Care of older people in hospital: Draft standards

Below is the letter I have sent to Healthcare Improvement Scotland on the recently published Draft Standards for Care of Older People in Hospital. You can submit comments to James Smith, Project Officer hcis.OP-AC@nhs.net The closing date for comments is  Wednesday 17 December 2014.

Dear James,
Thank you for inviting us all to “help to shape” the final Standards for Care of Older People in Hospital which were released in draft this November. It is also welcome to note that “at the end of the consultation period, all comments will be collated and the project group will respond to each comment received on the draft standards.”

I am writing to you in letter form as this is my preferred way of offering my thoughts on the draft standards. I hope that my letter can be published in full in terms of the consultation that Healthcare Improvement Scotland have set out.

I am aware that the new standards will form an “integral part of inspection programmes into the care of older people in acute hospitals.” I think here we should note that the previous standards were in place for 12 years without revision and so we should consider that these new draft standards might be in place for a similar period of time.

I would also suggest that the draft Standards need to be considered in the context of all the “progress reports” issued since February 2012.[1]

In general, the Standards are clearly written, free of jargon terms and largely well-referenced. These standards will help support further progress in improving hospital care for older adults in Scotland.

However, included in the 2002 Care Standards were definitions of all terms used. I note that no definitions, other than defining what is meant by a “standard”, have been included in the new draft Standards. This is a matter of concern to me.

It is my view that the new standards need to define what is meant by terms such as “detection”, “routine”, “validation”, “tool”, “cognitive impairment”, “capacity”, “consent”.

The following are areas where I think specific criteria can be improved upon:

It is welcome that the new draft standards now include Standard 5: Skills mix and staffing levels: [that]“older people are cared for by knowledgeable and skilled staff, with care provided at a safe staffing level.” Specifically, Criterion 5.5 states “There are clear processes in place for staff to escalate any concerns about staffing levels with associated plans to mitigate safety risk. There are robust processes for the monitoring of staffing levels.” The term “processes” is not defined. As an NHS Consultant I recently expressed my concerns about staffing levels. Unfortunately I found that my concerns were not being listened to by my employers. After following all “processes” available to me, I felt that I had no other option but to resign. I would urge the Project Group to be much more specific in their recommendations here.

I also have specific concerns regarding cognitive screening. The three extant Progress Reports for older people in acute hospitals contain terms such as: “screening”, “tools”, “toolkits”, “dashboards”, “pathways”, “protocols”, “tracers”, and “targets”. It is notable that these terms generally do not appear in the draft Standards. Given that these terms are used to measure and monitor progress by Healthcare Improvement Scotland, and that all NHS Boards are expected to follow the recommendations based on Inspections, it is concerning that the draft standards make almost no mention of them. I had expected to find clear guidance on screening in the new draft standards.  In fact the draft Standards, in contrast to the current 2002 Standards, do not use the term “screening” at all.  In terms of patient safety it would appear that “screening” has been re-branded as “detection”. The draft standards would thereby appear to side-step the ten criteria set out by Wilson & Jungner for the World Health Organisation[2].

The latest Progress Report states this:
“We are working together with healthcare teams from across acute hospitals in Scotland to test and introduce new tools with the aim of improving screening for frailty and improving early management of delirium”. The Report continues “National guidance states that every patient aged 65 years and over is assessed for cognitive impairment when admitted to hospital”. The Inspectors concluded: “In 12 inspections, we found that screening for cognitive impairment was not routinely carried out or recorded for patients when admitted to hospital.”

It is abundantly clear from all Healthcare Improvement documentation that current improvement methodology in Scotland’s acute hospitals is based on screening where “all patients over the age of 65” are to be assessed by a “screening tool”. The unintended consequences of such approaches may include any of the following: mis-diagnosis, heightened stigma, heightened fear of hospital, mistaken removal of autonomy, and increased prescribing of medications like Haloperidol[3],[4]. In terms of “pathways” the risk is that such harm may begin with a “screening tool”[5].  It is notable that the NICE guideline on delirium[6] does not endorse screening. It would also be helpful if the standards could confirm the view of the UK National Screening Committee.

