British National Health Service: Wellbeing of Older Patients

Abstract

The aim of this paper is to inform the readers of the latest developments in the British National Health Service relevant to the wellbeing of older people. In Britain, the wellbeing of the elderly is addressed from a wide range of perspectives, independence being one of the dominant themes underlying the efforts of medical and social services. Thorough and systematic investigation of older people’s needs is another important theme together with the understanding of the importance of end-of-life care that should be sensitive and responsive to the dying person’s wishes. As the issues of assisted living, day care, long-term care, residential care, home care and hospice care involve many processes and many different professionals, this discussion may be useful for researchers and social workers involved in the development of social/research programs aimed at promoting the wellbeing of older people. The readers will be able to evaluate and reflect on relevant British legislation and practices involved in the care of elderly patients.

Keywords: British National Health Serviceolder patientssocial workpalliative careindependence and well-being

Introduction

Older people in the UK can be divided into two unequal groups. Group 1 are those who are at least 80 years old. These resilient, strong in spirit and wise people carry the burden of their age with dignity. Group 2 are so-called baby boomers, born in the 40s and 50s during the sharp rise in the birth rate (Moneywise 2013, Baby boomers are the wealthiest Brits).

They are selfish, spoilt and demanding. Accustomed to a high standard of living and the benefits of social security, they have the highest pensions and thus exhaust societal resources leaving the next generation to work hard and gain less. (Independent 2011, Will the baby-boomers bankrupt Britain?).

It is not surprising thus that in the UK, it is evident that older people do not enjoy the special reverence that is associated with Russia's attitude towards seniors. Old age is not a factor that determined the degree of respect for people in the UK. One can say that the special respect of this kind is enjoyed only by one old person - the Queen. (The official website of British Monarchy 2015, Home -Her Majesty The Queen).

While older Britons do not rely on a special reverence and respect for themselves, they want to maintain their personal independence and continue doing what they did in their youth rather than becoming passive inactive pensioners sitting on a couch.

The wellbeing of older people in Britain: personal independence

Older people in Britain assert their right to maintain the same lifestyle as when they were young. Quite often, older men get married and have young children who are 30 or more years younger than their grown-up children. These are usually very happy families, where the young child is brought up in a secure and wealthy environment.

Older people claim their right to an active sex life. As a result, doctors seeing an increase in sexually transmitted diseases among the older generation. (CBSNews 2012, Sexually transmitted disease rates rise among elderly. Why?).

Older people – independence and well-being

Older people – independence and well-being. The challenge for public services ( Adult commission 2004, Older people – independence and well-being) an important document (public sector national report) prepared by the Audit Commission, an independent body that monitors public services and public spending.

The report calls for “a fundamental shift in the way we think about older people, from dependency and deficit towards independence and well-being.” (Adult commission 2004, Older people – independence and well-being). Older people value independence and know what factors are involved in maintaining it. An older person needs to live in a secure home and feel safe in his or her neighbourhoods. They want to be able to develop friendships and have opportunities both for learning and leisure. They want to be able to get out and about, to have sufficient income, be informed about what matters to them, keep active and stay healthy.

Older people’s entitlements to free medical care

As far as healthcare in concerned, older people in Britain have the following entitlements. Prescription drugs are free of charge to all who are older than 60 years. Eye tests are free to all who are older than 60 years. Low-income seniors can rely on additional benefits: free dental treatment, free prescription glasses, free transport to the hospital or clinic, free wigs. (Age UK 2015, Factsheet)

Care of older patients: the NHS guidelines

National Health Service (NHS) is the system in the UK that provides free medical care and is paid for by taxes. The National Health Service in England was created by the National Health Service Act 1946.

The following document outlines the NHS guidelines regarding the care of older patients: Safe, compassionate care for frail older people using an integrated care pathway: Practical guidance for commissioners, providers and nursing, medical and allied health professional leaders (NHS England 2013, Safe, compassionate care for frail older people using an integrated care pathway: Practical guidance for commissioners, providers and nursing, medical and allied health professional leaders).

