continuity of care for older hospital patients · in hospital can be life-changing; and,...

1 © The King’s Fund 2012

Continuity of care for older hospital patientsA call for action

Authors Jocelyn Cornwell Ros Levenson Lara Sonola Emmi Poteliakhoff March 2012

Key messagesn Continuityisfundamentaltohigh-qualitycare.Withoutit,careisunlikely

tobeclinicallyeffective,safe,personalised,efficientorcost-effective.Breakdownsincontinuityofcareputpatientsatrisk,causeduplicationandaddavoidablecoststobothhealthandsocialcare.

n Thispaperfocusesontheexperiencesofolderpeoplewithmultiplehealthproblems,andparticularlyontheirexperiencesinside hospital.Continuityisespeciallyimportantfortheseolderpatientsbecause:theyaremorelikelytospendtimeinhospitalandtobeinhospitalforlonger;iftheyarefrail,astayinhospitalcanbelife-changing;and,regrettably,insomehospitalsandsomewardsolderpatientsareexposedtounacceptablestandardsofcare.

n Thenationalinpatientsurveysprovideobjectivedataonpatients’experiencesbutnotonhowitfeelstothepatients.Wehavepresentedcasestudiesfromcarers,whichreflectcommonlyreportedconcernsandvividlyexemplifytheimpactthatpoorlyco-ordinatedcarecanhave.

n Patientsandcarersexperienceproblemswithcareplanning,communicationandco-ordination.Theirstoriesshowthatbreakdownsincontinuitycausepatientstolosetrust;however,ordinaryhumanrespect,kindnessandconsiderationshownonapersonallevelhasadisproportionatelypositiveimpactonpatients’andcarers’overallsenseoftheirexperience.

n Theobstaclestocontinuityofcareforolderpatientsinmodernhospitalsaresystemicandcomplex.Issuesinclude:thevolumeofworkinhospital;theordinaryroutinesthatgoverntheworkingdays(andnights);thecultureofcareinthehospitalasawholeandinteams;thelevelsoftrainingandskilloftheworkforce;andthevaluesofthestaff.Engagementofseniorstaffandboardmemberswithfrontlinestaffandwithpatientsandcarersisalsocritical.

n Intheshortterm,anumberofinterventionscanhelptoimprovecontinuityofcare.Weoutlinepracticalmodelsandmethodsforimprovingcontinuityofcareandmakerecommendationsforfrontlineandseniorexecutives.


Continuity of care for older hospital patients

ForewordEveryonewantspatientstoreceiveconsistent,reliable,high-qualitycare,andmosthealthworkersthinkthatthismeansprovidingpatient-centredcarewithcompassion.Sowhydoesitnotfeellikethatforsomanypatientsinourhospitalstoday?Musttheytradeinlow-techhumanvaluesforhigh-tech,effectivetreatment?Surelynot–buttoomanyrecentpublicreportsandinquirieshavehighlightedtheproblemforittobeafewchanceencounters.Thispaperdrawsonobjectivedataandpatients’stories;itishonest,and,yes,wehaveaproblem;butitisalsotimelyandwelcomebecauseitofferssomeexplanationsratherthanexcusesorsoul-searching,andsuggestsacollectivewayforward.

Itsfocusisonhospitals,buttheprinciplesaregeneral.Patientsandtheircarersvaluecontinuityofcare,whichtheyjudgebyhowitseemstothem.Co-ordinationamongourselvesmakesthatexperiencemorelikely.Ifwedothissuccessfully,thenclinicaloutcomesandsafetyimprove.Thispaperpresentsresearchevidencetosupportthis,butitthengoesontodescribethemanytrendsinmodernhealthcareandhospitalorganisationthatseriouslychallengeourabilitytobesuccessful.Ofcourse,atthepointofcare,itisaboutindividuals;butinacomplexsituation,carefulattention–tothemicro-andmacro-processesaswellastotheprevailinghospitalculture–isrequiredtomakeitmorelikelythattherightthingsaredoneandthatitfeelsrighttothepatient.

Thereare‘touchpoints’,oftentransitionsofcaresuchashospitaldischargesorinter-wardtransfers.Minimisingunnecessaryandunplannedtransitionswouldthereforeseemwise,andthispaperrecommendsthatprovidersreviewhowtheyfunctionwithregardtothis,includingconsiderationofpatients’experiences,albeitthatthetoolstomeasurethisaresofarrelativelyunderdevelopedinthehospitalsetting.

However,continuityofcareisnotonlyaboutindividualrelationships:lossatthispersonallevelcanbemitigatedbyconsistencyofpurpose,careplansandeffective,timelycommunication.Thispaperthereforerecommendsthatweadaptandevolveourbasicwaysofworking,includingwardrounds,handovers,record-keeping,multidisciplinaryworkingandmore.UsefulexamplesaregivenwhereconvincingimprovementhasbeenachievedintheNHS,withlocalclinicalteamstakingtheinitiative.Guidanceisalsoavailablefrommedicalcollegesandprofessionalassociations.

Integrationatvariouslevelscansupportthisclinicalco-ordination,andthispapercallsonseniormanagersandprofessionalleaders–bothlocalandnational–todemonstraterealcommitmentandsupportforthis.Educationandtrainingwillbecentral,butthereareimplicationsforresearch,too:thishasonlyrecentlybecomethesubjectofrigorousstudy,andwewillneedmore.

Toregretthatweneedthispaperisunderstandable,butpointless.Wedo,andIcommenditsreasoningandrecommendationstoyou.

Professor Finbarr C MartinPresident, British Geriatrics Society and Consultant Physician for Older People



IntroductionThisexploratorypaperdrawsattentiontoanoverlookedbutimportanttopic:thecontributionthatcontinuityofcaremakestothequalityofcareexperiencedinhospitalbypatientswithmultiplehealthproblemsaged70yearsandolder,andalsohowitaffectstheexperienceofthepeopleclosesttothem.Forthesakeofsimplicity,wehavedescribedthepeopleclosetopatientsas‘carers’,withapologiestothosewhodisliketheterm,preferringtobeseenasspouses,relatives,friendsorneighbours.

Therearemanyreasonsforfocusingonthecontinuityofcareofolderpeoplewithcomplexhealthproblemsandtheircarers,includingthefollowing.

n Mostpeople(65percent)admittedtohospitalareolderthan65years.Atanyonetime,patientsinthisgroupaccountforthelargemajority–70percent–ofbeddays,andsomeoftheirnumbercanbefoundoneverywardandinallclinicaldepartments(apartfromobstetricsandpaediatrics).Whenwearethinkingaboutqualityofcareinhospitalandolderpeople,wearetalkingaboutthepredominantexperienceofpatientsinhospitalingeneral,notjustpatientsondesignated‘careoftheelderly’wards.

n Manyolderpeoplewithmultiplemedicalproblemsarealsofrail.Theimpactofcontactwithahospital–howtheycomeintoit,whathappenswhentheyarethere,andtheprocessofleaving–candeterminethedirectiontheirlifetakesthereafter.Theirabilitytorecovertheirformerindependenceisgreatlyaffected,forbetterorworse.Toooften,formanyolderpeople,astayinhospitalisdisempowering:theenvironmentitself,thenoise,andtheroutinesonthewardsoverwhelmandunderminetheminwaysthataffecttheirabilitytorecoverwhotheywereandhowtheywerelivingbeforetheywereadmitted.

n Thereismountingevidencethatthestandardofcarereceivedbymanyolderpatientsisunacceptable,andpartofthatpictureisthatcareisfragmentedandlackscontinuity(Levenson2007;Francis2010;Abraham2011;CareQualityCommission2011a).Patientsaremovedaroundveryfrequently–frombedtobedandbaytobayonthesameward,andoftenfromonewardtoanother.Handoversbetweenprofessionalsandteamsarepoorlyplannedandexecuted,andcareisalsopoorlyplannedandco-ordinated.

n Patientsandstaffreportthedehumanisingexperienceforpatientsofbeingmovedaroundinsidehospitals‘likeparcels’(GoodrichandCornwell2008).Onewoman,describingherfeelingsaboutbeingmovedaround,evenwithinthespaceoftheward,said:‘IfeellikeI’mbeingmovedaroundlikeaparcel,I’mbeingmovedfromchairtocommodetobed.Ifeellikeaparcelandnotapersonanymore’(Mabenet al2012).

n Thereisevidenceofdiscriminationagainstolderpeopleinhospital(Lievesleyet al2009).Age-baseddiscriminationhasalmostdisappearedfromNHSpolicysincethe2001National Service Framework for Older People(DepartmentofHealth2001),butithasnotgonefrompractice.Inresponsetosurveyquestions,olderpeopletendtocomplainlessandbelesscriticalthanyoungerpeople(Lievesleyet al 2009).Evenso,theyarelesslikelythanpatientsinyoungergroupstodescribetheircareas‘excellent’andmorelikelytosaythattheyfelt‘talkedoverasthoughtheywerenotthere’(CareQualityCommission2011b).Thereisevidenceofageismamongallstaff;regrettablytheevidenceisstrongerfordoctorsthanforotherprofessionalgroups(Lievesleyet al2009).Olderpeoplehavedifferentialaccesstoservices:theywaitlongerthanyoungerpeopleinA&Edepartments;arelesslikelytobereferredtointensivecareortohavesurgeryfollowingtrauma;havelessaccesstopalliativecarethanyoungerpeoplewithcancer;andareinvestigatedandtreatedlessthanyoungerpatientsforarangeofconditionsincludingcancer,heartdiseaseandstroke.



n TheNationalInstituteforHealthandClinicalExcellence(NICE)ispreparingguidanceonstandardsofcareofacuteinpatients,whichisexpectedtoidentifycontinuityofcareasimportant(NationalInstituteforHealthandClinicalExcellence2012b).Oncetheguidanceispublished,acutetrustswillberequiredtorespondtoit.

Thescopeofthisstudyislimitedtowhathappensinsidehospital.Itdoesnotlookatwhathappensbeforepeoplecomeintohospital,orfollowthemtotheirownhomesorintoresidentialornursingcare,andsoitdoesnothavemuchtosayaboutcontinuityofcareacrosssectorsortheco-ordinationofhealthandsocialservicesinthecommunity.Weknowthattransitionsintoandoutofhospitalarecriticallyimportanttoolderpeople’shealthandwell-being,andthatforaverylongtimetheyhavebeen‘oneofthemostproblematicareasofpolicyandpractice’(Glasby2003;Ellinset al2012).

Transitionsintoandoutofhospitalaremuchstudiedandveryimportant,butwiththeresourcesavailablewefeltwecouldnotcontributeanythingneworusefulonthesetopics.Instead,weexplicitlyfocusedontherelational,interpersonalandemotionalaspectsofcare,andconcentratedonthepracticalapproaches,methodsandtoolsthataredeliberatelydesignedtosupportolderpeopleandtheircarersinhospital.OurparticularinterestisinNHShospitals,butwehavethrownthenetwideinthesearchforpracticaltoolsandmethodsthatcanmakeadifference.

