Since 1997 health-care professionals have been deluged with documents and initiatives aimed at improving the nation’s health. It is hard for busy professionals to keep up with these initiatives and harder still to work out how they will impact on day-to-day practice.
Linda Nazarko, BSc (Hons), MSc, RN, FRCN.
Director of Nursing, Nightingale House, and Visiting Senior Lecturer, South Bank University, London
This paper aims to enable readers to:
- Understand how the National Service Framework: Older people (NSF) (DoH, 2001a) fits into the health improvement agenda
- Understand the aims of the NSF
- Determine the implications for practice
- Be aware of the barriers nurses may face in delivering care for older people
- Understand the health improvement agenda.
When elected in 1997, the Labour Government began to determine how the NHS could move from a system that rose out of the aftermath of the Second World War to a 21st century service. It began with Modernising Social Services (DoH, 1998) and The NHS Plan (DoH, 2000a). The Care Standards Act, 2000 and the National Minimum Standards (DoH, 2001b) aimed to cover quality issues in the independent sector. Figure 1 illustrates the health improvement framework.
The NSF for older people is one of a series of NSFs (DoH, 2001a). It is arguably the most important of the NSFs because it covers the greatest number of people. It is certainly the most complex and challenging of the NSFs.
Older people and health
There are around 60 million people in the UK. It is the most densely populated country in Europe and has the world’s fourth largest economy. The UK, like other advanced industrial societies, has a falling birth rate and increasing numbers of older people. The ratio of taxpayers to pensioners is falling while the length of time during which people collect pensions is increasing. When old age pensions were introduced in the early 20th century few people survived long enough to collect them. Now people survive 25 to 30 years after retirement. The number of people surviving into extreme old age has grown dramatically but the number of NHS beds has fallen (Figure 2).
Ageing may be accompanied by declining health, a declining quality of life and increased demands on the health services (CSAG, 1998). Currently older people are the largest group of health-care consumers. The NHS spends £10 000 million on older people. Social services spend £5216 million annually.
The NHS spends 40% of its budget on people over the age of 65 and two-thirds of NHS beds are occupied by older people (DoH, 2000b). The oldest of the old consume the greatest amount of resources per head. Social services spend 48% of their budgets on older people. Yet despite all this spending there are real concerns about the quality of care older people receive (Help the Aged, 1999; Health Advisory Service, 2000). There are concerns that, despite expensive technology (such as hip replacements following falls), older people do not benefit from health and social-care interventions. The NSF aims to change this by ensuring that interventions are effective and evidence based and that older people remain in good health for longer. The aim is to reduce the period of disability and to increase the years of active healthy life.
The NSF has eight standards. These are illustrated in Box 1. The standards are evidence based and have been drawn up by experts from NHS hospitals, universities and social services. They aim to offer care that is seamless at the point of delivery regardless of where that care is delivered. Unfortunately, not a single representative of the independent sector was consulted despite the fact that the vast majority of care for older people is delivered in care homes and by independent sector home-care teams (Nazarko, 2002).
Standard 1. Rooting out discrimination
This standard makes clear that setting age limits for eligibility for services is unacceptable. Services are to be delivered on the basis of clinical need and likely benefit from those services. Under this standard it would be unacceptable to place an age limit on haemodialysis but it would be acceptable to choose the person most likely to benefit from it.
This is a challenging standard because ageism permeates every aspect of our society. Older people are forced to retire; even government committees have age limits. Age discrimination, unlike racial and sexual discrimination, is not illegal. All forms of discrimination are rooted in the belief that the people discriminated against are all the same and ‘different from us’. This mindset enables people to say: ‘Of course I’m not prejudiced but…’ Discrimination is based on ignorance and fear.
Education enables people to understand that differences do not make some people less valuable and less worthy of respect than others. The NSF recognises this and states that health- and social-care organisations should provide additional training for staff to enable them to develop a greater understanding of the needs of older people. This will foster more positive attitudes. The Government proposes appointing NHS non-executive directors who will support the implementation of the NSF. Health and social services are to appoint clinical or practice champions to lead professional development across the organisation.
