Following a report on care for older people in acute hospitals, Irene Oldfather reflects on its findings.
It is with some dismay that I read Healthcare Improvement Scotland’s Audit of Care of Older People in Acute hospitals published last week.
In three hospitals, inspection staff found a lack of meaningful stimulation and activity for patients and across all hospitals inspected, staff were not completing food and fluid balance charts accurately or consistently.
This inspection audit comes some five years after the Scottish Parliament Cross Party Group on Alzheimer’s, which I chaired, produced a report with recommendations on how we can improve the hospital experience of older people with Dementia.
The report recognised that with simple measures, we can save lives – minimising hospital moves, ensuring good hydration and nutrition, understanding the importance of exercise and stimulation.
We know that increased mortality rates, higher admission rates and functional decline are all associated with this vulnerable patient group who are particularly subject to adverse incidents in hospital.
The Report was launched in 2009 and was accepted in full by the Scottish Government. It should be operational in every Health Board in Scotland. So why do we still read of so many system failures?
Older and Wiser, Pressure for Change, Starved of Care, Remember I’m Still Me – previous Inspection Reports from the Care Inspectorate and the Mental Welfare Commission – all make for distressing reading. Regrettably despite a highly developed Policy Structure which includes the National Dementia Strategy, the Charter of Rights for People with dementia and their carers and the Dementia Standards, we still see Inspection Reports containing damning information about the care and treatment of our older people across all care settings.
The Dementia Carer Voices project, located within the Health and Social Care Alliance (the ALLIANCE), regularly receives reports of less than satisfactory care that falls far short of what would be expected in terms of the policy landscape.
Two things that can be concluded from this sorry story – clearly we are not talking about “one off” situations and we certainly don’t need another “strategy”. We have strategies coming out of our ears. As audit and monitoring is identifying, the central problem is that the gap between policy and implementation is wide. In fact not so much a gap, but a gulf.
Raising awareness, destigmatising dementia and creating a culture which values our old people is only a first step. Staff training is a huge issue and while Promoting Excellence, the skills framework to increase knowledge and understanding of dementia for health and social care workers, is beginning to kick in on the ground, as evidenced above, there is a way to go.
The role of caring for older people both paid and unpaid is undervalued in our society. We pay the lowest wages, with the worst conditions of service to those who look after our most vulnerable. We need to raise the profile and status of caring and pay wages and allowances commensurate to this. It is the right thing to do but in actual fact, the economic argument around keeping people well in their own home supported by carers who receive appropriate allowances, is incontrovertible.
As to institutional failures, it is time to get tough.
Frail older people are at risk but people with Alzheimer’s and Dementia are at particular risk because of their communication difficulties. This makes it difficult for them to articulate how they are being treated. We rightly accept the importance of protecting children in our society – indeed we have an independent Commissioner for Children and Young People to protect their rights and give them a voice. We have yet to place the same value on people with dementia and frail older people.
Wales has for some years had an Independent Older Person’s Commissioner, the present Commissioner is Sarah Rochira. She was a keynote speaker at the ALLIANCE’s annual conference this year and challenged us to ask the question – what constitutes abuse – lack of nutrition, hydration, inappropriate restraint, no outdoor activity, waiting for a bedpan – and why are there so few prosecutions for elder abuse?
If we are not completing nutrition and hydration charts, how do we know how well someone has eaten, across changes in staff shifts?
When staff tell patients that they’ll be there in five minutes with a bedpan – and five minutes becomes twenty minutes later, is this acceptable?
If we used inappropriate and disrespectful language towards ethnic minorities, we would rightly be branded racist. We have created a culture where such behaviour would not be tolerated and yet for older people this is identified as “an inspection area for improvement”. The recent case where someone with dementia had 106 care assistants through the door in less than a year is a classic example of system failure. Can we be certain that there is nowhere in Scotland where this happening today?
There needs to be what might feel like an uncomfortable discussion about sanctions and prosecutions. It is a language that many politicians and professionals don’t like. Interestingly it’s a language with which the Welsh Commissioner seems comfortable.
A clear message about the parameters of inappropriate and inadequate care and treatment of older people in Scotland is overdue. When does inadequate become criminal? How many prosecutions have taken place for elder abuse? We have no qualms about discussing these matters in relation to children so why are we so reticent to act on behalf of our older people?
There also has to be independent accountability in the system to ensure that change happens. Maybe its time to look to the Welsh Commissioner’s Office for a solution?