1
Introduction
Public Health Wales
is an NHS Trust providing professionally independent public health
advice and services to protect and improve the health and wellbeing
of the population of Wales. We welcome the opportunity to
contribute to this inquiry into an important aspect of care for
some older people.
2
Process by which older people enter residential care
2.1
Prevention and early intervention
Social services are
an integral component of services that promote public health and
wellbeing. Public Health Wales would strongly encourage the
rebalancing of services towards prevention and earlier
intervention, with health and social care services being more
proactive, evidence based and focused on recovery, re-ablement and
social inclusion, in line with current policy direction[i]
[ii].
2.2
Empowerment and maintaining independence
For many older
people, the decision to enter a care home can come quickly because
of a crisis, not always with adequate information or choice about
alternatives. Other people are in control and older people can feel
disempowered and voiceless in a care home environment. For a
substantial proportion of current residents, a care home is not
their preferred choice although for a minority, this move can be a
positive one[iii].
2.3
Access and equity
Access to the right
choice of care should be sensitive to the needs of all older
people, including those in more isolated rural areas and those
groups defined in the Equality Act 2010.
This should be driven
by a commitment to deliver a high quality service in a framework of
equity, rather than be driven simply by the necessities of the
current economic difficulties. Public Health Wales recognises
that the issue of paying for care is complex, but is concerned that
the issues are being considered in isolation of issues of wider
economic policy.
In addition the local
approach taken to providing housing for older people is a key
component of supporting older people to maintain independence and
enjoy a healthy life – residential care should be the last
option considered. A strategic approach to provision of a range of
housing support for older people should be considered by local
housing partnerships (local government, housing providers, third
sector) to meet the specific needs of the population of older
people including physical adaptations, floating support and
supported housing.
Key messages:
1.
Public Health Wales recommends that there are explicit
mechanisms for empowering older people to make choices and that
there are services available to meet diverse needs
flexibly.
2.
Public Health Wales is aware that the complexity and number of
forms that need to be completed in order to access help should to
be reviewed radically.
3.
Local housing partnerships should take a strategic approach to
the provision of a range of housing options for older
people.
3
Capacity of residential care sector
3.1
Changes in population and needs
The proportion of older people in the
Welsh population has been steadily rising over the past 25 years
and, with a decreasing birth rate, is likely to continue rising in
the future. The number of people aged 16-64 is projected to remain
relatively constant, increasing by only 1 per cent (20,000) between
2010 and 2035 while the number of people aged 65 and over is
projected to increase by around 306,000 or 55 per cent in the same
period.
There will, therefore, be more people
over 65 for every adult of working age in the future. In
2010, there were around 294 people aged 65 and over per 1,000
people of working age (16-64). This is expected to increase to
around 450 per 1,000 people of working age by 2035.[iv]
These demographic changes will
significantly alter the overall balance of the population, and are
likely to have most impact in certain communities such as remote
parts of the Valleys.
Increasing age is generally associated
with increasing disability and loss of independence, and with
functional impairments such as loss of mobility, sight and
hearing. Changes in health have often precipitated
people’s entry into a care home, and future projections
assume that this pattern will continue in Wales (see figure 1)
Figure
1
Source: Daffodil [v]
These projections are quite difficult to interpret as they may vary
depending on changing future health needs; changing models of
service provision; more effective early interventions and
prevention.
Public Health Wales challenges the common assumption that an ageing
population will necessarily lead to higher levels of dependency and
long-term care, as the proportion of life expectancy spent in good
health is increasing.
However, the increasing prevalence of chronic conditions, such as
those associated with obesity, alcohol and lack of physical
activity, may affect life expectancy and healthy life expectancy in
future. The burden of this will fall disproportionately on the
poor, as gaps in life expectancy and healthy life expectancy fail
to narrow.
Key messages:
1.
The proportion of the population over
the age of 65 and the proportion of very elderly over the age of 85
will increase significantly.
2.
Old age does not necessarily lead to
high levels of dependency and services should ensure longer periods
of independent living and innovative models of providing supported
accommodation to maintain this.
3.2
Integration with health services
Now that Wales has
new integrated healthcare bodies Public Health Wales believes that
consideration should be given to the case for integrating the
provision of health and social care. Health and social care
priorities on key strategic areas need be in tandem to avoid the
development of perverse incentives. These can leave the service
users in complex and unhelpful positions.
3.2.1
Primary care
The General Practitioner
Committee guidance for general practitioners (GP) on Treating
patients in private hospitals nursing and residential homes
states that :
“All UK residents
have a right to be registered for primary medical services with an
NHS practice… (GPs) would be expected to attend residential
and nursing homes as appropriate.”
