Elderly people are the fastest growing demographic in the UK. But are care levels rising to meet their needs? Sara Williams meets a surgery in Northampton who have improved their continuity of care, and changed the face of practice
“Scotland’s elderly care bill soars”, “Minister committed to elderly care”, “Doctor condemns Liverpool’s elderly care plans as ‘an insult’” – This is a collection of recent media headlines depicting the state of care for elderly people in the UK. It begs the question – are the needs of elderly patients being met?
Gary Fitzgerald, Chief Executive of charity Action on Elder Abuse (AEA), strongly believes that they are not. He argues that at a time when three regulatory bodies are merging, targets are being set to improve care quality for older people, and several reports have claimed that things are getting better, the reality for many older people is one of poor care and deprivation.
The BMA argue a similar point. They recently presented a paper to the European Parliament calling for the establishment of a policy for the long-term healthcare of older people that was “fit for purpose”.
"The EU should take a more holistic approach to ageing, and reform the way care is delivered by healthcare institutions"
Recognising that healthcare needs to deliver to a rapidly changing demographic, characterised by the older getting older, they argue that the EU should take a more holistic approach to ageing, and reform the way care is delivered by healthcare institutions.
In the paper they argue that the older population should have access to care which is:
- of high quality
- evidence based
- well resourced
- equitable
- available to all on the basis of need, and
- delivered with due regard to the dignity of patients.
Principles in practice
How can these principles be achieved in practice? King Edward Road Surgery, in Northampton, tackled the complicated system present in care homes head on. Working with the local practice-based commissioning group, Nene Commissioning, the surgery sought to streamline care by linking their practice with specific care homes across the town.
Dr Judith Reeder is the team lead for the project. “Before we introduced the elderly care plan, the surgery had 17 homes to visit, and some days we had to visit four or five of them. The traffic made it a logistical problem and we began struggling to meet their needs.
"Better care and more structured visits could be made if the practices had responsibility for the same number of patients but in fewer homes"
“The situation could only escalate in the future because more people are living into their eighties and nineties and going into care. We are keeping them alive with new drugs, so they live longer, which is fantastic, except someone has to look after them. More people are working and struggling to look after their elderly relatives. Much of the care of the elderly now devolves onto the medical and social services, so it vital that healthcare professionals develop health services that meet the needs of our patients.”
Forcing the issue
A local group of GPs and their commissioning body met to discuss the problem. At the meeting it was recognised that the standard of care provided by the care homes varied across the town, and it was thought that if the homes had designated practices, they could develop a closer relationship and improve care.
Justin Pearce, Practice Manager at the King Edward Road Surgery, said: “Of a 168-hour week practices have responsibility for 52.5 hours. The out-of-hours doctor services and ambulance services therefore hold the greater balance of responsibility, without any access to medical information. This lack of information led to a higher volume of hospital admissions, which may, in some cases, have been contrary to the patient’s wishes. Better care and more structured visits could be made if the practices had responsibility for the same number of patients but in fewer homes. The care plan was a winner all round so it was supported by the PCT.”
Action plans
The first stage of the plan kicked off in November last year. It involved dividing the 75 care homes, which house 2,600 residents, between the 40 GP practices in Northampton. King Edward Road Surgery were allocated four care homes, all of which were within half a mile of the surgery.
The surgery encouraged all existing and new residents to fill in care management plan forms, to gather information on their end-of-life plans, for example, whether they wanted to go to hospital or not. (See Box 1)
“The original end-of-life plan had much more on it, it had questions like – would you want intravenous antibiotics?” explained Dr Reeder. “When the residents saw this they were bewildered, so we simplified it.”
"It’s much easier to talk about a patient if you know them. It makes such a difference if you feel you can trust the staff and rely on their judgment"
A summary sheet of the resident’s medical history is also attached to the plan, containing information on medication and recent blood tests. Sonia Ingram, Care Manager for the day-to-day care at St Christopher’s Care Home, finds the sheets very useful. “We get patient summaries, which are brilliant, because they keep us updated with what is going on. They are extremely helpful when we have to call out-of-hours doctors because we have all the information they need in our hands.”
She adds: “The only possible problem with the individual care plans, is that old people can change their minds. Decisions have been made and then the mental health of the resident has been questioned, so we have had to revisit the plan. Generally the doctors will give the residents time, and come back if they cannot obtain informed consent.”
