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| Medical Practice and the care home - we can do better! |
| Email your comments There was literally standing room only, with some keen colleagues who were unable to register in time, arriving early in the hope that they were able to make use of any late availability! The meeting was the culmination of more than a year of planning with leads from BGS (Scotland), the RCGP (Scotland), with the support of RCPSG. The target group for the meeting was general practitioners and indeed these proved to be 70% of participants, the remainder being from geriatric medicine and old age psychiatry, along with a few non-medical staff. The proceedings opened with a brief presentation from the MSP, Shona Robinson, Minister of Public Health, summarising the significance the Scottish Government gave to older people and their support in community settings. There followed three short presentations. In the first Prof Marion McMurdo emphasised in her inimitable style the key point of a full geriatric assessment prior to care home placement. This was followed by Dr Jean Hannah, Clinical Director of the Nursing Homes Medical Practice in Glasgow, who highlighted the benefits of enhanced primary care services and contracts to support complex co-morbidity in care home settings. The final part of the first session was led by Mrs Anne Naylor of Alzheimer’s Scotland. She talked through, in a very moving way, her mother’s journey of care, with a slow decline in physical and mental health and eventual admission to a care home. There followed an all too common hip fracture and then eventual difficulties with hydration leading to periods of hospital care. She highlighted areas she and other carers feel are vital for the delivery of good care to a vulnerable population, with better training of all staff, including those in primary care, being the priority. There were then three workshops covering in small part, some aspects of key areas to care home medicine practice. Participants were able to attend two out of three though many indicated they would have wished to attend all three! However, achieving meaningful interaction within workshops of 50 or more was in itself a challenge, though innovative and expert facilitation did achieve this, with key points being reported back at the plenary afternoon session. The first workshop was taking the important area of end of life care, and led by Prof Scott Murray and Prof Marie Fallon. Key messages were to improve on anticipatory care for the care home population. The best opportunity for this was seen as around the time of admission with the opportunity of a review allowing for early planning of interventions in the event of inter-current illness. Improving knowledge of therapeutics for effective end of life care was also a priority, with the recognition that most of those dying in care homes did not have malignancy but still needed skilled and effective nursing and medical attention. The second workshop was led by Dr Gillian McLean and Al Dowie taking Adults with Incapacity/ Behaviour Management as the theme. Through the use of vignettes and by splitting the audience into multiple small groups we allowed for more of the concerns regarding capacity to be discussed. There was a particular focus on when to apply the Mental Health Act in contrast to the Adults with Incapacity legislation. It is clear that many patients both in care homes and in acute hospital settings, should have appropriate application of these Acts, which is presently not the case. The final workshop, led by Prof John Gladman, Jean Hannah and Rachel Bruce explored the complex area of Chronic Disease Management/ Medicine Review and Prescribing. Key areas of discussion related to the recognition of the time required to review medication, with opportunities both at the time of admission and on a regular basis, and how to engage with pharmacy to support the process. Communication both between practices and between primary and secondary care, were often sub-optimal, with essential correspondence sometimes taking months to reach the patient’s possibly new general practitioner. The opportunity of a lead practice taking the majority of individuals within a care home was seen as a way forward, though maintaining patient choice was likely to affect delivery of this goal. There was general recognition that there is required a greater degree of investment of time and resource to effectively support the needs of the care home population in a pro-active manner. It was seen likely that additional remuneration would be needed to follow the linking of practices to individual care homes and thereby delivery of a higher standard of care. It was also recognised that involvement by secondary care – both through geriatricians and old age psychiatrists would be essential to provide the necessary support to maintain high standards of care and avoid unnecessary hospitalisation, and the development of community geriatrics should be a priority for the coming decade. The afternoon ended with a summary of key points from the workshops and then a debate chaired by Prof Frank Clark, Chair of the Care Commission. The motion was quite simply ‘This house believes we need more care homes for an expanding older population’. This was led by Dr Andrew Elder who presented a compelling rationale for the inevitability of increased requirements for care home places to match the predicted demography in the coming decades. Dr Anne Hendry, as opposition to the motion, presented a vision of managing the future frail older population differently through increased community support. Both presentations were followed by questions from the floor and lively debate. Through Digivote process it was clear that the motion was carried with approximately two thirds supporting the proposition. Feedback from the meeting indicated great interest for further such educational opportunities. As a specialty we need to re-engage with our primary care colleagues in delivery of care to those in care homes, and in other community settings. This means working with community health partnerships and practices, as well as with clinical directors to ensure resource within job plans is identified with the development of community geriatrics. Within Scotland, this reflects the ethos of the Kerr Report and is specifically suggested in the most recent Scottish Government policy directive ‘Better Health, Better Care’. Willie Primrose BGS Newsletter, May 2008 |