Is the inappropriate warehousing of elderly people in acute hospitals as inhumane and unjust as the treatment of mentally ill people in asylums? This question was posed by Dr Steve Feast, a former GP and now the inspirational medical director of North East London Foundation Trust. He was speaking at a conference on integrated healthcare, which I was chairing, and he started by praising the NHS and public health improvements for adding 1 year on to male life expectancy every 2.5 years, and 1 year on to female life expectancy every 4 years. In the current system, it took just 7 years for the bottom 10% to get to the previous mean levels of life expectancy. Surely something to celebrate.
The treatment of mentally ill people has also improved dramatically. Sixty percent of mental illness hits you before you are 18, so the practice of committing people to asylums often meant they were there for life. Many were over-medicalised to the point where they became very overweight, smoked, and did not move much. We have since backed off on the drugs, concentrated mental health expertise into smaller, brilliant hospitals, and we now work with patients to help secure their own independence and recovery in the community.
Contrast this with the current treatment of frail and elderly people. Many are sent to hospitals, not because they need to be there, but because with current levels of community support there is nowhere else for them to go. Acute hospitals are all too often overcrowded, disease ridden, and unpleasant places to be. Confused, elderly patients are stripped off, put in a gown that does not respect their dignity, and left on a trolley for hours. Their rights are completely taken away from them in a social injustice reminiscent of the old asylums.
Worse still, they will be seen by numerous different hospital teams, all of which dispense their favourite drugs that can leave the patient incontinent and even more confused. No one coordinates their care and they deteriorate to the extent that it’s very unlikely they will get back to their own homes, so they are doomed to end up in a care home or nursing home, if one can eventually be found.
Fortunately, Dr Feast and his team have discovered another way. He has closed wards and shifted investment into the community. Investing £500,000 in rapid assessment interface and discharge (RAID) teams has saved 2600 bed days and £1.4 million. Partner hospitals and 2200 staff have been trained up to recognise and treat elderly problems better, with established delirium pathways and carer support. Outreach teams are using Skype and other remote assessment technology, and pioneering cognitive stimulation therapy, which is NICE (and SIGN) recommended.
One of Dr Feast’s consultants is so passionate about this that she has had no elderly admissions at all in the last 2 years. She has developed very close links with GPs, practice nurses, care homes, and community mental health teams. She hands out her mobile phone number and guarantees a quick response. She does talks and training sessions at surgeries and care homes, engaging GPs in face-to-face discussions. She has trained care home staff to spot crises before they occur and fits emergency slots into her clinics. She frequently follows up the acutely unwell to prevent hospital admission and encourages patients to ring in case of problems. Patients who don’t attend clinics are proactively phoned.
If all this sounds like a lot of hard work, it is. Dr Feast and his dedicated team work incredibly hard. There is no slack in the system, and with GPs facing their own workload crisis it’s hard to see how anything like this can be rolled out across the NHS. What is clear is that a competitive marketplace, where services are put out to tender, will not deliver the joined-up care and prevention that elderly patients not only need, but have the right to expect. As Dr Feast put it: ‘I would do anything humanly possible to keep my parents out of hospital.’ G