slow stream rehabilitation and this newly introduced ‘hot’ transfers directly from the admission unit, had gone down by 6 days during the time of this pilot. Following a successful initial evaluation the model is currently continuing (although still as a pilot pending further managerial decision) and has admitted 300 patients during the period December 2007 – June 2008. The Royal College (London) Audit Report for 2006, published in Spring 2007, described Stroke Services in Wales as being in need of urgent attention. The report states that the very low rate of admissions to beds or units that are co-located and dedicated for stroke patients is unacceptable. Although the numbers of people in Wales dying from stroke have been falling in recent years, a total 2,380 people died in 2005. Following this audit, the report written by the then Stroke Special Interest Group for the Welsh Medical Committee and the commitment given by the Health Minister to support development of stroke services in Wales, a Stroke Partnership was created to oversee the approved Program of Work for 2008 - 2011. In addition, we insituted the Welsh Stroke Alliance, which is a multi-disciplinary clinical collaborative which will be the clinical reference group for the Stroke Services Improvement Project. The Project Objectives are:
The Alliance met recently and was well attended by many multi-professional, enthusiastic clinicians and the first sub-group has already been established to look at imaging and thrombolysis. We are aiming to establish co-located beds in many hospitals during 2008 - though this may not be achieved in all hospitals. The drive and enthusiasm is out there to turn our stroke services around so that we move from being at the bottom of the scale in 2007 to becoming as good as the best in the rest of the UK by 2011. Falls and Fractures The management of falls and fracture has changed dramatically in the last 20 years. The NSF comments on the prevention and treatment of falls and osteoporosis and the integration of services to improve delivery of care. In 2005 an audit was undertaken by the Royal College of Physicians (London) to answer the question whether, ‘all local and health care systems should have established their local integrated falls and fracture prevention services’. 74 per cent of those sites responding reported an integrated falls/bone health service. However, most sites had no case finding strategy or referral system for fallers in A&E. The number of patients reaching specialist falls services and rates of key investigation was very low. For hip fractures, the mean length of stay was 16 days with 25 per cent staying longer than 26 days. Pre-operative management was good for analgesia, fluids, and routine observations. There was generally a lack of pre-operative medical review. 69 per cent of patients had surgery within 48 hours. The target was 90 per cent. The commonest delay was due to organisational problems. Only 39 per cent had multidisciplinary review within 7 days. With regard to falls assessments, syncope was considered in 14 per cent, medication review took place in 44 per cent, 23 per cent had standing BP measured, gait and balance was assessed in 68 per cent and an exercise programme delivered in 44 per cent of cases. Secondary prevention of fractures showed 35 per cent had osteoporosis risk assessed. 18 per cent had DEXA between ages of 65-74 (NICE TAG 87). Calcium and vitamin D and bisphosphonate were prescribed in 51 per cent and 42 per cent respectively. The organisational audit in 2005 demonstrates the danger that health care organisations highlight compliance with an NSF when actually nothing has changed. This is a worry that given that the role of the NSF is to set standards and put in place programmes to implement these standards. On a positive note, our overall scores are very similar to the national average. However the national average is not that good! For the NSF to work effectively we need to demonstrate clear improvement in patient services. So far the NSF has succeeded in only one of its goals, that is to set national standards and models of care. It has started to put in place programmes to support implementation but implementation has not yet been achieved. The National Audits of Falls and Bone Health should be our performance measure. There will be a repeat of the organisational audit this year and the clinical audit in 2 years’ time. These will test of how well the NSF is working. With falls and bone health, there are large numbers of patients still not identified. I doubt very much if the NSF will allow us to deliver better patient care on these standards. Conclusion I would like to acknowledge support from colleagues in BGS Wales and particularly those who provided written updates as indicated. Tony White
BGS Newsletter, Aug 2008 |
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