Webeganthestudywithareviewoftherelevantnationalandinternationalliteratureandsurveyevidencepublishedsince2005,plusinterviewswithexpertsinthetreatmentandcareofolderpeople,inprofessionalorganisationsandinvoluntarybodies.Wealsosoughtadvicefromahandfulofveryactivecarers.WesharedtheinterimfindingsataworkshopinMay2011,wherewealsogatherednewmaterial(seeAppendixA).Wethenrevisedthereportandpresentedthefindingstoexpertsinpolicy,practitioners,researchersandvoluntarysectorcampaignersattheSirRogerBannisterHealthSummitinNovember2011.Thediscussionatthesummitfocusedontheimportanceofstaffexperienceaswellasthatofpatientsandcarers,andbroughtagreaterappreciationofthecomplexsystemicandorganisationalissuesthatprovokebreaksincontinuityofcare.

Thispaperlooksatwhatweknowaboutcontinuityofcareandabouttheexperienceofolderpeopleinhospitalandreflectsonwhycontinuityofcareissodifficulttoachieveintheenvironmentoftheacutehospital.Inthefinalsectionwedescribegoodpracticeincontinuityofcare,andthepracticalmodelsandmethodsforimprovingcontinuityofcarethatwefoundcomingclosesttoconformingtothoseprinciples.

WebelievethatrealcontinuityofcarecannotbeachievedwithoutfundamentalchangeinthewaythattheNHSasawholethinksabouttheroleandprioritiesofthegeneralacutehospitalandhowitisrun.Aconsensusisbeginningtoformaroundtheunacceptabilityoftheverypoorstandardofcareofolderpatientsinsomehospitalsandtheneedforaction.Almosteverypieceofresearchandofficialreportonthetopiccallsfornewanddifferentbehaviouronthepartofhospitalleaders;moreandbetterclinicalleadership;greaterengagementonthepartofboardmembersandexecutivedirectorswithfrontlinestaff,patientsandcarers;greaterpriorityforclinicalqualityandsafety;andmoreandbettermeasurement(CarruthersandOrmondroyd2009;Taddet al2011;TheKing’sFund2011).Ineffect,acompletetransformationinhospitalorganisationandcultureisrequired,whichwilltaketimetoachieve.Morepositively,thereismuchthatcanbedonequicklytoimproverelationshipsandcommunicationbetweenpatients,carersandfrontlineclinicalandsupportstaffandthatwillmakeaprofounddifferencetopatientsandrelatives.Mostoftheapproacheswerecommenddonotneedtowaitfortherootandbranchchangethatisneeded.



The current situation What we know about continuity of care

Continuityisfundamentaltohigh-qualitycare.Withoutit,thecarethatisofferedisunlikelytobeclinicallyeffective,safe,personalised,efficientorcost-effective.Breakdownsincontinuityofcareputpatientsatrisk,causeduplicationandcreateadditionalcoststobothhealthandsocialcare(Kohnet al2000;CommitteeonQualityofHealthCareinAmerica,InstituteofMedicine2001;Haggertyet al2003;FreemanandHughes2010).

IntheUnitedKingdom,mostoftheresearchintocontinuityofcarehasbeencarriedoutintheprimarycareandcommunityservicesetting(FreemanandHughes2010).Thereisrelativelylittleresearchintocontinuityofcareinsocialcareorinhospital.

Theterminologyintheliteratureisconfusing:theterms‘continuity’,‘co-ordination’and‘integrationofcare’tendtobeusedlooselyand,althoughtheyarerelated,theyaredifferent.Weseenoneedtoinventnewterminologyandofferthefollowingdefinitions.CourtesyofHaggertyet al(2003),wedefinecontinuityfromthesubjectivepointofviewofpatientsandcarers:‘Continuityisthedegreetowhichaseriesofdiscretehealthcareeventsisexperiencedascoherentandconnectedandconsistentwiththepatient’sneedsandpersonalcontext.’

FreemanandHughes(2010)offerausefuldistinctionbetweentwodifferentaspectsofcontinuity:

n continuityofrelationship,whichreferstocontinuoustherapeuticrelationshipswithoneormoreclinicians

n continuityofmanagement,whichreferstocontinuityandconsistencyofclinicalmanagement,includingtheprovisionandsharingofinformationandcommunicationaboutcare-planning,alongwithco-ordinationofthecarerequiredbythepatient.

Thetermco-ordinationisusedheretorefertopolicies,processes,systemsandpracticaltoolsthatunderpincareprovision.Bodenheimer(2003)definesco-ordinationinthesetermsas:‘Afunctionthatensuresthatthepatient’sneedsandpreferencesforhealthservicesandinformationsharingacrosspeople,functionsandsitesaremetovertime.’

Co-ordinationofcareisoneofthetopprioritiesofthemajorhealthcharitiesintheRichmondGroupbecauseofthecentralanddeterminingpartitplaysinshapingthequalityofcare(TheKing’sFundandtheRichmondGroupofCharities2010).

Thetermintegrationoccursfrequentlyalongwithco-ordination,butweseeintegrationashavingadifferentandwiderapplicationthatisespeciallyrelevanttodiscussionsabouthealthandsocialcare(GoodwinandSmith2011).Fulopandothersofferdefinitionsofdifferentaspectsortypesofintegration(Fulopet al2005;RamsayandFulop2008).Theseinclude:

n systemicintegration:acoherenceofrulesandpoliciesatallorganisationallevels

n normativeintegration:anethosofsharedvaluesandcommitmentsthatenablestrustandcollaborationindeliveringcareservices

n serviceintegration:theefforttobringdifferentstepsinaprocess,partsofanorganisation,orprofessionalsindifferentteamstogethertodeliveraservice

n functionalintegration:theworkofnon-clinicalsupportandback-officefunctions,includingaccessanduseofinformationtechnology,dataanalysisandelectronicpatientrecords

n clinicalintegration:adherencetoclinicalguidelinesandprotocolsortocareplans.

Continuityofcarematterstoeveryone,butit‘becomesincreasinglyimportantforpatientsastheyage,developmultiplemorbiditiesandcomplexproblems,orbecome



sociallyorpsychologicallyvulnerable’(FreemanandHughes2010).Thegreaterthesocialvulnerabilityanddependencyofanindividual,themoreweightheorsheattachestocontinuityofcare,whichmakesitcriticallyimportantfor,forexample,youngpeople,asylumseekersandpeoplewhoarehomeless.Thesaliencevarieswithage,healthproblem,context,personalcircumstancesandpreferences,butgeneralisationscanbemisleading.Patientsthemselves,andtheircarers,playasubstantialpartinsecuringcontinuity,workinghardtobridgegapsincommunicationandco-ordinationwheretheyoccur.Itisespeciallysignificanttoolderpeoplebecauseofthewayinwhichthemedicalproblemsassociatedwithageingoverlapwithothermedicalproblems.

Continuityofcarematterstopatientsandtheircarersateverystepofthejourneywithinthehospitalenvironment,butarrivalinA&Eorontoawardandthemomentofdischargeareoftenparticularlyassociatedwithhighlevelsofanxietyandstress.These‘touchpoints’,sometimescalled‘momentsoftruth’,arekeytimesand/orplacesatwhichpeople’scontactwithaserviceshapestheirsubjectiveexperienceinaglobalway(BateandRobert2006).Asaspokesmanfromoneofthenationalvoluntaryorganisationstoldus:‘Continuitymattersaspatientsusetheirexperienceasabarometeroftheserviceingeneral,eg,whetherinformationabouttheircarepassesbetweenprofessionalswithinhospitalsorbetweenproviders.Goodcontinuityinspirestrustandconfidencefrompatients’(interview).

Surprisinglyperhaps,giventhesheervolumeofresearchinthisarea,therearenosimple,practicalmeasuresofcontinuityofcareavailable,possiblybecauseoftheconfusioninterminologynotedearlier.Ifwearetoimprovecontinuity,itisimportanttomeasureitsothatwecanassessthescaleoftheproblems,understandwhatiscausingthem,andbegintoovercomethem.Expertsagreethatthemostmeaningfulandpracticallyusefulwaytodothisistoaskpatients(FreemanandHughes2010).

SurveyscomparingtheUnitedKingdomwithotherinternationalhealthsystemssuggestthattheUKsystemisbetterco-ordinatedthanmost(TheCommonwealthFund2008,2010).TheUnitedKingdomtendstodobetterthantheNetherlands,NorwayandSweden,withtheUnitedStateshavingtheworstrecordforco-ordinationproblems.

CommentatorsgenerallyattributethebetterperformanceoftheUKhealthsystemtotheroleoftheGPastheproviderofprimarycareandgatekeepertootherservices.Althoughpatientswithchronicconditionsexperiencedmoreproblemswithcontinuityandco-ordinationofcare,andlittleornoimprovementinthepastfiveyearsinallareassurveyed,intheUnitedKingdomsomeaspectsofco-ordinationdidimprove.Forexample,theproportionofpatientsreportingthattheirregulardoctor‘always’or‘often’co-ordinatedorarrangedcareincreasedfrom58percentto68percent,asdidreportsofhospitalscontactingtheregulardoctorfollowinganemergencyadmission.Itisamixedpicture,however:problemsinvolvingco-ordinationoftestresultsandrecordsdiminishedalittle,forexample,buttheoverallproportionreportingoneormoreco-ordinationproblemsinthepasttwoyearsincreasedfrom13percentto19percent.

What we know about older people and their experience in hospital

Olderpeopleareatgreaterriskoffragmentedcareinhospitalforavarietyofreasons.AnalysisbyTheKing’sFundofHospitalEpisodeStatisticsupto2009/10(excludingobstetrics,midwifery,learningdisability,adultmentalillness,childandadolescentpsychiatry,forensicpsychiatry,psychotherapy,old-agepsychiatryandwellbabies)showedthefollowing.

n Older people account for the majority of inpatients:sincetheturnofthecentury,theinpatientpopulationhasbeengettingprogressivelyolder.Inthepast10years,theproportionofbeddaysoccupiedbypatientsaged65yearsandoverhasremainedstable:theproportionoccupiedbythoseaged65–84yearshasfallen(from48per



centto44percent),buttheproportionoccupiedbypeopleaged85yearsorgreaterhasrisen(from22to25percent).Overthenext10–20yearsthetrendisexpectedtocontinueasthepopulationagesandtheabsolutenumberofveryoldpeopleincreases.

n The length of time a person spends in hospital is directly related to age:theolderyouare,themoreoftenyouwillbeinhospitalandforlonger;thelongeryouareinhospital,thegreateryourexposuretoriskofphysicaland/ormentaldeteriorationduetoiatrogenicillnessand/orinjury(Hoogerduijnet al2007;Lafontet al2011).Theaveragelengthofstayincreasesdirectlywithage:itiseightdaysforpatientsaged65–74years;10daysforpatientsaged75–84years;and12daysforpatientsaged85yearsorolder.Theaveragesmaskverywidevariationsinactuallengthsofstay,however.Morethanaquarterofpatientsolderthan85yearsadmittedasemergenciesstayformorethantwoweeks,andabout10percentstayformorethanamonth.

n Older patients are more likely than others to be readmitted to hospital within a short time of discharge:readmissionshavebeenrisingforthepast20yearsforallpatients,butrisingfastestforpatientsolderthan75years.In2006/7,thereadmissionrateforpeopleyoungerthan75yearswas9percent,butforthoseolderthan75yearsitwas14percent.Thereisnoevidencethattheriseinreadmissionsisassociatedwithreducedlengthsofstay,buttherehasbeenaconsiderableincreaseintheproportionofemergencyreadmissionsthatoccurwithin0–1dayoftheoriginaladmission,whichsuggeststhatsomepatientsarebeingdischargedtooquickly.Theolderthepatientis,themorelikelyitistohappenmorethanonceinthesameyear:7percentofpatientsolderthan85yearsarereadmittedthreeormoretimesinoneyear.Onaverage,patientsolderthan75yearswhoarereadmittedremaininhospitalafurther14days(Lafontet al2011).

n They are often moved about within the hospital:unfortunately,itisimpossibletosayhowmanypatientsaremovedbetweenwardsaftertheyareadmitted,ortocommentaccuratelyonthenumberoftimesindividualpatientsaremovedasthedataarenotcollected.Thenationalpatientsurveyaskspatientshowmanytimestheymovedduringtheirlast‘admissionepisode’.In2010,themajority–63percent–reportedstayinginoneward;28percentmovedonce;and8percentwereinthreeormorewards.Askedwhethertheirdischargefromhospitalwasdelayed,themajority–60percent–saiditwasnot,with40percentsayingitwas(upby2percentfrom2005).