Public Health Wales
Primary Care Quality and Information Service[vi]
provides support to GPs who have also taken on a contract to
provide enhanced services through the GMS contract in Wales
2008-09 enhanced service for care homes specification[vii]
In line with the National
Service Framework for Older People this service aims to:
•
Provide patients with 6 monthly medication reviews thus ensuring
that prescribing is appropriate for the patient minimising risk to
the patient
•
Build effective communication links between primary health care
teams and nursing and residential care staff
•
Ensure, where appropriate, that patients have the opportunity to
record their end of life care plans and to ensure such plans are
available when required
•
Reduce inappropriate admissions
•
Improve this vulnerable group’s overall health by providing a
more holistic service
Key
messages:
1.
The Welsh Government should ensure that every care home has
access to a local GP practice that provides the Enhanced Service
for Care Homes
4
Quality of services
4.1
Health promotion
Of the ten priority outcomes in Our healthy
future, the Public Health Strategy for Wales, the most
important for older people in care homes are:
·
Reducing inequities in health
·
Reducing the level of smoking
·
Increasing physical activity
·
Reducing unhealthy eating
·
Improving people’s mental well-being
·
Reducing the number of accidents and injuries
With regard to nutrition, older people in
residential care have the right to enjoy healthy and nutritious
meals. A recent trading standards survey of nutrition provision in
residential care homes and supported living accommodation in Wales
found issues around low calorie content of meals, high levels of
fat including saturated fat and high levels of salt[viii]. Whilst this
survey only provided a one-day snapshot of provision, it
nevertheless indicates that there is a problem around the provision
of healthy nutrition in these settings. The WAG nutrition in
community settings pathway and dietetic pilot project on tackling
malnutrition in residential and other settings contributes to
several of the trading standards report recommendations. However
the recommendation of the need for a minimum nutrition standard for
the food in care / residential / supported living homes warrants
consideration by the committee.
4.2
Falls
Between 30% and 60%
of people over 60 will fall every year. Falls are estimated to
increase by 50% by 2020 if we do not put preventive measures in
place. After a fall, an older person has a 50 per cent probability
of having seriously impaired mobility and a 10 per cent probability
of dying within a year. Hip fracture is the most common serious
injury related to falls in older people, with 70,000 per year in
people aged over 65, of whom less than 50% return to their usual
place of residence, accounting for many admissions to care homes.
Falls account for over 4 million bed days per year, with a cost to
health & social services in Wales of £84 million per
annum.
There is evidence
that people in care homes have an even higher rate of falls: a
study in Cardiff found that, compared with the community dwelling
population, care home residents had an overall fracture risk of 2.9
times (95% CI 2.5-3.3) and a hip fracture risk of 3.3 times (95% CI
2.6-4.2). This was weighted for age[ix].
Much harm from falls
is preventable. One of the simplest and most effective methods of
falls prevention is exercise to improve strength and balance. By
carrying out annual risk assessments in primary care, fall risk
factors can be identified and modified before an injury occurs.
This means that the burden of emergency care on the NHS is
reduced.
4.3
Medicines management
Medication
administration errors in care homes are common despite regulations
and national minimum standards introduced to protect
residents’ safety. A study[x]
conducted in 55 UK care homes found that in just two drug rounds
more than one in five (22%) residents had been exposed to an
administration error.
Research
studies[xi]
have identified a range of administration errors including, dose
omission, overdose, wrong administration technique (for example
crushing slow-release formulated tablets thus interfering with the
slow-release properties), wrong patient, wrong drug and wrong
strength.
Medication reviews
for patients in care homes result in an overall reduction in
prescribing, less medicines waste and fewer falls[xii].
Following the introduction of mandatory pharmacist medication
review for patients in care homes in the United States, prescribing
of inappropriate medication decreased[xiii]
The Care and Social Services Inspectorate Wales (CSIW) have
identified medication management as an area needing attention. In
2007-08 almost a third of inspected care homes failed to meet
required standards for medicines management. Prior to 2002 when
CSIW was established, every Health Authority employed a pharmacist
whose remit was to make announced and unannounced visits to inspect
the home on medicines management issues and to provide advice any
necessary improvements. Initially CSIW employed pharmacist
inspectors to provide specialist input on medicines issues however
this is no longer the case.
4.4
End of life care
About 20% of the
population of the UK die in care homes, and most of these are the
frail elderly, many of them with dementia. It is this group of
people that are more likely to be inappropriately admitted to
hospital, at considerable cost to the NHS and not always in
accordance with their own preferences. The UK Gold standards for
end of life care[xiv]
provide specific guidance and support for care homes[xv].
4.5
Dementia
People with dementia
should be supported in the community so far as possible.
Where care for
patients with dementia has to be provided in a residential setting,
health and social care managers should ensure that the design meets
the needs of people with dementia and complies with the Disability
Discrimination Acts 1995 and 2005.