The doctors are able to give the patients more time because they visit the patients once a month. Dr Reeder commented that before the plan she would see different staff each time she visited, so she didn’t strike up a relationship with any of them. Now each doctor looks after specific wards, so they know the staff and the patients. “It’s much easier to talk about a patient if you know them. It makes such a difference if you feel you can trust the staff and rely on their judgment.”
Striking up good relationships, through regular meetings with managers and other key staff, has greatly improved the standard of care in the homes. Dr Reeder and her team worked with the staff on skills like good communication across the home, which has greatly improved care.
Box 1: Care Management Plan (CMP)
- Each resident will be provided with a current CMP
- New patients will complete a CMP within six weeks of admission. The practice will then request a copy of their computerised medical summary.
- CMP must be kept in a secure area with restricted access, eg, locked cupboard
- CMP updates must be kept in a secure area, eg, care manager’s office
- Any updated CMP information sent from the practice must be filled in by the individual as soon as practically possible
- A named person will be identified as a contact
- When a GP is requested the care home staff will prepare all the relevant information for their arrival.
Service Level Agreement between King Edward Road Surgery and care home.
A bumpy road
The plan hit a few bumps in the early stages – one of these problems was moving the residents to new GPs. According to Dr Reeder, her team encountered problems moving all the people in the homes, as some of them wanted to stay with their existing GP. “We respected this and let them.
However, our experience was that most patients were not seeing their GP anyway; they were seeing someone from the practice, so there wasn’t much continuity to begin with.”
Practices hoping to employ a similar management plan should be wary of issues surrounding confidentiality. Dr Reeder and her team inadvertently sent care management plans to bungalows next to one of the homes, assuming that they were part of it. However, it transpired that the bungalows were not actually part of the home, so the information that was sent was a breach of confidentiality.
She added: “When we realised what had happened, I went and spoke to the home and explained why the mistake had been made. I stressed that it was to improve care and generate information for out-of-hours doctors. The residents weren’t upset, but we are now very careful, and liaise with them first before sending any information.
Benefits for practice and patients
The care plan’s anniversary is fast approaching and the successes and failings of the plan will be evaluated.
There is less pressure from the doctors to get the patients seen as quickly as possible, because they have more time to be here
King Edward Road Surgery identified a number of benefits:
- Reduced travel to distant care homes
- Better relationships with care home staff
- More efficient visits, standard requirements met (blood pressure checks, etc)
- Designated admin person to deal with the prescriptions from the homes
- Fewer administration errors
- Improved standard of care in the homes.
Marjorie Holt, 90, was a resident in the independent flats at St Christopher's Care Home, she is now seen by doctors in the home itself. “I have a care management plan with the surgery. I have a good relationship with them and my standard of care is very good. The doctors come and see me and weigh me.”
Dr Reeder believes the plan has helped improve the care of residents like Marjorie. “Before we set the plan up, we would visit a home, then find out we should have visited someone else while we were there – the system was very disorganised. Now we can plan ahead, we look to see when medication reviews are due, the nurses do the blood tests in advance and we inform the homes of when we will visit, so that all the residents will be there and not going shopping or having their hair done.”
The plan has also helped improve the liaison between home and practice. Sonia Ingram says: “We have to phone one surgery to contact three or four GPs. So it saves us time, and it helps that the receptionists are now used to us calling. There is less pressure from the doctors to get the patients seen as quickly as possible, because they have more time to be here.”
Nene Commissioning has allocated additional resources from other areas to further invest in this project, and is planning to put in extra training for the staff in the homes and organise a visiting pharmacist to review medication with the GPs.
Scope for the future
The plan is still in the early stages but the team are already forging plans to take it to new levels. “At the moment our focus is trying to get the structured visit schedule correctly organised,” explains Justin Pearce. “But in the future Nene will be releasing funding to purchase blood pressure machines for homes. We will also be looking at including the homes’ clinical staff in any appropriate training that we undertake.”
The care management plan delivers to patients in homes, but not elderly patients in their own homes. Their latest project, Pro Active Care, focuses on forging better relationships with PCT provider services, social services and the voluntary sector to help elderly patients with long-term conditions to stay at home and increase their independence.
At a time when the delivery of continuity of care is threatened by outside forces, the proactive approach undertaken by Nene Commissioning and Dr Reeder and her team has changed the face of care for her elderly patients. But this is only the beginning as both parties will continue working across Northamptonshire to drive services forward and revolutionise care.
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Last updated: September 2008
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