WeweregivenaccessonananonymisedbasistodatafromtworecentlyconductedsmallauditsoftransfersofcareinoneNHStrust.

Thefirstauditcollecteddataon12patients(10medicaland2surgical),mostofwhomhadcomplexmedicalproblems.All12patientsweretransferredfromacutecareintorehabilitationsettingswithoutthefacilitationofadischargeco-ordinator.Theresultsshow:

n ameanlengthofstayof49days

n 7/12patientsweremovedatleastonceout-of-hours,3/12weremovedthreetimesout-of-hours,and10/12weremovedafter8pm

n patientswerenotalwaysawareofthereasonsforbeingtransferred

n allthepatientsweretransferredbetweenmorethanonemedicalteam,withtheaveragenumberoftransfersbetweenmedicalteamsbeingthreeperpatient.

Thesecondauditcollecteddataon10,mainlyorthopaedic,patientswhoweretransferredfromtheacutehospitaltoacommunityhospital,withadischargeco-ordinatorarrangingallthetransfers.Theresultsshow:

n allbutoneofthepatientsexperiencedthreetransfers;onepatienthadfourtransfers

n allbutoneofthepatientswereawareofthereasonsforthetransferandweretransferredduringtheday



n thepatientstypicallycameintotheemergencydepartment,weretransferredfirsttoamedicaladmissionsunit,thentooneormoreacutewards,andfinallytorehabilitation.

What we know about older people and their experience of continuity of care

Themainsourceofdataonpatients’experienceinhospitalisthenationalinpatientsurveysthatbeganin2002.Thepicturepaintedbythesurveydataisconsiderablylessrosyandmorenuancedthantheonepaintedbytheinternationalsurveyswelookedatearlier.

In2010,morethan66,000patientsrespondedtothenationalinpatientsurvey,aresponserateof50percent.Justoverhalftherespondentstothesurveywereaged66yearsorolder;35percentwereagedbetween66and80years;and16percentwereolderthan80years(upby2percentsince2002).Thesurveyreflectsboththepreponderanceofolderpatientsandtheincreaseinthesizeofthepopulationofveryoldandfrailpatients.Itisbasedonarepresentativesampleofthepatientpopulationineachtrust,andresultsaregeneralisable(CareQualityCommission2011b).

Inthepastdecade,writteninformationforpatientshasimproved,butinotherrespectslittlehaschangedintheexperiencesofpatientssincethesurveybeganin2002.Thefollowingaspectsofcarehaveremainedalmoststatic:

n theinvolvementofpatientsindecisionsabouttheircare:48percentofpatientsanswered‘tosomeextent’or‘no’(2005–2010surveys)

n doctorsornursesfailedtoprovideinformationtocarersaboutlookingafterthepatient(32percentsaidthiswasthecasein2010)

n staffexplaininghowtotakemedicationinanunderstandableway:25percentofpatientshadnotbeentoldortoldonly‘tosomeextent’(2009–2010surveys)

n staffexplainingpotentialmedicationside-effects:44percentofpatientssaidthishadnothappened(2010survey)

n staffprovidinginformationaboutdangersignalstowatchforafterdischarge:38percentofpatientssaidthishadnothappened(2010survey)

n staffprovidinganamedcontacttoanswerconcernsafterleavinghospital:24percentofpatientsreportedthatthiswasnotgiven(2010survey).

Someaspectsofexperienceinhospitalhaveslightlyworsenedovertheperiodsincethesurveybegan,withasmallriseintheproportionofpatientswhosaidthey:

n couldnotfindamemberofstafftotalktoaboutworriesandfears

n feltthatthepurposeoftheirmedicationwasnotcompletelyexplainedinawaytheycouldunderstand.

n hadadelayeddischarge

n didnotfeelenoughinformationwasprovidedabouttheirtreatmentorcondition

n reportedthatstaffoftensaiddifferentthings.

Surveydatatracktrendsovertimeandallowustocomparedifferenthospitals.Whattheydonotdoisshowhowpatientsfeelabouttheirexperience,theimpactithashadonthemorthesensetheyhavemadeofit;forthat,werelyonstories.Weaskedcarerscurrentlyinvolvedwithaveryoldpersonwithrecentexperienceinhospitaltotellustheirstories.Belowwereproduce(withpermission)threesuchaccountsinfulltodemonstratetherichinsightstheyaffordandtoillustratethestrikingdegreeofcommonality.Wedonotclaimthatthestoriesarerepresentative,buttheydoreflectissuesthathavebeenpickedupby



agreatmanyothers,andvividlyexemplifytheimpactonolderpeopleandtheirfamiliesthatpoorlyco-ordinatedinpatientcarecanhave.

A granddaughter’s storyOverthepast20years,my92-year-oldgrandmotherhasenduredtheprogressivestagesofParkinson’sdisease.Sheisnowdependentonmy93-year-oldgrandfather(hermaincarer)andothersforalltheactivitiesofdailylife.

Shehashadmanyhospitaladmissions,almostalwaysduetoproblemsswallowing,whichhavemeantsherequiresanintravenousdriptotakefluidsforshortperiods.Wheninhospitalshehasoftenbecomeconfusedordeliriousandherconditionhasworsened,entailingalongerstay.Wehavetriedtoaskcommunitynursestoprovidethenecessaryintravenousdripathometoavoidanadmission,butthelocalcommunitynursesarenottrainedtoprovidethis.

Shehashadtwoperiodsofadmissionthisyear.Duringbothperiodswefoundthenursingcaretobeerratic,andcommunicationbetweennursesanddoctorstobepoor.Mygrandmotherhadadifferentnurseeachday,eventhoughnursesshehadbecomealittlemorefamiliarwithwerestillworkingonthesameward.Thetimingofdrugs,essentialinParkinsonism,waspoor.Whenthepaperdrugchartranoutofspacefornewdatesittooknearlythefulldayforanewcharttobestarted,causingworrythatthedrugsdueintheinterimhadnotbeenadministeredproperly.Ononeoccasion,IhadtostaylateatthehospitaltomakesuremygrandmotherreceivedhereveningdrugssoIcouldcallandreassuremygrandfather.

Duringthefirstadmission,herdeliriousstatemeantmygrandmotherknockedherlegsonthebedbarscausingbruisingandeventuallyalargehaematomaandnecrosisoftheskin.Weweretoldthatnopaddingorothersolutionwasavailable.Thewoundstooksixmonthstohealandrequireddaily,thenthrice-weekly,communitynursevisitsandexpensivedressings.Wehavesinceseenpaddingtobedbarsusedelsewhereandlearned(fromconsultantsinthesamehospital)thatbestpracticewouldhavebeentonurseherinalowbedwithoutbars.

Duringthesecondadmission,anearlydischargefailedwithin24hours,possiblyduetoinadequatemedicationtoquellherdelirium.Theprocessofdischargeandre-admissioncausedgreatdistresstobothgrandparents.Theywereforcedtowaitinthedischargeloungeforaboutsixtosevenhourswithnoinformationastowhentheymightbeabletogohome.Thefollowingmorning,realisingmygrandmotherwouldneedtobereadmittedasshehadagainbecomedelirious,mygrandfathercalledtheGP,whotoldhimtocallthehospital.Hespoketoanadministratorwhosaidthataconsultantwouldcallhimback,butseveralhourslater,whentheconsultantcalled,mygrandparentswerealreadywaitinginA&E.Althoughitwasclearlyafaileddischarge,mygrandmotherhadtogothroughalengthyprocessoftestsbeforeshewasadmittedtoabedlateintheevening.

Mygrandmotherwasmovedtwiceinthefirstcoupleofdays.Thesecondmovewascarriedoutat4am.Agitatedonbeingwoken,shepulledoutherfeedingtube.Herdentureswerelostintransitandcouldnotbelocateddespiteusrepeatedlygoingtoaskstaffatthewardshehadcomefrom.Thelackofdenturesleftherunabletocommunicateandincreasedherdifficultywitheating.Shedevelopedaspirationpneumonia,whichcouldhavebeeninpartduetothelackofdentures.

Thepneumoniakeptmygrandmotherinhospitalforalmostamonth.Bythetimeshewasdischargedshewasveryweakandcamehomeunderthepalliativecareteam.



Thisseemedtoimprovecareco-ordination,insofaraswhenshewasdischargedshebypassedthedischargeloungeandtheambulanceteamtookherstraightfromthewardtoherbedathome.

Thepalliativecareteaminstructedthefamilynottotrytoohardwithfeedingandmedicationregimesandnottogetmygrandmotheroutofbed,butmygrandfatherdidn’tagree.Heacquiredreplacementdenturesandmobilisedher.Twomonthslatershecouldwalkafewstepswithhelp,andenjoyedcelebratingher92ndbirthdaywithfriendsandfamily.

A daughter’s storyMymotherwasalwaysveryactiveandindependentuptohermid-80s,enjoyingactivitiessuchasbookgroups,gardeningandspendingtimewithherfamily.Untilrecentlyshelivedindependentlynextdoortomybrother.Shehasnowmovedtoacarehomecloseby.

Sixyearsagoshehadcommunity-acquiredpneumoniaandwasadmittedtohospitalforsevenweeks.InhospitalshecontractedClostridium difficile[infection]andwastransferredbetweensixdifferentwards,includinggynaecology,whichwasobviouslynotappropriate.Itwasverydifficulttofindoutwhowasresponsibleforhercareorwhoknewthemostinformationabouthercondition.Thenursescouldonlytellusthenameoftheconsultanton-callthatday,andtheconsultantsrotatedfromdaytoday.

Throughouthertimeinhospital,staffcontinuallycalledmymotherbythewrongname.ShehasbeencalledHarrietallherlife,butitishermiddlename,soherfirstnameiswrittenonallherrecords.Wedrewthistotheattentionofstaffontheward;itwasimportant,especiallyasshewassufferingfromepisodesofconfusion,butitdidnotstop.Everydaysomeonefromthefamilywouldvisitherandwipethewrongnameoffthewhiteboard.Ononeoccasion,aftertrackingdownaregistrarresponsibleforhercare,weexplainedthesituationandhewrote,‘likestobecalledHarriet’inbiglettersonthefrontofhernotes,butitstillhadlittleeffect.