There will be policy reviews to identify and tackle areas of age discrimination including, it is hoped, issues such as why residential care for older people is more poorly resourced that for younger people. Figure 3 illustrates fee rates for residential care for younger people and older people.
Implications for practice - Relevant policies and procedures that may discriminate on the basis of age will be identified, examined and rewritten by a newly set up scrutiny group.
Standard 2. Person-centred care
This standard aims to ensure that older people receive appropriate and timely care across sectors. It affirms the core values of professionals who have struggled to ensure that older people do not fall through the chasm between health and social care (Nazarko, 2001). This standard is about dignity and choice, recognising differences in culture and values and delivering care that is tailored to those values. This standard is about fundamentals such as treating people with dignity and respect and meeting fundamental needs in ways that enable the person to maintain dignity and self-respect.
This standard aims to encourage health and social services to work together and sets out proposals for integrated care trusts. This aims to integrate health and social care and to provide integrated services to deliver equipment and continence services.
Implications for practice - This is an exciting and challenging standard. Staff from health and social care work in different cultures with differing sets of core values and different levels of expertise. The creation of care trusts will remove many of the structural barriers that prevent the delivery of integrated care services - breaking down organisational barriers will take longer.
Standard 3. Intermediate care
This standard aims to prevent unnecessary hospitalisation, to ensure that hospital care delivers maximum benefits and that discharge delays are minimised. It aims to maximise a person’s ability to live independently.
Currently an estimated 20-25% of people admitted to care homes could be successfully rehabilitated if rehabilitation services were available (Millard, 1999; Nazarko, 1997). This standard aims to increase the number of intermediate care places by 5000 by 2004. It also aims to decrease the number of care home places required by 50 000 by 2004.
This standard aims to prevent unnecessary hospital admission. People admitted as emergencies occupy nearly 60% of NHS beds. Most of the people admitted as emergencies are older people. Around half of the people aged 75 or more were admitted for ‘symptoms, signs and ill-defined conditions’.
The research also found that 20% of older people occupying hospital beds could be discharged if alternative facilities were in place (DoH, 2000b). The NSF aims to reduce these unnecessary admissions by:
- Providing intensive support such as ‘hospital-at-home’ schemes within the person’s home.
- Providing step-up care in the community, very sheltered housing and care homes
- Providing specialist assessment and equipment. Comprehensive assessment and goal planning reduce the risks of an individual requiring hospital treatment or long-stay care (Sinclair and Dickinson, 1998) and physical and mental function can increase by 35% (Audit Commission, 2000).
This standard also aims to cut unnecessary or premature permanent admission to care homes by assessing a person’s rehabilitation potential before considering permanent admission to a care home.
Implications for practice - This standard will increase demands for district nursing. District nursing will be more intensive and providing such care will take longer. District nursing services will face increased demands for out-of-hours care. District nursing teams will need to develop higher levels of expertise in caring for older people and increase the flexibility of services.
Hospital-based staff will also find their workload more intensive because the least dependent and most stable older people will be cared for in the community. Care home staff may find that dependency rises further as only the most highly dependent of older people are admitted.
Standard 4. General hospital care
This standard aims to ensure that older people receive specialist care to enable them to recover fully from illness and accident.
This standard recognises that timely and appropriate care is crucial. It aims to ensure that waits in accident and emergency departments are minimised and that hydration is maintained. It aims to reduce the risk of pressure damage while the person is awaiting admission and aims to reduce admission waits to a maximum of four hours by 2004.
This standard recognises the important role specialists have to play in the care of older people and states that hospitals must form specialist teams comprising consultant geriatricians, physicians and nurses, physiotherapists, occupational and speech therapist, dietitians, social workers and physiotherapists.