There are also two specific areas where the use of references should be re-considered:

(1) There is a mistake in the draft Standards where it is referenced “Alzheimer Scotland. Assessing cognition in older people: a practical toolkit for health professionals. 2013”. This is actually not a publication by Alzheimer Scotland. This “Toolkit” by the Alzheimer Society recommends assessment “when cognitive impairment is suspected” (not screening). In Acute Care they recommend use of any of the three following tests: Abbreviated mental test score (AMTS), 6-Item cognitive impairment test (6CIT), General practitioner assessment of cognition (GPCOG). In terms of the draft care Standards it is necessary to define what “tools” or “tests” are being recommended, as well as the evidence behind their use.

(2) Scottish Intercollegiate Guideline Network (SIGN) Guideline 86 – Management of Patients with Dementia. This guideline is now 6 years beyond the review date set by SIGN and as a national guideline it has compared very poorly when compared to 12 other national guidelines. SIGN 86 was particularly criticised for narrowness of approach and lack of ethical considerations[7]. As such better documents on which to base the standards need to be sought.

This brings us to Draft Standard 2 – Consent and decision-making; “Older people are involved in every decision about their care and treatment.” It is my certain view that Consent Standard (Standard 2) needs developing and more meaningful inclusion in each of the 16 proposed standards. My fundamental concern is that the approach subsequently described in the criteria as currently worded appears to ignore consent. An up-to-date and comprehensive systematic review of this important area is presented in this paper: The full spectrum of ethical issues in dementia care: systematic qualitative review [8].

We must be wary of treating broad concepts such as delirium or “cognitive impairment” as identical to specific diseases (which they are not). We must remember that cognition has a parabolic distribution through life and age related cognitive changes are actually more common than dementia or delirium. This is particularly true of the age group most commonly admitted to acute care in NHS Hospitals today. This does not mean that delirium or dementia should be considered any less lightly.

I wish to conclude with this consideration: the exercise of compiling standards must be immensely difficult. The range of issues is very broad and the standards have to apply fairly to all of Scotland’s elders. For this reason, I would argue that a development group would be best served by a wider distribution of inputs: including a GP, a public health representative, an ethicist, and an older person! I would argue that at the “drawing up stage” of standards that it is important to have direct involvement of those with experience. In my view it is not sufficient for an organisation to collect views and then to chose which views are most important.

I am very grateful to have had the opportunity to offer my considerations on the Draft Standards. I hope my comments are received as well-intended comments from a dedicated NHS clinician. Thank you again for inviting responses. I hope that you will receive helpful feedback from all quarters.

Yours sincerely,
Dr Peter J Gordon

[1] Care for older people in acute hospital (Progress Report, May 2013 – July 2014) Healthcare Improvement Scotland http://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/opah_overview_reports/opah_overview_report.aspx

[2] J. M. G. Wilson, G. Jungner Principles and practice of screening for disease. World Health Organisation http://whqlibdoc.who.int/php/who_php_34.pdf

[3] Gordon, P.J. Delirium Screening https://holeousia.wordpress.com/2014/03/26/delirium-screening/ 26 March 2014

[4] Prescribing & Medicines: Medicines for Mental Health, Financial Years 2002/03 to 2011/12. A National Statistics Publication for Scotland http://www.isdscotland.org/Health-Topics/Prescribing-and-Medicines/Publications/2012-09-25/2012-09-25-PrescribingMentalHealth-report.pdf#

[5] King, G. Speak Up! The Mini Mental State Examination a tool or a weapon? Mental Health Lecturer, University of Dundee. Mental Health Nursing. Oct/Nov2013, Vol. 33 Issue 5, p14

[6] National Institute for Health and Care Excellence. Delirium: diagnosis, prevention and management. 2010 [Cited 2014 November 7]; Available from: https://www.nice.org.uk/guidance/cg103/resources/guidance-delirium-pdf

[7] Gordon, P. J.  Dementia Guidelines: research and clinical criteria are not simply “interchangeable” http://www.bmj.com/content/347/bmj.f7282/rr/676567

[8] The full spectrum of ethical issues in dementia care: systematic qualitative review. The British Journal of Psychiatry (2013)202: 400-406 http://bjp.rcpsych.org/content/202/6/400.full

Below is page one of my letter to Healthcare Improvement Scotland. Previous correspondence is here.

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