Recentlyshewasveryunwellagainandconfusedanddisorientated.Shewasmovedbetweenseveralwardsandunsurprisinglycontractednorovirus.Ithadaprofoundeffect:athermostconfusedandsickwewereunabletovisitforaweek,leavingherisolatedandfrightened.

Beforeshewasdischarged,therewasamultidisciplinarycaseconferenceincludingthefamily,whichwentwell.Unfortunately,despitethepositivecaseconference,hercareplandisintegratedandeverythinghappenedinarush.Thewardwaskeentodischargeherbecauseofthenorovirus.ShewasdischargedwithoutthefamilyortheGPbeingtold,andnoonemadesurethatthecommunitynurseswereaskedtodoherinjectionsandshedidnotgetareferralforchiropody.Thecarehomewasexpectingher,butonthedayshewasdischargedtheyhadverylittlenotice.Ihadtointervenetomakesurethewardstaffspoketothem.Aftershewasdischargedshewasverylow,emotionallyandphysically.

Shehasalsohadexceptionalcare.Onarecentadmission,whenIarrivedtovisither,thewardsisterintroducedherself,explainedthatshewasthemaincontactandevenknewmymother’scorrectname.Theatmosphereonthewardwascompletelydifferent;thenurseswerebusyandengaged,ratherthanhuddledaroundreception,theycheckedonherregularlyandintroducedthemselvesbeforestartingtreatingher.



Overall,shehasreceivedthebestcarefromstaffwhohavetreatedandrespectedherasapersonratherthanstereotypingherasanelderlypersonwho’snotcapableofthinkinganddoingthingsforherself.

A wife’s storyIbecameafulltimecarerformyhusbandfiveorsixyearsagoduetohisincreaseddependencyandweakness.HehashadmanyhospitaladmissionsbecauseofproblemsassociatedwithCrohn’sdiseaseandwithhislonger-termsteroidmedication.Hisweaknesshasresultedinmanyfalls,andIhavetocallanambulanceeachtimebecauseIcannotlifthim.Inthecommunity,Ihavebeensupportedbysocialservicesandthelocalcarers’organisation,whichisveryhelpful.Thereareoccupationaltherapistswhoassessneedsandprovidestair-rails,bathaids,wheelchair,commodes,etc,allvitaltohiscareandsafety,andthereisthedistrictnursingserviceandtheincontinenceservice.Theincontinenceserviceprovidedpads,etc,butwasbyfartheleasthelpfulandmostinefficientservice,difficulttogetthroughtobytelephone,unhelpfulindiscussingneeds,andveryslowinprovidingmuch-neededitems.Liaisonbetweenthesevariousserviceswaspoor,andIhadtogivethesameinformationoverandoveragain.

Hespenttwoperiodsinhospital,inOctober2010forthreeweeks,andinJanuary2011whenhewasinforfiveweeks.Hiscarewasinadequateinmanyareas…InhospitalIfounditdifficulttocommunicatewiththedoctorswhowereincharge.Theywerenoteasilyavailable.Theydidnotliaisewith[theotherhospitalwherehehadbeentreated].Medicationwasstoppedorchangedwithoutmyknowledge.Myhusbandspentlongerinhospitalthanwasclinicallynecessarybecauseofadministrativemuddlesoverdischargeprocedures.Thehospitaloccupationaltherapistdidnotliaiseproperlywithdistrictnurses,andmyhusband’shospitalbedwasprovidedathomewithoutamattress.Dischargeprotocolsclashed.Theoccupationaltherapistsaidhecouldnotorderabeduntilthedischargedatewasprovided,butthewardmanagersaidthebedhadtobeinplacebeforeadatecouldbegiven.Thiscausedmyhusbandgreatdistressanddespondency,andhehasneverfullyregainedwhatwaslostinhismobilityandcontinencewhileinhospital.

Thesestoriesshowaqualityofinpatientcarethatisveryvariable:itisgoodsomeofthetimebutitisneverreliable.Theyshowthatpatientsandcarersexperiencemultiple,overlappingproblems,withdifficultiesincluding:

n thewaythatnursesorganisetheirwork,thecultureoftheward,andthewaynursesinteractwiththem

n accesstoconsultantsandseniormedicalstaff,andcommunicationwithdoctors

n poorcommunicationbetweenhospitalstaffandstaffinthecommunity

n poorandnon-existentcare-planning

n thefailureofthesystemtoidentifyanamedpersonresponsiblefortheircareandwithenoughofanoverviewofwhatishappeningtotalktopatientsandcarers

n theabsenceof,orfailuretoadhereto,sharedprotocolsandguidelines

n disruptioncausedbythepatientbeingmovedaboutinsidethehospital.

Thestoriesillustratehowandwhybreakdownsinthecontinuityofcare–plustheabsenceofarelationshipwithprofessionalstaff,poorinformationandopaqueornon-existentclinicalmanagement–leadpatientsandcarerstolosetrust,andthedamagingconsequencesfortheirhealthandwell-being.Theyillustratetheprecariousandcomplexarrangementsonwhichhouseholdsoffrailolderpeopledepend,andtheworkcarersputintoco-ordinatingcaretopreventbreakdownsincontinuityandrepairthemwhen



theyoccur.Perhapsmostimportantly,theyalsoillustratethewell-knownphenomenonthat,despiteanydifficulties,ordinaryhumanrespect,kindnessandconsiderationshownonapersonallevelhasanextraordinaryanddisproportionatelypositiveimpactontheexperienceofpatientsandcarers(Ellinset al2012).



The roots of the problemsTheobstaclestocontinuityofcareinhospitalaresystemicandcomplex.Theyarerootedinfactorsdeeplyembeddedinthecurrentdesignofthehealthandsocialcaresystemandtheprioritiesofthosewhocommissionacutecareandrunhospitals.Theyaffectthevolumeofworkinhospital,theordinaryroutinesthatgoverntheworkingdays(andnights),thecultureofcareinthehospitalasawholeandinteams(microsystems),thelevelsoftrainingandskilloftheworkforce,andthevaluesofthestaff.

Theconceptualframeworkforunderstandingtheanalysisofintegrationoutlinedearlieroffersawayintotheissues.

Systemic integration

Althoughweexcludedpolicyfromthescopeofthestudy,itisimpossibletoignoreitsimpactonolderpeople,carersandservices.Policiesandrulesdevelopedtofixanimmediateconcernoronepartofthesystemcanhaveunintendedconsequencesthatimpactonthem.Examplesincludethefollowing.

n Formorethanadecade,thegovernment’smainprioritiesfortheNHShavebeentospeedupaccesstoA&E,electivesurgeryandgeneralpractice,andimproveclinicalcareforpatientswithcancer,heartdisease,strokeandmentalhealth.Serviceshaveimprovedacrosstheboardforcancer,heartdiseaseandstrokepatients,butlessforolderpatientswiththoseconditionsthanforothers(Lievesleyet al2009).

n Thedifferentrulesgoverningpaymentinhealthandinsocialcareresultinpatientsandcarersbeingcaughtbetweenhospitalstaffandsocialcareworkerswhoareatloggerheads(Ellinset al2012).The National Service Framework for Older People(DepartmentofHealth2001),whichwasdesignedtoredressthebalance,didnotcomewithadditionalfundingearmarkedtosupportimplementation,asitspredecessorshad(Oliver2008).

Fundamentally,theresponseofthehealthcaresystemtothechangesoccurringinthehealthofanageingpopulationisinadequate.Thesystemisnotgearedtomeettheneedsofthemajorityandthepeoplewhoneeditmost.Weneedaradicalrethinkabouttheroleoftheacutehospitalinmeetingtheneedsofpeoplewithlong-termconditionsandpeoplewhoareold,withcomplexhealthproblems,andfrail.

Hospitalsaredangerousplaces,anditisvitaltoavoidunnecessaryadmissionsanddevelopbetterservicesforolderpeopleinthecommunityandintheirownhomes.Itis,however,amistaketothinkthatthiswillcompletelysolvetheproblemsinhospitals.Itisneitherdesirablenorpossibletokeepallfrail,olderpeopleoutofhospitalallofthetime:therewillalwaysbeaneedforsometoaccessthediagnostics,treatmentandcarethatcanbeprovidedonlybyanacutehospital.

Formorethanadecade,hospitalshavebeenunderpressurefromavarietyofsources:legislation,changesinmedicaleducation,andthedrivetocontaincostshaveallexacerbatedproblemsinrelationtocontinuityofcare.

TheEuropeanWorkingTimeDirective,coupledwithchangesinmedicaleducation,haveradicallyalteredthewaydoctorsworktogether.Consultantsusedtoworkinfirms,withjuniordoctorsworkingforthemonsix-monthrotations.Today,theymostlybelongtoaconsultantteamthathasteamsofjuniordoctorsonfour-monthrotations.Mabenfoundthat:‘Consultantphysiciansspokeofnotgettingtoknowtheirjuniorstaffbecauseofthenewrotationsystemsothat[seniorhouseofficers]wereonlyinoneplaceforfourmonths.Juniormedicalstaffspokeofisolation,highworkloadandtheneedtodebriefwithpeers’(Mabenet al2012).



Thecoincidenceofreducedhoursofwork,shift-workingandthemovementintoteamshasdisruptedoldmethodsofcommunicationbetweendoctors,andmadeitmoredifficultforprofessionalsworkingwiththesamepatienttokeepintouchwitheachother.Intheabsenceofeasyandfrequentface-to-facecontactbetweenpeople,thequalityofthecommunicationathandoverandinpatientrecordsisparamount.

Tosurvivefinancially,hospitalsmuststrivecontinuouslytoimproveproductivitybyincreasingpatientthroughput,maximisingtheuseofbeds,andreducinglengthsofstay.Coupledwiththesecularreductioninthetotalnumberofbedsoverthepast20years,itisnormalformosthospitalstofunctionat90–100percentoccupancywithverylittleornosparecapacityonthewards.Itisoftennotpossibletoadmitemergencypatientsstraighttoabedintherightplace.Typically,patientsforadmissionaretransferredfromA&Eintoanassessmentunit,fromwheretheyaresenthomeortransferredtothefirstavailablebed.Ifitisonawardassignedtothewrongspecialty,theyaremovedagain,possiblymorethanonce.Otherfactorscontributingtothevolumeofmovementinsidehospitalsincludetheshortageofindividualroomsforend-of-lifecare,andtheincidenceofhospital-acquiredinfections.

Normative integration

Agediscriminationandageistattitudesareprevalentinhospital(Lievesleyet al 2009).Atacorporatelevel,thebusinessisorganisedonthebasisofspecialties,departments,workforcecategoriesandothermanagementunits,notgenericpatientgroups.Ageismmeansthatolderpeople’sissues,includingcontinuityofcare,rarelygetthefocustheydeserve.Thehospitalisnotdesignedaroundtheirneedsintermsofworkforce,thephysicalenvironment,theorganisationofthedayorattitudestowardsvisitors.

