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I was looking forward to the Nursing and Midwifery Council (NMC) guidance for Care of Older People, in the hope that it would further support my role as a senior practitioner in the field.

Throughout my 31 year career I have actively used my Professional Code as a tool to review my own practice and to challenge both practitioners and managers when care has been compromised, or the environment or resources has negatively impacted on the delivery of optimum care.

What has been missing for some time is a clear, affirmative document as to the specialist skills and knowledge required to ensure best practice is applied wherever older people are receiving care and treatment.

There is much written about the needs of older people and the impending resource implications of the ageing population, as well as the continuous media horror stories of where care fails. But there has never, I believe, been a commitment to address the true issues behind the failures.

This latest publication of guidance for Nurses on the care of older people identifies in a 39 page booklet the principles of care and the behaviours expected. There is nothing wrong with the fundamental principles and they are in total concordance with the NMC Code and the raft of documents which have been produced over the past 10 years, stemming from the work that has developed through the dignity in care campaign.

They are no different from the attitudes and behaviors I was taught and assessed on back in the late 1970’s and 80’s.

However, this publication misses the opportunity to emphasise that older people need from the professionals who manage their care, advanced, specialist assessment skills which go beyond those involved in general care. There is no clear message around the competence to recognise and detect ill health in people unable to ask for help, or the need to detect underlying illness resulting from ageing systems which do not present in classic textbook fashion, but which will impact on recovery or worse still, result in premature death. There is no recognition of the skills in pharmaco-kinetics and pharmaco-dynamics needed to monitor and prescribe treatment to a group of people who have complex multi-pathology and are already suffering poly-pharmacy.

Instead, the guidance promotes the focus on preventing acute hospital admission and on commissioning out health and social care services, with increasingly complex care being carried out in the community by a range of providers - the recipients of much of this care being older people. However, I suggest with the changes comes little evidence of a commensurate commitment to providing specialist nurse and geriatrician access and expertise in these settings.

Given that people “do not know what they do not know”, care of frail, older people is so common place that it can be over-simplified in people’s minds to the fundamentals, nutrition, hygiene, respect. This leads many to believe that elder care basic care, deliverable by non specialist staff. What is not recognised by non specialists, is the impact of the ageing process on the delivery and consequences of those fundamentals, when not provided appropriately, or adapted and managed during episodes of physical or psychological instability in a timely fashion.

My hope was that this guidance would clearly identify the skills and knowledge required to ensure the older people’s safety, and I feel it is a missed opportunity to lay down some clear educational and resource standards which nurses could use, both to review their own competency, but also to challenge service commissioning and delivery.

In my cynical moments I believe that nobody is prepared to clarify the level of specialist nursing staff, the knowledge and skills they require, and skills mix of the teams they work with, to ensure excellence in older people’s care, because they wish to avoid the cost implications.

Soline Jerram
Consultant Nurse
– Older People and Intermediate Care

BGS Newsletter, May 2009
Issue 21 ISSN 1748-6343 21