Thursday, 21 November 2013

The right intention, but the wrong idea?

Here at the British Geriatric Society Conference, much of the conversation so far has been based around the challenge of meeting the needs of residents in care homes.

At face value, it seems like a good idea: care homes are where the frail elderly often go to live. It makes sense, therefore, to organise care around these units, as they are good ways of selecting out the people most in need of comprehensive geriatric care.

But I have a number of concerns about this shift in organisation. Let me explain:

1) A great many frail and elderly patients live in care homes, but a great many do not. By organising care around care homes, the risk is that we create differential levels of care for those inside care homes compared to those outside them. Perversely, this may create a driver to admit patients to care homes, so that they receive the kind of long term care that they need. Our challenge, however, is to create a system that meets all need, not just those of an artificially selected care home population.

2) By organising services around care homes, we are doing very little to influence the use of care homes in the first place. As a strategy, it does not change the game enough: it is a response to a situation we find ourselves in, and not an attempt to modify that situation to something more acceptable, and more effective. By organising services around care homes, are we acknowledging that there is nothing we can do to support the frail elderly in their own homes? Could we not, with differently organised, and better managed services, respond to the needs of the frail elderly at home, and forestall or delay the need for them to enter care homes altogether.

3) A care home is simply where someone lives. It is perhaps a marker of their needs, but it also represents more: it could be a function of the choices that individual has made, the nature of their family and social support networks, and a whole range of other factors. A good system responds to the needs of individuals wherever they live, and adapts around that person. A system that organises around care homes is using the admission to the care home as its surrogate marker for frailty. This may well be fairly accurate, but it is not comprehensive, and it encapsulates a fatalistic view of our ability to influence the need for individuals to enter long term care.

The current use of care homes is currently unsustainable, and it is impersonal. Stories abound about patients admitted to hospital in a crisis, and then without ever having the chance to visit their own homes again, are admitted to long term care. Life sometimes falls off a cliff, but perhaps, with better and more intelligent organisation, we could slow down that falling trajectory.

My fear is that, as we enter a period of great change in how we look after our frail, elderly patients, we resort to type, and continue to organise care around physical units (acute hospitals, community hospitals, and care homes) and not around the individuals. The care we give, and how we give it should be influenced by the needs of the patients. The organisation of services should adapt to those needs. Historically, and currently, the care we offer our patients is significantly influenced not by their actual needs, but by the resources and set-ups available. We approximate the needs of the patients to the needs we can meet.

This is classic cart before the horse stuff, and I think we ought to put it right. Perhaps more importantly, I think we can put it right.

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