Nice clinical
guideline 42 should be followed. Specifically, consideration should
be given to the size of units, mix of residents and skills of staff
to ensure a therapeutic and supportive environment.
Built environments
should be enabling and aid orientation, with attention to lighting,
colour schemes, floor coverings, assistive technology, signage,
garden design, access to and safety of the external
environment.
Medication must be
used appropriately, for example antipsychotic medication should not
be used for mild to moderate non-cognitive symptoms in
Alzheimer’s Disease, vascular dementias, or mixed dementias
because of increased risk of cerebro-vascular adverse events and
death. Even with severe symptoms, antipsychotic medication
should only be given in line with the guidance.
Key
messages:
1. The
workforce in residential homes should have adequate protected time
out to access good quality training to deliver high quality
care.
2. Care
homes should be able to provide good and enjoyable nutrition
– the committee is asked to consider the need for a minimum
nutrition standard for the food in care / residential / supported
living homes.
3. Care
homes should provide an environment that promotes mental wellbeing
and physical activity.
4. Attention
must be paid to creating an appropriate and supportive physical
environment.
5. Care
homes should be monitored for the rate of falls among their
residents and all should have a program of falls prevention that
includes exercises for residents to improve strength and
balance.
6. There
should be access to specialist pharmacist advice in care
homes
7. Medicines
management should be included in inspection of care homes.
8. Care
homes should be supported to provide the best end of life care in
partnership with the resident’s GP, and these standards
should be included in monitoring of care home quality.
9.
Medication for challenging behaviour should be used with caution
and in line with NICE guidelines.
10.
In addition to specific dementia care, all residential homes
should provide for optimum mental well being, enabling people to
connect with others, enjoy appropriate activities and be as
physically active as they are able.
4.6
Value for money
Any transformation of
social services should provide increased leverage for an
improvement in value for money and quality in residential and
nursing homes[xvi].
5
Regulation and inspection
The committee should note that there are
multiple bodies for regulating and commissioning residential care
therefore no one agency has overall responsibility for quality of
all care in the setting. This means that some issues that fall
between several agencies may not have an overall regulatory
lead.
Key messages:
1.
Public Health Wales recommends that
the committee review the different regulatory components covering
residential homes to ensure overall oversight of delivery of all
care.
2.
These should take into account the
views of users and carers, and embed this in any inspection
regime.
3.
Indicators of quality should include
those related to health outcomes such as nutrition, physical
activity, mental well being, end of life care and access to primary
health care services.
6
New and emerging models of care provision
Public Health Wales recognises that a care home can be a valuable
resource for older people with support needs. There is a continuum
of care from support in people’s own homes to supported
accommodation through intermediate care (step up or step down),
respite care to hospital care. These arrangements should become
more flexible and responsive to the diverse needs of older people
and their choice should be facilitated and reviewed as time passes
and their needs change.
More needs to be done
through adopting innovative preventative and early therapeutic
approaches towards the development of frailty, in order to ensure
longer duration of independent living. Mental and physical health
is positively influenced by social networks, access to green spaces
and sense of control – new models of care will have improved
health outcomes if they support rather than disrupt what keeps
people healthy.
Public Health Wales
believes there is a need to strengthen joint working not only with
the NHS and other partners, but also through national and local
policies and guidance ensuring priorities across services are
consistent.
The integration of
social care and health services for the frail elderly (e.g.
district nursing and home care) is but one of a number of areas
that would benefit from new models of joint working based around
emerging evidence.
Key messages:
- To ensure that
integrated health and social care is achieved Public Health Wales
believes that emerging evidence based methods of joint working
should not necessarily be optional, but form part of the statutory
guidance to local authorities.
- Public Health
Wales believes that models of care for the elderly based on the
concept of social enterprise, e.g. community co-operatives, are
worthy of further exploration.
7
The balance of public and independent sector provision
Public Health Wales
believes there is a central role for the state in the funding of
care for elderly. Solutions that do not recognise this are likely
to have an adverse effect on population health and increase health
inequalities, and inequity, in Wales.
From a public health
perspective it would not be desirable for individuals to migrate
from Wales to England (or vice versa), if differences in the
charging system made this an attractive option from a purely
financial perspective. With regard to charging policies,
inconsistency across Wales has led to inequalities in the past. Any
charging policy should be established on an all Wales basis and be
underpinned with equity of access and quality standards for the
provision of care.
With regard to the
issue of integration of social security benefits into the social
care funding system, there will be a need to simplify the existing
system in line with UK Government policy.
Key messages:
1.
Public Health Wales recommends that there is equivalence of
charging systems across England and Wales.
2.
Public Health Wales recommends that any solutions are carefully
planned to avoid exacerbating or causing inequities.
7.1
References