Arecentmajorstudy(Taddet al2011)ofthecareofolderpatientsonacutewardsfoundthatpeopleinchargeandfrontlinestaffalmostunanimouslyheldtheviewthathospitalis‘thewrongplace’forolderpatients,especiallyolderpatientswhohavementalhealthproblems.Despitethefactthat,aswehaveseen,themajorityofpatientsinhospitalareold,theyareseenasnotbelonging,andthereforelessentitledtobethere.Hospitalsarefelttobe‘right’,apparently,onlyforpatientswhoareacutelyillandcanbetreated,andthehospitalculturethereforemerelytoleratesolderandfrailpatients,whoarereferredtopejorativelyas‘inappropriateadmissions’,‘bed-blockers’and‘socialadmissions’:dehumanisingtermsthatbothreflectandshapestaffattitudesandbehaviours.

Attractinghealthprofessionalstoworkwitholderpeopleisaprobleminmostdisciplinesinalladvancedeconomies.

People have not insisted on a change in priorities. We all like medical gizmos and demand that policy-makers make sure they are paid for. They feed our hope that the troubles of the body can be fixed for good. But geriatricians? Who clamours for geriatricians? What geriatricians do – bolster our resilience in old age, our capacity to weather what comes – is both difficult and unappealingly limited. It requires attention to the body and its alterations. And it requires each of us to contemplate the course of our decline, in order to make the small changes that can reshape it. When the prevailing fantasy is that we can be ageless, the geriatrician’s uncomfortable demand is that we accept we are not.

(Gawande2007)

Professionalvaluesreflectthevaluesofthewidersociety,andoldagespecialtiesinmedicineandnursinglackstatus,areperceivedasunattractiveandarehardtorecruitto.Ofcourse,thereareindividualsinallprofessionalgroupswhoaredeeplycommittedtoworkingwitholderpeopleandwhofindtheworkchallengingandrewarding,butfordoctors,‘thecareofolderpeopleisseenasunattractiveandlowstatusbymany,



compoundedbythelackofpotentialforprivatepractice’(Oliver2008),anditisnotapopularnursingspecialty.Mabenquotesnursessayingcareoftheelderlywardsare‘adeadendpartoftheservice’where‘youcan’tgofar’,and‘anareawhereyouaren’tpickingupskills’(Mabenet al2012).

Lackofrecognitionandlackofownershipoftheproblemsolderpatientsandcarersfaceinhospitalmeanthatolderpatientsareofteninthehandsofstaffwhoarenottrainedtocareforthemandlacktheknowledgeandskilltodosoconfidently.Geriatricmedicinedoesnotfeatureprominentlyinthecurriculaofmanymedicalschools,andplaysonlyasmallpartinnursetraining.Careoftheolderpersonisanoptionalspecialty,notsomethingthatisfundamentaltothegeneralcurriculum.Thevastbulkofthephysicalcareofolderpatientshasbeendelegatedtountrainedhealthcareassistantswhohavefewifanyqualifications.Theworkistypicallylabelled‘basic’,ratherthan‘essential’.Ifitwasdefinedas‘essential’,perhapswewouldbegintoseethatitrequiresbothknowledgeandskill.Thegovernmenthasannouncedthatfrom2013healthcareassistantsmustbetrainedandemployerswillberesponsibleforthattraining.Thismaybeastepintherightdirection,butitwillnotmakeadifferencewithoutchangesinthewidercultureinhospital.

Service integration

Itisaplatitudetosaythathospitalsareplacesofsilosandhierarchies.Frontlineclinicalandsupportstaffindepartmentsandwardshavesurprisinglylittleface-to-facecontactwithcolleaguesinotherareas,andprofessionalsdonotmeettogethertoplantheirworkbeyondformalmultidisciplinarymeetings.Managershigherupintheorganisationareoftenbetterplacedtolookacrosswhole-carepathwaysthanarethepeopledirectlydeliveringpatientcare.

Ifanything,achievingcontinuityismoredifficulttodaythanitusedtobeasaresultofincreasingspecialisationinbothmedicineandnursing.Medicalsub-specialties,alongwithbothdisease-andorgan-basednursingspecialties,haveproliferated–moresointheUnitedKingdomthaninotherEuropeancountries(GeneralMedicalCouncil2011).Thereare61approvedmedicalspecialtiesand34approvedsub-specialtiesintheUnitedKingdom,comparedwith57specialtiesinSweden(thenextclosest),and52inIreland,GermanyandRomania.Norwayhasthelowestnumberwithonly30(GeneralMedicalCouncil2011).

Specialisationcanimproveclinicalqualityandsafety,butithasnegativeconsequenceswhenthecarefromthespecialistsispoorlyco-ordinated.Forolderpeoplewithcomplexneeds,aswellasforsomeothergroupsofpatients,specialisationwithintheprofessionsbringsdisadvantagesifitisnottemperedbyaccesstoappropriategeneralistsandotherprofessionalstoensureaholisticapproachisalsotaken.Geriatriciansmainlyremaingeneralists,butnotallolderpatientsarecaredforbyageriatricianand,insomehospitalsandteams,geriatricianslackinfluence.

Liaisonpsychiatryorliaisonmentalhealthservicesaredesignedtosupportthementalhealthneedsofpatientsinhospital,particularlythosewithlong-termhealthneeds.Theseserviceshavebeenshowntoprovidearangeofbenefits,suchasimprovementsinhealthoutcomesandpatientexperience,whilereducinglengthofstay,readmissionsandhealthcarecosts(NHSConfederation2011).

Liaisonpsychiatryhasparticularimportanceforolderpeoplewithinacutecareasitprovidesanintegratedapproachtoaddressingtheirphysicalandmentalhealthneeds.Thepsychiatricliaisonmodelforolderpeopleisbeingimplementedacrossthecountry,withdifferingservicemodels.Thecommonaspectsofaneffectiveserviceincludeamultidisciplinaryteamwitharangeofdisciplines,trainedinmentalhealthliaisonandledbyapsychiatricconsultant.Theserviceshouldbeembeddedintheacutehospitalsetting



sothatstaffcanworkcloselywithacutestaffongeneralwardsandhavesufficienttimetoprovidetrainingandeducation(WorkingGroupforLiaisonMentalHealthServicesforOlderPeople2005;NHSConfederation2009).

ArecentNationalInstituteforHealthServiceDeliveryandOrganisationproject(Holmeset al2010)tomaptheprovisionoftheseservicesintheUnitedKingdomfoundthattherehadbeenashiftsince2002,awayfromthetraditionalhospitalconsultationmodeltowardspsychiatricliaisonservices,butthatprovisionacrossthecountryremainedpatchy.

Intheabsenceofco-ordinatedservicesandcareprocesses,thequalityofthecommunicationbetweencliniciansisparamount.Theproliferationofrolesandpersonnelcanbebewilderingforpatientsandcarersunlessthevariousfunctionsandresponsibilitiesofeachteammemberarecarefullyexplained.

Co-ordinatingthecontributionsofallthedifferentprofessionalsinvolvedwithaparticularpatientrequires:

n teamleadership

n clarityabouttherolesandinputstotheteamthateachindividualandprofessionalbackgroundbrings

n clarityaboutwhoisaccountableforwhatandwhatdelegationmeans

n theavailabilityofmembersoftheteamtomeettogetherreliably

n goodrecord-keeping.

Inthecomplexenvironmentofacutehospitals,wherepatientsinthecareofasinglespecialistmedicalteammaybedistributedacrossmanywards,andwhenpatientsaremovedaboutwithinandbetweenwards,multidisciplinarymeetingsareoftenexceptionallydifficulttoorganiseandthusrarelyoccur.

Somehospitalstrytostrengthencontinuityandreducedelaysinclinicaldecision-makingthroughmedicalscheduling.Somehaveoptedfor‘consultantoftheweek’(orfortnight)schemes,wheretheconsultantisbasedonthewardforthewholeperiodwithhisorhermedicalcolleaguestakingoverdutiesinclinicsandelsewhere.Otherslinkageriatriciantoeveryacuteward,orhavegeriatriciansinteamsofferingspecialistadvicetootherdisciplines.Thereareprosandconstoallofthesevariousschemes.Solongasthegoalsofgreatercontinuityandfewerdelaysareagreed,eachhospitalcanfindthesolutionthatbestsuitsitsmedicalworkforceandpatientpopulationprofile.Aschemethatworkswellinonehospitalwillnotnecessarilyworkinall.

Functional integration

Thequality,speedandreliabilityofinformationandcommunicationsystemsarefundamentaltocontinuity.Mostacutetrustsdonotyetofferaccesstoelectronicmedicalrecordstoallstaffthroughoutthehospital.Manyprofessionalstaffhavelittleornoaccesstocomputerterminalstoreviewcareplans,recordcareandcommunicatewitheachother.

Recordscontinuetobemainlyhandwrittenandpaper-based.Itisnormalfordifferentprofessionalsworkingwithonepatienteachtokeeptheirownrecords,forthosevariousrecordstobekeptindifferentplaces,andforpartsoftherecordnottobeavailableoutofhours.Nursescomplainabouttheburdenofpaperworkandabouthavingtocompletecomplexpaper-basedpatientassessmentsthatfrequentlydonotcontributetopatientcare,butatthesametimeitisnormalfornursestore-dothepaperworkwhenapatientarrivesintheirarea,ratherthanrelyingonanassessmentcarriedoutbyacolleagueinanotherpartofthehospital.



Patientsandcarerscomplainthatstafftakeactionoraskthemtoprovidemoreinformationbeforecheckingforthemselveswhatinformationhasalreadybeenrecorded.Theyalsocomplainabouthavingtorepeatpersonaldetailsandanswerthesamequestions,andworrythatbehindthisphenomenonisthepossibilitythat‘no-oneknows,orcares,whoIam’.Theybecomeworriedifthepeopletheymeetcannotgivethemanoverviewoftheplanofcareandwhendifferentpeopletellthemdifferentthings.

Electronicrecordscanplayasignificantpartincontributingtothecontinuityofcareandensuringthatcareisbetterco-ordinated.AstudyoftheHospitalatNightscheme,introducedaftertheEuropeanWorkingTimeDirectivewasimplemented,concludedthatelectronichandoverimprovesinformationtransfer,improvescontinuityandhelpstoreducemedicalerrors(Raptiset al2009).

Clinical integration

Ageistattitudesandprofessionalvaluesthatreflectthemhavedirectconsequencesforthequalityofclinicalcare.Theyhaveshapedanapproachtothemedicalcareofolderpeopleinwhichitisacceptableforthestandardsofcareandprocedurestodifferfromthoseappliedtothemedicalcareofotheragegroups.Oliver(2008)coinstheterm‘therapeuticnihilism’todescribethephenomenonofolderpatientsbeingadmittedtohospitalandtreatedwithoutproperdiagnosisandassessment,withtheresultthattreatableproblemssuchasincontinence,depressionanddeliriumarenormalisedandgountreated.‘Thecustomarydiagnosticrigour,whichwehavebeentrainedtoapplyasstandard,canbemysteriouslyreplacedby“therapeuticnihilism”.’(Oliver2008).

