[A version of this item appears in: Dementia: the Latest Evidence Newsletter (RWHT), Volume 1 Issue 10, May 2011].
By Dr Daryl Leung Clinical Director
Care of the Elderly
New Cross Hospital.
A Personal View from the Sharp End
Disclaimer: The ideas argued with impeccable clarity in this article do not necessarily reflect the views of the Royal Wolverhampton Hospitals Trust (RWHT), the New Cross Hospital Dementia Project, Wolverhampton City Council, Wolverhampton City Primary Care Trust, West Midlands SHA or NHS West Midlands. This article has been written to provoke thought and discussion, and should be read in this positive light.
Acute sector care for patients with physical illness and dementia has been criticised as too often poor and lacking an empathic understanding by NHS staff. Specialist acute hospital wards of today run at a fast pace. Pathways and protocols force early discharge back into the community. This process is driven by the rising cost of such care and the chances of hospital acquired infections or other patient harm. Dementia patients in acute hospitals have a higher rate of mortality, increased morbidity and a higher chance of going into supervised twenty-four hour care.
Progress Since 2008
An influential West Midlands SHA report, written in 2008, identified a worrying lack of access to dementia services, lack of continuity between services and service providers, inconsistencies between funding sources during the disease journey and a lack of advanced care planning. Less than perfect coordination between NHS and social services remains an issue today.
“Dementia services straddle Mental Health Services and Older People services alongside Primary Care, Social Care, Acute Care, Care Homes, and the Independent, Charity and Voluntary sectors. Funding sources vary and there is no overarching co-ordination of services for dementia sufferers across their disease journey.” (Saad, 2008).
Real progress may indeed have been achieved in many areas since 2008, of which we should all be justifiably proud, but concerns do remain and there is scope for further improvement. Discharge decisions concerning home alone with a package of care, or residential or nursing home placements are relatively easy in principle but commonly hit barriers in practice. Saad’s 2008 diagnosis of there being an inadequate over-arching co-ordination of services for dementia sufferers across the patient pathway applies today, particularly in regard to hospital discharge.
Discharge In Practice
Continuing healthcare assessments, both for physical and mental health, coupled with seemingly lengthy delays in response can be frustrating at best. A home alone care package, involving two carers four times a day, may take weeks to arrange and agree financially. Intermediate brokerage agencies may be involved between Social Services and private home care providers. Progress may be complicated by occupational home visits, waits for special beds and hoists, installation of telecare devices etc. Improved coordination in the planning of these necessary components could usher in the delivery of a speedier, higher quality, safer, personalised and more effective service.
Discharge to private twenty four hour care is no less complex. Elderly Mental Health homes, with special registration to care for dementia and challenging behaviour, are in short supply. The good ones are, not surprisingly, full; making the “choice” of care facilities slim and delays to hospital discharge unfortunately common and protracted. The patient may be left waiting for weeks, sitting in a chair, blocking an NHS bed, deteriorating. An adverse event waiting to happen… The New Cross Hospital Dementia Project has achieved much in identifying and ameliorating some of the underlying risks within the acute setting, but it must be remembered that the hospital is only one link in the chain.
So called “Step Down” beds, purchased by the hospital to move “bed blockers” out of acute care are not necessarily helpful for patients with dementia. They are purchased by the hospital out of frustration with lengthy delayed discharge processes. They represent a financial saving to the hospital, because one week in a residential home costs the taxpayer little more than one day in an acute hospital bed.
Too Many Unintended Consequences
Once in these beds, however, arguments may ensue as to ownership of the patient. Following such moves, the general practitioner may effectively disown patients. The Acute sector says it’s not their problem, Social Services say they are under-resourced and lack the capacity to respond in a timely fashion.
Vulnerable adults may end up being bounced about in the system, causing confusion and unnecessary issues for people with dementia and their carers. Discharged from hospital they may be appointed to a new social worker who might not know them.
Dementia Pathway Coordination?
Where is the all-important psychogeriatric liaison? Where is the joined up care, the leadership, the Dementia Pathway Coordination? Our attitude as a society to frail and vulnerable older patients may be the problem. These problems could be fixed.
Building a Better Future…
We are proud to celebrate innovative developments in dementia care on the part of the New Cross Hospital, Wolverhampton City Council and Wolverhampton City Primary Care Trust (and of charitable and voluntary organisations such as the Alzheimer’s Society’s Wolverhampton Branch). These initiatives might be strengthened further by facing up to the need for a more cohesive, seamless and pro-active strategic approach to hospital discharge for dementia patients.
Kumari, S. (2010). Dementia Strategy Forward Plan. Wolverhampton: Wolverhampton City Council: April 13th 2010.
Mukadam, N. Sampson, EL. (2011). A systematic review of the prevalence, associations and outcomes of dementia in older general hospital inpatients. International Psychogeriatrics / IPA, 2011, Vol.23(3), pp.344-55. (Click here to view the PubMed abstract).
Royal College of Psychiatrists’ Centre for Quality Improvement, (2010). National audit of dementia: care in general hospitals. London: Healthcare Quality Improvement Partnership (HQIP), December 16th 2010.
Saad, K. Smith, P. [and] Rochfort, M. (2008). Caring for people with dementia: it’s really time to do something now! Birmingham: West Midlands Strategic Health Authority (Dementia Clinical Pathway Group), April 2008.
Sampson, EL. Blanchard, MR. [and] Jones, L. [et al] (2009). Dementia in the acute hospital: prospective cohort study of prevalence and mortality. The British journal of psychiatry : the journal of mental science, 2009, Vol.195(1), pp.61-6.
Suarez, P. and Farrington-Douglas, J. (2010). Acute awareness: improving hospital care for people with dementia. London: The NHS Confederation, 2010.
Tsaroucha, A. Benbow, SM. Merchant, R. Kingston, P. (2010). Workforce development for dementia: development of the role, associated competence development and proposed training required for the new “Dementia Pathway Coordinator” in the West Midlands to support those with Dementia and their intimate carer(s). Keele: Centre for Ageing and Mental Health (Staffordshire University), June 30th 2010.
Watkin, L. Blanchard, MR. [and] Tookman, A. [et al] (2011). Prospective cohort study of adverse events in older people admitted to the acute general hospital: risk factors and the impact of dementia. International Journal of Geriatric Psychiatry, February 28th 2011. (Click here to view the PubMed abstract).
Wiggins, H. (2011). Good practice compendium: an assets approach to “Living well with dementia: a National Dementia Strategy”. Leeds: Department of Health (Social Care, Local Government & Care Partnerships), January 10th 2011.