We need to talk about frail older patients

How do you explain the actions of someone who ignores the plight of an older patient in a soiled bed? Or who fails to respond when a patient cannot reach a glass of water and has not eaten her meal?

The CQC report on the State of Care published last week attributed the neglect of older people to failures in leadership, resources (on some, but not all the wards that failed the inspection) and staff attitudes. But the media wanted answers to only one question: ‘What has gone wrong with nursing?’

Some commentators, worried about community values, believe we have lost our capacity to care; others blame the move towards a graduate nursing workforce. But there is nothing new about vulnerable people receiving bad care – 40 years ago, Dick Crossman established the Hospital Advisory Service to inspect hospitals for the elderly and mentally ill patients precisely because they were so vulnerable. Equally, it is difficult to believe that educating nurses to degree level is to blame when research shows that the higher the level of education of nurses, the better the care. 

What is so shocking in this report is that the neglect is taking place on acute hospital wards. The CQC is right: everyone who works in hospital knows there are good and bad wards. The scale of the problem is considerable – not confined to elderly care wards. Today, patients aged over 65 account for 70% of hospital bed days and 80% of emergency readmissions – 60% also have a mental disorder (depression, delirium or dementia). From our work with NHS trusts on the Hospital Pathways programme (in partnership with The King's Fund) we know that managers and staff are anxious about the quality of care for these frail, older people with cognitive impairments who can be found in almost every clinical area, not just in the elderly care wards.

But there are good examples of patient-centred care too. Northumbria Healthcare Trust demonstrates outstanding commitment to getting it right for every older person, every time, in every clinical area. The multi-professional team of consultant, matron and service manager lead the work using a three-pronged approach. They ensure that every patient who is cognitively impaired receives an accurate diagnosis to differentiate delirium and depression (which are treatable) from dementia (which is not). This means redesigning almost every care process in the hospital to make sure patients get a full cognitive assessment on admission and at regular intervals thereafter.

The trust is also driving a person-centred approach to the care of patients with dementia by incorporating the Alzheimer’s Society’s This is Me into the medical notes. This document is completed by the patient’s carer and tells the professionals about the patient’s past and current circumstances and individual preferences. Last, but by no means least, the trust executive wants to be assured that staff in every department and ward are confident in their ability to care for older patients and those with delirium and dementia. It has sponsored an education programme, taught in collaboration with local patients and carers, to challenge ageist stereotypes. So far, staff have loved the course and the results are visible – with improvements to the hospital’s physical environment and to the patients’ nutritional intake and the appointment of designated staff to help vulnerable patients eat and drink.

The example from Northumbria proves that influencing attitudes and transforming working practices is not simple. It is intricate, complex work and the change process itself needs good leadership and adequate resources. The rewards are surely worth it, but the drive to improve and sustain better care for frail, older patients must come from the top.

Jocelyn is Director of The Point of Care programme at The King’s Fund.