Thereisnoexcusefortreatingolderpatientsasagroupdifferentlyfromyoungerpatients.TheNationalInstituteforHealthandClinicalExcellencehaspublishedguidelinesandqualitystandardsrelatingtothecareofolderpatients,notablyonfalls(NationalInstituteforClinicalExcellence2004),criticalillnessrehabilitation(NationalInstituteforHealthandClinicalExcellence2009)incontinence(NationalInstituteforHealthandClinicalExcellence2007),dementia(NationalInstituteforHealthandClinicalExcellenceandtheSocialCareInstituteforExcellence2006),delirium(NationalInstituteforHealthandClinicalExcellence2010),stroke(NationalInstituteforHealthandClinicalExcellence2008),chronicheartdisease(NationalInstituteforClinicalExcellence2003)andend-of-lifecareforadults(NationalInstituteforHealthandClinicalExcellence2012a).Theseshouldbemadeavailabletoandimplementedbyallhealthprofessionalswhoworkwith



adultsinhospital.

Practical solutionsPractices that promote continuity of care

Theevidenceoncontinuityofcareforpeoplewithlong-termconditions,mentalhealthproblemsand/orwhoneedend-of-lifecareisthesame,withtheessentialrequirementsbeing(FreemanandHughes2010):

n anamedkeyworkeravailable24/7

n acareplan

n acompletemedicalrecord,ideallyheldelectronically

n multi-skilledcarers,whethertheirbackgroundbenursingoranassociatedcareprofessional

n generalistsworkingalongsidespecialists.

Frominterviewswithexpertsandcarers,forinpatientacutecarewewouldadd:

n anamedprofessionalcapableofhavinganoverviewofthecaseandwhoisaccountableforthecareplan

n informationforpatientsandcarersaboutthetimeswhentheaccountablepersonisavailabletoanswerquestionsanddiscussthecareplan

n trainingforallstaffinthecareofolderpatients,includingcareofpatientswithcognitiveimpairment

n cognitiveassessmentofallolderpatientstodiagnosedelirium,dementiaanddepression

n operationalplanstoreducethenumberoftimesthesamepatientismovedaroundahospital

n operationalplanstomitigatetheeffectofmovements,includingpoliciesonout-of-hourstransfers

n useofchecklistsforessentialinformationtosupportcommunicationwithpatientsandcarers

n emailandtelephonecontactbetweenconsultantsandGPs

n emailandtelephonecontactbetweenward-basedstaffandtheircommunity-basedcounterparts.

Thedistinctionbetweencontinuityofrelationshipandcontinuityofmanagementisanalyticallyhelpfulbut,inpractice,effortstopromotecontinuityofcaredonotfitintoneatcategories.Initiativesaimedatstrengtheningrelationshipshaveknock-onbenefitsforclinicalquality,andinitiativesaimedatimprovingcommunicationwithpatientshelppatientsandcarerswiththeworktheydotobridgethegapsinservices.

Wefoundtwotypesofinitiativetopromotecontinuityofcare.

n Interventionsaimedatasingleaspectofcontinuity,forexample,communicationorrelationalcare.Interventionsinthisgroupcanberelativelycomplex,butwhatdistinguishesthemisthataslongasfrontlinestaffhavethesupportoftheirimmediatemanager,theycanimplementthem.

n Interventionsaimedatpromotingcontinuityofcarefromthebeginningtotheendofthepatient’sjourney.Thesekindsofchangesusuallytakealongtimeandneedthesupportofveryseniorclinicalandoperationalleadersoversustainedperiods.



Interventions aimed at promoting one aspect of continuity

ThereareseveralpracticaltoolsinuseintheUnitedKingdomtostrengthencontinuityofcommunicationbetweenprofessionalsandpatients,andprofessionalsandcarers.Typically,thesearesimple,paper-baseddocumentsorformsforpatientsorcarerstocomplete,givingprofessionalsinformationaboutthepatients’livesoutsidethehospitalandtheirindividualpreferences.Theideaisthattheprovisionofthisinformationempowerspatientsandcarersbecausetheycanurgeprofessionalstorefertoit,andithelpstheprofessionalsbygivingthemasenseofwhotheirpatientsareoutsidethemedicalsetting.

OnesuchtoolthathasbeentestedandiseasilyavailableisThis is Me,aleafletforpatientsand/ortheircarerstocompletebeforepatientsgointohospital(Alzheimer’sSociety/RoyalCollegeofNursing2010).This is Meprovidesasnapshotofthepatients’normallivesoutsidethecaresetting,detailingtheirhabits,interests,likesanddislikes.Simpleandpractical,itwasfirstdevelopedbytheNorthumberlandAcuteCareandDementiaGroupatNorthumberlandHealthCareFoundationNHSTrust,andwaslaunchedbytheAlzheimer’sSocietywiththesupportoftheRoyalCollegeofNursinginFebruary2010.

Welookedforexamplesofinterventionsdesignedtostrengthenrelationshipsbetweenpatients,carersandprofessionalsintheUnitedKingdombutstruggledtofindany.IntheUnitedStates,Planetree,anot-for-profitorganisationthatpromotespatient-centredcare,haspublishedmaterialontwopracticalmethodsofstrengtheningrelationshipsbetweenpatients,carersandstaff(Framptonet al2008).Botharetheproductofafundamentalphilosophyofcarethatexpectsprofessionalstoincludethepatient–andwhomeverelsethepatientwishes–incare-planninganddecision-making.

Partners in CareThisprogrammeisadeliberateefforttoenhancetherolepatientsandtheirrelationsplayinpatients’hospitalcare.Patientsnominateamemberoftheirsocialnetworkastheir‘carepartner’.Thegoalisforthepersonal,emotional,physicalandpsychologicalneedsofpatientstobemetbyallowingandencouragingtheirnormalsupportsystemtobeinvolvedintheircareduringtheirhospitalstay,whilerespectingandprotectingpatients’senseofdignityandindependence.

ThewayPartnersinCareworksisthataprimarynurseresponsibleforthepatienthasaninitialdiscussionwiththepatientandthenominatedcarepartnertogaugethepatient’sinterestsandpreferences.Within48hoursofadmission,themembersofthemultidisciplinaryhealthcareteamholdacollaborativecareconferencewiththepatientandcarepartnertodiscussdiagnosis,treatmentandpost-hospitalcareneeds.

Theroleoftheward-basednurseaftertheconferenceistypicallytoprovidethecarepartnerwitheducationandtraining,sothatheorshecanparticipateinroutinecareactivitieswiththepatientsuchas:personalcare,menuselection,assistancewithmeals,monitoringfluids,reading,writingandotherdiversions,mouthcare,dressings,catheteranddraincare,andmobilisation.Theroleofthecarepartnerisexplicitlynottoreplacethenursingcarebuttoenhanceit.

Patient and family-centred ward rounds and clinicsThedifferencebetweenfamily-centredwardroundsandfamily-centredclinicsisthatthewardroundisheldatthepatient’sbedside,theclinicawayfromit.Thepurposeofbothistopromoteanopenexchangeofinformationandideasbetweenthepatient,thepatient’sfamilyandtheprofessionalsinvolved.Carefulattentionispaidtorespectingthewishesofthepatientandfamilymembersaboutissuestodowithconfidentiality,privacyandthedegreeofinvolvementwanted.

Thefamilyistoldthetimesoftherounds/clinicsandintroducedtothemembersofthecareteam.Therolesofthemembersofthecareteam,andtheprofessionals’expectationsofthepartthatfamilymemberswillplayareexplained.



Theaimistogivethefamilytheopportunitytoaskquestions,toreceiveinformationandprovideadditional,newinformation,toreviewthecareplanandtodiscussplansfordischarge.Attheendofthesession,theprofessionalcheckswhethertherearelast-minuteconcernsandexplainshowanyadditionalinformationwillberelayedtothefamily.

ItispossiblethatthehospitalsthathaveimplementedthePlanetreemodel,withitsemphasisonpatient-centredcare,areexceptionalintheUnitedStatesaswellasintheUnitedKingdom,andthatthelackofpublishedexamplesofrelationship-buildinginterventionsintheUnitedKingdomdoesnotindicateaprofoundphilosophical/culturaldifferencebetweenUSandUKhospitals.Itisalsopossiblethatthereisgreaterawarenessandrespectforpatients’autonomyintheUnitedStatesbecausepatientsareviewedmoreasactiveconsumers.

Interventions aimed at promoting continuity across the care pathway

Fromthepatient’sperspective,managementcontinuityisaboutknowing:

n thatheorshehasacareplan

n thatclinicalcareisconsistentwiththatplan

n whotospeaktoifthereareanyproblems.

Therearemanywaysinwhichpatientsandfamiliescanbeempoweredinandaroundtheirhospitalstays.Despitetheimpactofphysicalandmentalfrailty,itshouldnotbeassumedthatpatientsareincapableorunwillingtobemoreinvolvedintheirowncare,althoughsomewillneedsupportfromtheirfamiliesorotheradvocatestohelpthemtodoso.

IntheUnitedKingdomandelsewhere,continuityisachievedbybringinganadditionalpatient-navigatororpatient-advocateintothesystem.TheStrokeAssociation’sLifeAfterStrokeServicesmodel,forexample,providesstrokesurvivors,familiesandcarerswithinformation,supportandassistance(StrokeAssociation2012).Ithelpsensurethattheirneedsarebeingmet,andhelpsthemcometotermswithlifeafterstroke.Co-ordinatorsdirectclientstowardsotherservicesthatcanmeettheirneedsandhelpthemtoachievetheirgoals.Theyseektodevelopstronglinkswithallthesourcesofsupportavailable,bridgingandnavigatingacrosssystemsandorganisationalboundaries.Theworkisledbytheneedsandgoalsoftheclient.

Theserviceusuallycoversthetimefromearlyrecoveryandadjustment,givingpersonalisedinformationontheward,throughtouptoayearafterstroke.Beingasupportivepresencethroughouttoboththestrokesurvivorandhisorhercarer,staffaretrustedtohelpwiththeemotionalconsequencesofstroke,andcanmakeimportantearlyinterventionstopreventcrisesdeveloping.

OnesuchschemeistheHospital-BasedCarerSupportWorker(HCSW)providedbyCarersLeedsandfundedbyLloydsTSBCharitableTrust.TheHCSWaimstoprovideinformation,adviceandconfidentialsupporttoallcarerswithinthehospitalsetting.Thismayincludevisitors,patientsorpaidstaffthathaveacaringroleathome.ThechallengesfacedbyCarersLeeds’HCSWarecommontomanyhospitalswherethesheersizeandcomplexityoftheorganisationanditspoliciesandprocedurespresentdifficultiesknowingwheretogotofollowupcertainissuesraisedbycarers.

ThemaincarerissuethathasfacedtheHCSWinLeedsconcernedthedischargeprocedure.Patientsandcarersdonotalwaysknowwheretogoforhelpandtheycanbecomelostintheworldofcareplans,benefits,homecareservices,enablementandmedication.CarersLeeds’HCSWhelpscarers‘throughthesystem’toenablethemtofeelmoreconfidentandassuredwhentheircaringrolestartsforthemathome(interview).



InPennsylvania,intheUnitedStates,Naylorandcolleagueshavedevelopedandrefinedamodelofcaretoaddresstheunmetneedsofhospitalisedolderpeopleandtoimproveoutcomesafterdischarge(Naylor2002,2004;Nayloret al2009).Themodelreliesonanadvancedpracticenurse(APN)withgerontologicalexpertisetodocomprehensivedischarge-planning.TheAPNtailorspost-dischargeservicestothepatientandprovidesfollow-upcarebytelephoneandhomevisits.