It emphasises (as the other standards do) the importance of staff development. Hospitals are required to profile staff and audit their skills in caring for older people. When gaps in staff education have been identified the hospital must put in place education to address these.
Implications for practice - This standard is significant because it places gerontology and gerontological nursing at the heart of hospital care. It finally lays to rest the notion that no specialist skills are required to care for older people.
In education it will ensure that universities that are not yet organising specialist elderly care placements for students will do so. It will also increase the demand for post-registration education in gerontology. It will ensure that hospitals that have not yet appointed a consultant nurse in gerontology will do so. It will increase the numbers of gerontological nurse specialists.
Standard 5. Stroke
The first aim of this standard is to reduce the incidence of stroke by treating risk factors in primary care settings. The second is to ensure that when people have a stroke they benefit from integrated stroke services to maximise recovery. This standard states that all hospitals must have specialist stroke units by 2004. These will follow care pathways to ensure that the effects of stroke are minimised.
The standard recognises that stroke recovery can take years and will ensure that rehabilitation programmes are put in place to maximise recovery in hospital and in community settings.
Implications for practice - This standard will impact on primary care teams. GPs and practice nurses will have a greater role to play in identifying people at risk of stroke and of minimising risk factors through encouraging lifestyle modification and prescribing medication.
Hospital staff will be responsible for setting up specialist stroke units in hospitals that do not yet have these. Additional training will be required to enable staff to follow stroke pathways. Dependency within stroke units will be high and the interventions required to minimise damage will be labour intensive. Stroke units will require additional funding and staffing to enable them to deliver.
Standard 6. Falls
There are two elements to this standard. The first is to reduce the number of falls that result in serious injury. The second is to ensure that people who have sustained a serious injury receive effective treatment and rehabilitation (Box 2).
Implications for practice - This standard will impact on primary care teams who will have responsibility for reviewing medication and ensuring that older people are not exposed unnecessarily to the hazards of polypharmacy (American Geriatrics Society et al, 2001). It will also impact on hospital staff who will be responsible for setting up falls prevention clinics and using care pathways to provide evidence-based care. This standard links with the standard on intermediate care.
Community staff will be responsible for hospital-at-home schemes, which aim to rehabilitate and reduce risk factors to prevent further falls.
Standard 7. Mental health
There are two elements to this standard. The first is to promote good mental health in older people. The second is to treat and support older people with dementia and depression. This standard recognises that other mental health problems such as schizophrenia also occur and can be dealt with within the Mental Health NSF.
This standard provides evidence-based care pathways for the treatment of acute confusional states, depression and dementia.
Implications for practice - One of the problems nurses face in caring for people with dementia is that they work in buildings that are poorly designed and ill-suited to caring for this group of people. Local hospitals are to receive funding to enable them to convert Nightingale wards into specialist dementia units.
The standard emphasises the importance of specialist teams to support general nurses and staff working in care homes.
Standard 8. Health promotion and active life
This standard aims to prevent or delay the onset of ill health and disability by encouraging people to live a healthy, active life. It aims to identify any barriers to healthy living and to place healthy living within a cultural context for the older person. It aims to reduce the impact of illness and disability on health and well-being. This standard aims to encourage older people to remain physically active, to eat a healthy diet and to have immunisations.
This final NSF standard breaks new ground because it promotes well-being rather than adopting the traditional approach of treating sickness.
Implications for practice - This requires a change of attitude. People must be encouraged to look after their health. Nurses must develop partnerships with older people in order to challenge assumptions that older always means frail and dependent.
This NSF is exciting because it places older people and their well-being at the heart of health and social services. In the future it may also explicitly include the views of the independent and voluntary sector. It aims to improve staff knowledge of gerontology and to enable staff to nurse well. It is a courageous step along a road to truly valuing older people and those who care for them. If it is to succeed further social changes such as outlawing age discrimination, providing decent pensions and introducing measures to protect the cognitively impaired will also be required.
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