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Quality Health Care conference report
Quality Care for Older People

This report by Denise Nicholls and Josephine Negro on the Conference organised jointly by Southwark Pensioners Action Group and King's College Hospital on 17 February 2004 was published in SPAG's March 2004 Newsletter.

The SPAG/King's Health Conference was an exciting initiative. We have to thank Rhona Burchill who carried out most of the early planning and who developed very productive relationships with Dr Jacqueline Close, consultant geriatrician at King's College Hospital, and her team. Tragically, Rhona died before the conference took place, and the day was dedicated to her memory. The conference was chaired most effectively by Tony Farsky, Chair of SPAG, with support from Dr Close who was present throughout the day.

The conference was introduced by Malcolm Lowe-Lauri, King’s NHS Trust's Chief Executive. He told us that this was a time of transition for King's, from an exclusive concern with treatment to an approach where listening to patients and learning from their experience was equally valued. This approach meant that life-style factors such as diet and exercise were considered alongside drugs and surgery.

‘Expert patients’

Miranda Jenkins, a Facilitator of Health and Ageing in the Pursuing Perfection Unit spoke about some current health problems. As an example of the part that patients can play in their own care, she focussed on chronic obstructive pulmonary disease (COPD), which needs managing rather than treating. There is a ‘Breathe Easy Group’ of ‘expert patients’ which stresses care at home, exercise, and the need for early diagnosis. Members of the group have advised on times for clinics and on access by public transport - a problem for many older people. They have also developed a personal ‘credit card’, which the patient keeps and on which their notes are recorded, making it easier for staff to access information quickly.

We were told that 81% of patients on the COPD programme showed some improvement. About 88% of patients continued with the regime after the programme concluded. Although the number of places on the scheme has doubled in the past year, it is apparent that still more places are needed.

Joint replacements

The other focus of this section of the day was joint replacement. Here too there is a patient group involved in the planning of after care. The need for good follow-up was emphasised, with physiotherapy before and after surgery. Patients were encouraged to do regular exercises and were introduced to the programme before surgery so they could get used to the changes needed in their normal routine. For example, getting downstairs on your bottom can be difficult and it is best to practise before the operation! An exercise video is being developed.

In terms of general health in age, Ms Jenkins emphasised the importance of physical activity, of diet, of avoiding risk factors such as smoking or too much alcohol. It was also important to seek attention at an early stage if problems occurred.

Questions showed participants' worries about early discharge, the level of support needed in the home, and access to transport for the patients' carers as well as for patients themselves.

Planning for discharge

Next, Susan Wood, a Matron specialising in health care for the elderly, spoke of the need for ‘total care’ of hospital in-patients, beginning with planning and discussion on admission and continuing until the planned discharge. Professionals need to bear in mind at all times that the patient is in hospital because s/he is unwell and may not be happy taking part in detailed discussion . The plan does not always work exactly as envisaged but, when this is the case, the whole team will consider how to learn from any failings revealed.

Questions from the floor to Ms Wood showed concern with
• the number of agency nurses employed;
• the follow up of complaints;
• the level and quality of advice to patients' carers;
• problems experienced by frail patients in getting nurses to help with feeding.

We heard that King's tried to maintain an adequate 'bank' of reserve nurses trained by the Trust. Worries about advice to carers were one reason for the introduction of the ‘new style’ Matron.

But most concern was about arrangements for patient discharge, especially in view of the new rules for fining Social Services Departments in cases of delayed discharge. There was a lively discussion and we were assured by Dr. Close that in fact no cash transfer will occur when discharge has to be delayed. Any money nominally available under the rules will be allocated according to joint agreement between Social Services and the Hospital Trust, perhaps in the creation of new posts or facilities. She emphasised the importance of recognising that Social Services are an integral part of the care team and attend the regular weekly ward meetings.

Appropriate care for older patients

Nicky Hayes, Nurse Consultant for Older People on the training of staff, concluded the morning session. She, too, emphasised the need for nurses to work as a team with the range of specialists and therapists caring for older people in hospital. She pointed out that when two people, one young and one elderly, contracted the same illness, the effects could be very different, and emphasised the need to understand what is involved in the ageing process, so that the right sort of care can be given. Skills needed to work with older people need to be developed.

She went on to speak briefly about what constitutes appropriate care: for example, in the case of an elderly patient who had had a fall, it might include investigating problems of dizziness, recognising that falling is not normal. For some people the right sort of care would be to enable a peaceful and comfortable death.

Ms Hayes contribution was curtailed by the lunch break, but she took the names of volunteers who were prepared to help her take her work forward.

Male osteoporosis

The first half of the afternoon was devoted to men’s health problems. Dr Ann Blackburn, a consultant at King's, gave a very interesting talk about osteo-porosis, a condition where the bone is thinner than normal and therefore more fragile and likely to fracture. Bone density declines with age, particularly for women at the time of the menopause. Osteo-porosis, therefore, is most commonly a female problem, but a sizeable proportion of sufferers are men.

Dr. Blackburn told us that the most common fractures are to hip or wrist (compact bones) or the spine (spongy bone). Diagnosis of osteoporosis is made through a bone scan. Treatment - calcium supplements backed up with drugs - is a major cost for the NHS. Risk factors, apart from age and sex, include race (some ethnic groups are more prone to osteoporosis then others), a history of fractures, immobility through lack of exercise, smoking, overweight and use of steroids.

Ways to avoid osteoporosis are:
• a good diet with plenty of fruit and vegetables;
• physical activity;
• no smoking;
• little alcohol;
• avoidance of steroids where possible.

Prostate cancer

The other specifically male health problem looked at by the Conference was prostate cancer. King's urologist Dr. Srinath Chandrasekera explained some of the problems with men's genito-urinary system: in particular, prostate enlargement, cancers and erectile problems. Symptoms that should lead to seeking medical advice are blood in the urine, problems with erections, poor stream of urine, frequency of need to urinate, and sudden urgent need to do so. Prostate enlargement is not necessarily cancerous but should be checked, since any undiscovered or untreated cancer could spread to other organs. Treatment needs to start with a visit to the G.P. who can make a referral to a specialist if necessary. It can include male hormones or a drug to relax the muscles of the bladder.

Prostate cancer is the most common cancer in men over 60, with 20,000 new cases a year. A healthy diet (cranberry juice is thought to be helpful) and exercise are important in avoiding the development of this condition. There is currently doubt about the value of routine screening, as treatment for prostate cancer is often unnecessary. New treatments are being introduced and King's has a range of specialist services including a rapid access clinic.

The day concluded with a discussion session led by Dr Close. She told us about the Pursuing Perfection Unit at King’s. She and her colleagues are keen to learn from patients and to make any possible improvements to the service. She was asked about the over-75 health-check and said that G.P.s are obliged to offer annual screening to older patients, but that the form of this is not standardised.

Plans are in place to develop our very positive relationship with King’s, in the interests of ensuring that older people receive the best possible care.