Although older people are the key user group of hospitals in the developed world, the institutions often seem to work to a model of younger adults presenting with single illnesses.
They still do not adequately factor in the increased complexity and frailty of this core group of service users.
If overall care standards in hospitals drop against this background, the vulnerability of older people renders them more likely to suffer and die – the hospital equivalent of the canaries in the coal mine.
And so it proved in a major care scandal in Stafford Hospital in Britain, where an inquiry published in February of this year indicated that many hundreds of older people died unnecessarily as a result of a truly shocking decline in general care standards.
The lead author of the report, Robert Francis QC, gave a chilling overview of the findings last week at a British Geriatrics Society conference in Belfast. While the lessons are applicable to virtually every country in the developed world, this is particularly true for the Irish hospital system, where recruitment embargoes and non-replacement of staff are placing huge pressures on services, and where the development of hospital trusts is a project in the wings.
Despite its size – almost 1,700 pages – the report should be required reading for managers and care professionals in the Irish health system, including the Department of Health and its special delivery unit.
At the heart of the problem in Stafford was a management style that prioritised meeting government targets and reducing financial costs while neglecting the impact on care and outcomes, as characterised by the memorable phrase: hitting the targets but missing the point.
Allied to this was a culture of inattentiveness to professional concerns and intimidation of those who spoke up. A component of this relentless cutting back on staff and expertise arose from a drive to become a self-governing hospital trust.
The problem was amplified by a failure of the regulatory agencies to detect the problems and intervene. Equally troubling was the erosion of professional responsibility for patient care, highlighted in the report as among nurses in particular, but also within the medical profession, in the face of shockingly poor care.
While all understand that health services need to provide value for money, it is clear from the Stafford scandal that those involved in finance and management need to provide a level playing field for the clinicians and to plan appropriately for dealing with risks and care standards arising from changes in staffing and reduction in funding.
My own experience suggests that we could learn from this, as much of the retrenchment in the Irish health services relies on a haphazard system of not filling gaps due to retirement and maternity leave, without clear planning as to how to adapt to the risks entailed.
“Sort it out”, “organise yourselves” and “make do and mend” are just not good enough in complex care settings, and are uncomfortably reminiscent of what happened in Stafford.
'Get on with it'
A looming example is the implementation of the European working time directive due this June, a welcome change in terms of improving conditions for trainee doctors, but one which in the UK was preceded by a 40 per cent increase in staffing. No such increase has happened here, and stretched health services are being told to "get on with it" or suffer huge daily fines. Something will have to give.
More specifically, many geriatric medicine services are suffering significantly. In one Dublin day hospital, staffing in occupational therapy has dropped by 100 per cent (to zero), physiotherapy by 66 per cent and social work by 80 per cent, gravely affecting the ability to provide a service that is key to modern hospital care.
Apart from a clarion call for better management of care and change, an impressive feature of the Stafford Hospital report was its identification of the need for a universal increase in skills for nursing older people – gerontological nursing.
n entire chapter of the report was dedicated to this, a very striking vision which gains all the more impact given that the author is a lawyer. Our own Bord Altranais might be prompted to reflect on the prominence it gives to what should be a core skill for all nurses working with adults in our health services.
Prof Des O’Neill is a consultant in geriatric and stroke medicine