Theinterventionisnotableforitsemphasisonidentifyingpatients’andcaregivers’goals,individualisedcareplansdevelopedandimplementedbyAPNsincollaborationwithpatients’physicians,educationalandbehaviouralstrategiestoaddresspatients’andcaregivers’needs,andco-ordinationandcontinuityofcareacrosssettings.Naylorandcolleagueshaveevaluatedtheinterventionforitseffectoncostsandoutcomes,toidentifythepatientgroupsforwhomitiseffective,andtodefinetheintensityanddurationofservicesnecessarytoimproveoutcomes.

Thescaleandcomplexityofthechangesneededtodeliverco-ordinatedcaretopatientsusingexistingstaffalonecanbeseenintheexamplesbelowfromLeedsandtheRoyalBoltonHospital.

Leeds Hospital Mental Health Team for Older PeopleIn2006,inresponsetorisinglengthsofstayamongolderpatientswithdementia,deliriumordepression,hospitalsinLeedschosetomovefromatraditionalpsychiatricconsultationmodeltoapsychiatricliaisonservice,theHospitalMentalHealthTeamforOlderPeople(HMHTOP).

TheHMHTOPisaserviceforthoseaged65yearsandolderprovidedbythementalhealthtrust–theLeedsandYorkPartnershipNHSFoundationTrust–andphysicallylocatedonthesiteoftheLeedsTeachingHospitalsNHSTrust.

Theteamprovidesaquickreferralserviceto:

n identifyandassessolderpeoplewithseriousmentalhealthneedswithingeneralacutecare

n managetheeffectsofphysicalhealthonmentalhealth

n providetrainingandsupporttohospitalstaffcaringforolderpeoplewithmilddementiaanddeliriumontheirwards.

Itoperatessevendaysaweek,between9amand5pm,andcomprisesaconsultantpsychiatrist,seniorhouseofficerinpsychiatry,severalbandfiveandsixnurses,anoccupationaltherapistandadministrativesupport.Thismultidisciplinaryapproachbringstogetherstaffwitharangeofskills,andeverymemberoftheteamistrainedtocarryoutassessments.

Onanygivenday,theteamoperatesonanad hocbasis,receivingreferralsfromdepartmentsthroughoutthehospitaltrust.Mostreferralscomefromcare-of-the-elderlywards,butoncology,orthopaedicsandsurgicalwardsareincreasinglyreferringpatientstotheserviceaswell.

Onceareferralformisreceived,theadministratorcheckswhetherthepatientisknowntothementalhealthtrust.Casesareassignedtoteammembersinthemorning,andthenassessmentsarecarriedoutwiththepatientsusingastandardassessmentpack.Staffusethistimetospeaktothepatient,hisorherfamily,carersandstaffmemberstobuildupadetailedpicture.

Laterintheday,themorning’scasesarereviewedatamultidisciplinaryteammeeting.Thefindingsfromtheassessmentaresummarised,anddiagnosesarediscussedasagroup.Whilethisisgoingon,notesoftheassessmentareenteredintothepatient’selectronicrecord.PatientsareoftenreferredbacktotheirGPforafollow-up,buta



significantproportionarereferredontoinpatientpsychiatricwards(largelyduetodifficultdementia)ormemoryclinicsorsignpostedtowardsinformationaboutdementia,forexample.

ProvidingeducationandtrainingtostaffacrossthetrustisanotherkeyfunctionoftheHMHTOP.Astheserviceisdesignedtointegratementalandphysicalhealth,teammembersworkcloselywithgeneralstafftoensurethatappropriatereferralsaremadeandtoprovideadviceaboutmanagingpatientswithlow-leveldementia,deliriumanddepressiononthewards–ensuring,forexample,thatolderpatientsarekeptsufficientlyhydratedasdehydrationcanexacerbateorcausedelirium.

ThecreationoftheHMHTOPwasfundedbytheDepartmentofHealthaspartofthetwo-yearLeedsPartnershipforOlderPeople’sProgrammepilotbetween2006and2008.Thispilotevaluationfoundthatlengthofstaysignificantlydecreasedforpatientswithdementiaasaprimaryorsecondarydiagnosiscomparedwiththegeneralpatientcohort(Godfrey2009).HMHTOPhasalsoincreasedthenumberofreferralsby87percent,fromonly200peryearin1999,andnowaccountsfortwo-fifthsofallmentalhealthreferralsinLeeds.

Themajorityoftheirpatientsarediagnosedwithdelirium,dementiaorboth,andover60percentareolderthan80years.Interestingly,three-quartersoftheirpatientsarenewtothementalhealthtrust,suggestingthattheserviceispickingupahighproportionofpreviouslyundiagnosedconditions.

Respiratory gateways at the Bolton NHS Foundation Trust AttheRoyalBoltonHospital,theaimhasbeentoachieveacontinuous,co-ordinatedandreliablecareexperienceforpatients.Since2005,theBoltonNHSFoundationTrust hascommittedsignificantresourcestoanorganisation-widestrategytoimprovethequalityofservicesusingso-called‘lean’methodology.Alargenumberofclinicalstaffhavetrainedintheprinciplesandtechniquesofqualityimprovementandarefamiliarwithrapidimprovementevents,processmapping,observationsofpracticeandactivityanalysis.Thetrustexecutiveknowsthatittakestimetoprepareimprovementideasandthatitisessentialforclinicalteamstotaketimeawayfromclinicalworktomonitoranddevelopimprovementplanstogether.

In2009,theRoyalBoltonHospitalidentifiedrespiratoryservicesasbeingapriorityforqualityimprovement.Attheoutset,servicesinBoltonwerethoughttobegoodlocally.Likeservicesforpatientswithchronicconditionsalloverthecountry,differentcombinationsofpersonneltreatedpatientswithrespiratoryproblemsindifferentsettings.Theseincluded:

n twoinpatientwards

n specialistnursesforasthma,lungcancer,tuberculosis,chronicobstructivepulmonarydiseaseandlong-termoxygentherapy

n nurse-ledclinics

n pulmonaryrehabilitation

n ahospital-at-homeservice

n outpatientservices.

Theteamthatledtheworktoimprovetherespiratorypathwaycomprisedarespiratorynursespecialist,amatronandtwomedicalconsultantssupportedbyqualityimprovementspecialists.Theycreatedwhattheycalleda‘patientgateway’,underpinnedbytheprincipleof‘onedecisionflow’.Putsimply,thismeanshavingtherightteammembers,withtherightinformation,presentattherighttimetomakethedecisionsrequiredtoaddvaluetothepatient’sjourneybyeliminatingentirelydelays,errors,duplicationandnon-patient-relatedvariation.Theideaisthateverydaythatthepatientisinhospital,itisabsolutely



clearwhatactionsarebeingdoneandbywhichmembersoftheteam,withtheresultthatthepatientcanbetreatedanddischargedwithoutdelay.

Overaperiodof18months,therespiratoryserviceimprovedclinicaloutcomesandaachievedamuch-improvedexperienceofcontinuity(seeTable1).

Table 1 Changes in outcomes for respiratory patients, 2009—11

Measure 2009—10 2010—11 Change (%)

Mortality* 119 91 –23.0

Length of stay 8.9 days 6.9 days –23.0

Readmissions 9.5% 8.5% –10.5

Escalation to intensive care unit 101 patients 64 patients –34.0

Home visits by respiratory specialist nurse 269 (July—January) 410 (July—January) +34.0

Respiratory specialist nurse time on wards seeing patients 26.25 52.5 +50.0

Notes: *hospital standardised mortality ratioSource: Bradley et al (2011)

Onepatientisquotedassaying:‘Ihavebeenapatientherefor30years,carehasalwaysbeengood.Butthechangesnowonthewardaremarvellous,youseeaconsultanteveryday,youknowwhatisgoingonandcanactionthingssoonerifnecessary’(Bradleyet al2011).

Behindthescenes,themodificationsthatmadetheimprovementspossibleincluded:

n allconsultants’jobplanswerereviewedandchangedtoallowdailyreviewofpatientcare

n consultantswererosteredtoworkonthewardscontinuouslyforaperiodoftwoweeks

n dailymorningwardrounds

n dailymultidisciplinaryboardrounds(meetingsatthewhiteboard)

n wardroundsat4pmonFridaystomakedecisionsbeforetheweekend

n respiratorynursespecialists’roleswerechangedfromdisease-basedtopatient-basedallocationforallrespiratorypatients

n therespiratorynursespecialistservicewasmadeavailablesevendaysperweek

n changesweremadeinthewaythatjuniordoctorsandnursesworktogether

n separateroundsformedicationwereinstituted.

Thechiefexecutiveofthetrustdescribedthechangesthus:

Within respiratory services, there may be five consultants. Ours each do a two-week ward duty, during which time they do not do routine clinics. These doctors are responsible for all the respiratory patients for that fortnight. That offers most patients continuity, but where they experience a changeover of consultant, the plan continues. This is being rolled out across the hospital. We have done complex care wards, cardiology, gastroenterology, orthopaedic and respiratory.

(Interview)

Thescaleofthechallengetotheusualwaysofworkinginacutehospitals,andofthechangesthatindividualsandteamshadtomaketodeliveraco-ordinatedrespiratoryservicecannotbeunderestimated.Forthatreason,wecannotsimplyrecommendtheBoltonapproachasthesolutioneverywhere.Beforetheyarereadytotacklethe



fundamentalimprovementsrequiredtoco-ordinatecare,hospitalleadersneedtobesatisfiedthattheyhavethefoundationsinplace.Theseinclude:

n thewillamongleadersatseniorandwardlevelandthedeterminationandpersistencetoseethechangesthroughovertime

n knowledgeofimprovementmethodsandtechniques

n arealistictimehorizonforplanningandimplementation:transformationdoesnotoccurquickly

n awillingnesstoallowtheteamtotakerisks

n reallygoodcommunicationwithinclinicalteams

n measurementandanalyticalcapabilitythatcanbeusedbytheteam.

Better information and metrics

Ifcontinuityofcareandco-ordinationofservicesaretohappen,muchmoreworkneedstobedoneonmeasures,includingmeasuresthatassesspatients’experienceofcontinuityandtheimpactofinterventionsdesignedtoimproveit.Itissurprisingtodiscoverhowlittleworkhasbeendonetodateonthisimportanttopic,andprobablyfairtosaythatthemeasurementofcontinuityofcareisunderdeveloped.Thismay,inpart,reflectalackofconsistencyaboutthedefinitionsofcontinuityofcareandco-ordinationofcare.

ThesituationisnotimprovedbytheexistenceofseparateoutcomeframeworksfortheNHSandsocialcare,whichdonothingtopromoteanoverviewofpeople’sjourneythroughthesystemand,indeed,encourageanorganisationalratherthanpatient-focusedviewofperformance.Organisationsarenotcurrentlyjudgedonhowsuccessfultheyareatprovidingcontinuityofcare,butthisshouldbethecase.

IntheUnitedKingdom,thequestionnairesusedbythenationalpatientsurveysofclinicalconditions(suchasstroke,heartdiseaseandcancer),ofsomepatientgroups(womenusingmaternityservices),andforcommunityrehabilitationprovideagoodbasisfordesigningsurveyinstrumentsthatcanmeasurecontinuityofcare.