The document highlights the fact that in the recent years the approach to the care of older patients has improved whereby ‘[c]omprehensive geriatric assessment’, ‘frailty units’, ‘discharge to assess’ and ‘self-care’ are becoming touchstones of good practice.’ (NHS England 2013, Safe, compassionate care for frail older people using an integrated care pathway: Practical guidance for commissioners, providers and nursing, medical and allied health professional leaders). The improvement of care involves recognition that unnecessary hospital admissions and unnecessary long stay in hospital are not beneficial to older patients a they can deteriorate in hospital and later unable to return home. On the other hand, the general view is that a hospital can be the right place for an older person if he or she is acutely-ill, because hospitals can offer the specialist expertise and technology when it is required to deal with challenging medical problems.

In terms of what is needed for successful care of frail older people, the following elements have been identified and highlighted:

Royal college of general practitioners. the clinical example on care of older adults

THE CLINICAL EXAMPLE ON Care of Older Adults (Royal college of general practitioners curriculum 2010, Care of Older Adults) provides guidelines intended specifically for general practitioners, or family doctors. The document’s key message reflects the fact that the United Kingdom’s population is ageing and therefore a general practitioner must be prepared to dedicate a greater proportion of his or her time to the care of older people. The specific problems that a general practitioner (GP) needs to be aware of in regard to older patients are ‘[c]o-morbidity, difficulties in communicating, the problems of poly-pharmacy and the need for additional support for the increasingly dependent patients in general practice.’ (Royal college of general practitioners curriculum 2010, Care of Older Adults).

General practitioners are encouraged to bear in mind that the epidemiology of problems in older people differs from that in younger ones. This is particularly notable in cancer patients, whereby elderly people are prone to certain cancers more than younger ones.

Caring for elderly patents: case illustration

In order to illustrate guidelines for general practitioners, ROYAL COLLEGE OF GENERAL PRACTITIONERS CURRICULUM 2010 offers a case illustration (Royal college of general practitioners curriculum 2010, Care of Older Adults).

An elderly man (aged 80) is discharged form hospital after he had been treated for a femoral fracture to be cared for by his 75-year-old wife. He is immobile, complains of a severe back pain, suffers from dementia and is incontinent. Apart from that, he is diabetic and suffers from hypertension. He is also a cancer patient, but his cancer is in remission. His wife has a cataract and because of that she has previously given him wrong medication by mistake. Both of them have mobility problems, as he is unable to climb the stairs in their two-story house and she is on a waiting list for a hip replacement operation as she suffers from osteoarthritis. She is his official carer receiving a ‘carer’s allowance’ and does not want him to leave home insisting that she will care for him at home.

After the man is discharged from hospital, their general practitioner makes a home visit. He finds that the patient has not been cleaned, is lying in soiled bedding and the house is cold. The general practitioner concludes that there has not been adequate discharge planning where an occupational therapist would assess the situation and recommend changes at home to help the couple manage their situation.

The following questions would help the general practitioner apply relevant guidelines to this situation.

In regard to primary care management, the general practitioner should ask himself or herself, (1) what immediate medical and social problems need to be addressed here and (2) what support should the primary care team and hospital outreach services offer?

In terms of person-centred care, it is important to think about secondary gain being an issue here. Reasons for refusal of help must be investigated. It is important to ascertain whether or not one of the patients or both suffer form clinical depression. Can these patients realistically retain autonomy under the circumstances? What problems are likely to arise when communicating with these patients?

Using his or her specific problem-solving skills, the general practitioner must be able to evaluate the complexity of this situation from the point of view of healthcare provision. It is also necessary to decide on the method of conducting a risk assessment of the patents’ situation.

Applying a comprehensive approach, the general practitioner must ascertain whether or not the practice team have anticipated the issues highlighted in this situation. Was there an opportunity to prevent any of these problems form happening? Taking into account the wife’s role as carer, it is important to consider her own healthcare needs. Are there other services that could be offered in their situation? What can be made to ensure that continuity of care is improved?

In terms of community orientation, the general practitioner must ask himself or herself how common is this type of problem in his or her practice? What he or she can do to become aware of these problems? Are there any voluntary support services that my patients could use?

The general practitioner is also expected to implement a holistic approach and consider the consequences to the wife of her spouse going into ‘care’. These consequences can involve not just practical issues such as housing and finance but emotional issues as well. Planning a discussion with the patient’s future carer, the general practitioner should decide on the range of questions that will be raised regarding his long-term care and placement.

Taking into account contextual features relevant to the general practitioner’s caring for elderly patients would involve considering the specific challenges in his or her working life in caring for elderly patients. The general practitioner must make sure that he or she is familiar with the specificity of residential and care homes in his or her practice area.