IntheUnitedStates,recognisedmeasuresincludeColeman’sCTM-3andCTM-15(Colemanet al2005,2007).TheCTM-3,completedatahomevisit,hasthreestatements,theCTM-15hasmore.TheCTM-3statementsare:

n ThehospitalstafftookmypreferencesandthoseofmyfamilyorcaregiverintoaccountindecidingwhatmyhealthcareneedswouldbewhenIlefthospital.

n WhenIleftthehospital,IhadagoodunderstandingofthethingsIwasresponsibleforinmanagingmyhealth.

n WhenIleftthehospital,Iclearlyunderstoodthepurposeoftakingeachofmymedications.

IntheUnitedStates,thePickerInstituteispromotingtheconceptof‘AlwaysEvents’asapositivetool(PickerInstitute2012).Theflip-sideofthecoinfrom‘NeverEvents’–incidentsthatshouldneveroccurduringthedeliveryofpatientcare–AlwaysEventsareseenasanexcitingwaytopromotebettercommunicationandbettercaretransitions,being‘aspectsofthepatientandfamilyexperiencethatshouldalwaysoccurwhenpatientsinteractwithhealthcareprofessionalsandthedeliverysystem’,asascertainedthroughfocusgroupscomposedofpatients,familiesandfrontlinecaregivers(PickerInstitute2012).

ThePickerInstitutehasidentifiedfourcriteriathatshouldguidetheselectionofAlwaysEvents.Theyare:



n significant:patientsshouldhaveidentifiedtheexperienceasimportant

n evidence-based:theexperienceshouldbeknowntoberelatedtotheoptimalcareofandrespectforthepatient

n measurable:theexperienceshouldbesufficientlyspecificsothatwhetheritoccurredcanbeaccuratelyandreliablydetermined

n affordable:theexperienceshouldbeabletobeachievedbyanyorganisationwithoutsubstantialrenovations,capitalexpenditureorthepurchaseofnewequipmentortechnology.

Atthisstageofdevelopment,thePickerInstituteisfundingtwo-yeardemonstrationprojectsbasedonarangeofAlwaysEvents.Whentheprogrammeends,itwillproduceaguidetolessonslearnedandtoolstosupportfutureadopters.

IntheUnitedKingdom,theDepartmentofHealthhasbeguntofollowtheUSleadbyissuing,in2011,alistof25NeverEventsthatprovidersmustreportandthatarelinkedtofinancialpenalties(DepartmentofHealth2011).Thelistwasupdatedin2012(DepartmentofHealth2012).

Althoughbettermetricsareimportant,itisalsovitaltorecognisethevalueofqualitativedataandinformalfeedback.Clinicalstaffandmanagerscouldlearnagreatdealabouthowtoimprovecontinuityfromaskingpatientsandcarersabouttheirexperienceandposingquestionsassimpleas:

n IsthereanythingelseIcandoforyou?

n Doyouknowwhomtocontactwhenyouneedto?

n Doyouhavetheirnameandnumber?

n Doyouhavetheinformationyouneedaboutyourdrugs?

n Doyouhavetheinformationyouneedaboutwhatwillhappennext?

n IsthereanyinformationIcanhelpyouwith?

Patientsandcarersoftenhangbackfromaskingquestions,buttheyarearichsourceofserviceintelligenceforthosewhotapintoit.

Whilethereisscopetodevelopbettermetrics,itisalsoimportanttoacknowledgethatqualitativedatacancontributetoserviceassessment.

Conclusions and recommendationsContinuityandtheco-ordinationofcarearefundamentaltohigh-quality,cost-effectivehealthcare.Inthecontextofacutecare,therisksoffragmentationandbreakdownincareco-ordinationarehigh,especiallyforolderpatients.

Thescaleoftheproblemandthenumberaffectedisunknown,butitquiteclearthataverygreatmanyolderandveryoldpatientsarereceivingsub-optimalcare.Toomanypatientsandcarersdonotknow‘whoisincharge’ofthepatient’scare,whotheycantalktoaboutit,andhowtogetanswerstotheirquestions.

Relativelysmallchangesinpracticecansignificantlystrengthenpatients’andcarers’relationshipswithcliniciansandcontributetogreaterconsistencyofclinicalmanagement.Solvingthedeepandsystemicproblemsthatunderliemanyoftheproblems,however,requiresthecommitmentoftheseniorleadershipofthehospital,adeliberatestrategicintent,clearaims,investmentinandknowledgeofserviceimprovementmethods,awillingnessandpersistencetopursuethegoalsovermonthsand,ifnecessary,years,andthecapabilitytomeasureandmonitorthechanges.

Ourrecommendationsarepresentedbelow.



Recommendations

Patients and carers Frontline clinical and support staff Senior executives and board members

Patients and carers should receive high-quality care that is appropriate for their needs in all clinical areas

Should have confidence in their own level of knowledge and skill in relation to the medical care of older people

Should develop and implement a hospital-wide strategy for high-quality care for frail, older patients with complex medical problems that promotes continuity of care

Patients and carers should always know the name of the person in charge who will be able to answer questions and discuss the care plan

Should introduce themselves to patients and carers by name and explain their role

Should consider whether a dedicated care co-ordinator is needed in complex cases, and make sure that a named professional is responsible and accountable for every patient

Patients and carers should always know when and how to get hold of the lead professional

Should agree who is the named professional in charge and give that name to the patient and carer

Should make sure that patients and carers know when and how to get in touch with that named professional

Should agree when and how the lead professional will be available, and make sure that patients and carers know the details

Team members should make sure that the lead professional is aware of changes in the patient’s plan

Patients should be invited to nominate a partner in care

Should invite patients to name their partners in care and invite those people to be more closely involved with the care plan

Should pilot and implement partners-in-care schemes on the wards

Patients and carers should have the opportunity to complete a This Is Me document or a suitable alternative

Should use a This Is Me document or a suitable alternative

Should review patient documentation to ensure This Is Me or a suitable alternative can be adopted

Older frail patients should be moved in hospital as little as possible, and never out-of-hours for non- clinical reasons

Should avoid moving older and frail patients unless it is clinically necessary

Should regularly audit the number of transfers that occur internally, the reasons they occur, and at what time of day

Should not move frail, older people out-of-hours for non-clinical reasons

Should aim to reduce the number of transfers occurring internally

Should prohibit the movement of frail, older people out-of-hours for non- clinical reasons

Patients should be looked after by people who are appropriately trained to care for them

Should ensure all staff receive training in the care of older people

Patients should know how to give feedback about their experience of services and should feel that it will be welcomed

Should invite feedback from patients and carers, and act on it

Should invite formal and informal feedback from patients and carers about continuity and the quality of care, and act on it



Appendix A Individuals interviewed for this studyConorBurke ChiefExecutive,RedbridgePrimaryCareTrust

JaneBuswell Consultantnurse

ProfessorCyrilChantler Chairman,UCLPartners

AmandaCheesley Long-TermConditionsNursingAdviser,RoyalCollegeofNursing

GillyCrosby Director,CentreforPolicyonAgeing

NatashaCurry Fellow,TheKing’sFund

LesleyDoherty ChiefExecutive,RoyalBoltonHospitalNHSFoundationTrust

RuthEley Independentconsultant,formerProgrammeHeadOlderPeople,DepartmentofHealth

DrSamEverington Generalpractitioner

DianaForster Carer

LizFradd Independentconsultant

TomGentry PolicyAdviser,HealthServices,AgeUK

NickGoodwin Seniorfellow,TheKing’sFund

PippaGough Independentconsultant

DrNoriGraham EmeritusConsultantinthePsychiatryofOldAge,RoyalFreeHospital

NickyHayes ConsultantNurseAdviseronOlderPeople,RoyalCollegeofNursing

RichardHumphries Seniorfellow,TheKing’sFund

ProfessorSteveIliffe ProfessorofPrimaryCareforOlderPeople

LouiseLakey SeniorPolicyOfficer,PolicyandPublicAffairs,Alzheimer’sSociety

ProfessorFinbarrMartin President,BritishGeriatricsSociety

DrJacquelineMorris DignityChampion,BritishGeriatricsSociety

KieranMullan HeadofEngagementandStrategy,thePatientsAssociation

ShilpaRoss Fellow,TheKing’sFund

ProfessorIqbalSingh ConsultantPhysicianinMedicinefortheElderly

KarinTancock ProfessionalAffairsOfficerforOlderPeople,CollegeofOccupationalTherapists

JeremyTaylor ChiefExecutive,NationalVoices

RachelThompson DementiaProjectManager,RoyalCollegeofNursing

SueWallace-Bonner OperationalDirector,HaltonBoroughCouncil



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The King’s Fund 11–13 Cavendish SquareLondon W1G OANTel 020 7307 2400

Registered charity: 1126980

www.kingsfund.org.uk

The King’s Fund is a charity that seeks to understand how the health system in England can be improved. Using that insight, we help to shape policy, transform services and bring about behaviour change. Our work includes research, analysis, leadership development and service improvement. We also offer a wide range of resources to help everyone working in health to share knowledge, learning and ideas.


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About the authorsJocelyn CornwelldirectsThePointofCareProgrammeatTheKing’sFundandwasapanelmemberonthePublicInquiryintoanOutbreakofC DifficileintheNorthernHealthandSocialTrust,NorthernIreland.Jocelynoriginallytrainedasamedicalsociologistandethnographer.ShehasworkedatseniorlevelsintheNHS,ingovernmentandinregulationattheAuditCommissionandtheCommissionforHealthImprovement.

Ros Levensonisanindependentresearcher,writerandpolicyconsultantworkingonarangeofhealthandsocialcareissues.ShehasworkedonseveralprojectsforTheKing’sFundandforawiderangeofstatutoryandvoluntaryorganisations.Shehaspublishedonmanyhealthandcaretopics.Inadditiontoaninterestinworkforceissues,Roshasaparticularinterestinoldage,mentalhealth,healthinequalitiesandpatientandpublicinvolvement.

Lara SonolaisaresearcherofhealthpolicyatTheKing’sFund.Sheiscurrentlyworkinginseveralareas,includingresearchinvestigatingtheimplementationofhealthandwellbeingboards,areviewofintermediatecareandaprojectexaminingsuccessfulmodelsofcareco-ordination.Priortothis,sheworkedintheFacultyofMedicineatImperialCollege,London,duringtheestablishmentoftheUK’sfirstacademichealthsciencecentre.LaraholdsadegreeinbiomedicalsciencefromKing’sCollege,London,andanMScinpublichealth(healthservicesresearch)fromtheLondonSchoolofHygieneandTropicalMedicine.

Emmi PoteliakhoffwasaresearchfellowatTheKing’sFundonsecondmentfromherroleasaneconomicadviserattheDepartmentofHealth,whereherworkencompassedpatientchoice,performancebenchmarkingandhealthcareforsociallyexcludedgroups.BeforejoiningtheDepartmentofHealthin2003,sheworkedattheHomertonHospitalinEastLondon,wheresheledaprojectinvestigatingcommunicationproblemswithlocalGPs.EmmireadeconomicsatCambridgeUniversityandcompletedthedualLondonSchoolofEconomicsandColumbiaUniversityMasterofPublicAdministrationprogrammein2007.