The attitudinal features concern the general practitioner asking himself or herself, in the scenario described who is my patient and how should I be involved in the hospital discharge process?

The scientific features here concern the issue of treatment for the patient’s hypertension and making sure that this is a treatment of choice. Whilst addressing the issue of the patient suffering from vascular dementia, the general practitioner must enquire where he or she can access relevant information which would allow him or her decide on the strategy of the management of vascular dementia in that patient.

Dementia: screening and care

Continuing the issue of dementia, Dementia. Commitment to the care of people with dementia in hospital settings is the document on the subject of dementia issued by Royal College of Nursing.

According to this document, the problem of dementia cannot be overestimated:

‘Dementia is a challenge for hospitals. Surveys show that around a quarter of hospital beds are occupied by somebody with dementia; a figure which increases in older people and individuals with a superimposed delirium.’ (RCNFoundation 2013, Dementia. Commitment to the care of people with dementia in hospital settings).

Dementia means a range of conditions which affect the brain and cause a general impairment of the person’s ability to function in a social context. This involves impaired reasoning, loss of memory, communication problems. People affected by dementia experience difficulties with daily living. Changes in behaviour take place, and this makes them unable to live independently and has an impact on social relationships.

Alzheimer’s disease, vascular dementia, alcohol related dementia, dementia with Lewy bodies, fronto-temporal lobe dementia and Pick’s disease are examples of dementia as there are more than one hundred types of dementia. Patients may have mixed dementia as well when several types of dementia affect their function.

The 6 Item Cognitive Impairment Test (6CIT) is used when screening patients with dementia. (Patient 2000, Six Item Cognitive Impairment Test). It involves asking a patient the following questions: 1. What year is it? 2. What month is it? 3. Asking the patient an address to memorise with 5 components, eg Alex, Black, 57, Blackburn Rd, Accrington. 4. What time is it approximately (within 1 hour)? Count backwards from 20-1. 5. Say the months of the year in reverse. 6. Repeat the address phrase which the patient was supposed to memorise.

The 6 questions of the test are asked over the period of 3-4 minutes. As the practitioner progresses with the assessment, points are given for wrong answers. The maximum inverse score is 28. If the patient scores 0-7 this is considered normal. Scores of 8 or more are considered significant. (Patient 2000, Six Item Cognitive Impairment Test).

Caring for someone affected by dementia involves selecting living aids that prolong their independence and assist them in daily tasks. They also include devices that monitor the patient’s behaviour and remind him or her about taking medication etc (HSRhealhcare 2015).

Alzheimer’s society produced a document Mistreatment and abuse of people with dementia highlighting the issues that are associated with caring for patients with dementia (Alzheimer’s society 2015, Leading the fight against dementia).

The main problem here is that patients suffering from dementia can be maltreated and abused. The abuse can be emotional, psychological, financial, and physical and even include the improper prescription of anti-psychotics drugs. This can happen both in formal and informal care settings. People who do not have the ability to make decisions for themselves as a result of dementia are protected and supported by the Mental Capacity Act 2005 (Alzheimer’s society 2015, Leading the fight against dementia).

British media intermittently reports cases of abuse suffered by people with dementia. For example, The Guardian published an article ‘Care workers found guilty of abusing dementia patients 'for laughs'’.

The article describes how three care workers mistreated dementia sufferers at a nursing home:‘Residents were mocked, bullied and tormented because they would have no memory of the abuse, with one man having his foot stamped on deliberately and another tipped out of his wheelchair.’(The Guardian 2013, Care workers found guilty of abusing dementia patients 'for laughs').

The Mental Capacity Act was implemented in court and the carers were found guilty of ill-treatment or neglect of a person who lacks capacity.

End-of-life Care: Palliative and Therapeutic Harmonization Process (PATH)

Palliative care is an important issue in British healthcare system addressing the problem of caring for a dying person.

Palliative and Therapeutic Harmonization is a new model for end of life care in frail older adults that takes inot account various issues associated with decision making towards the end of one’s life. (Paige Moorhouse & Laurie H. Mallery, 2012)

A practicing doctor’s understanding of palliative care is this: ‘Palliative care medicine is the consummate sub-specialty as it to pertains to applying the expertise of several medical and ancillary disciplines in caring for the dying patient.’(Earl Stewart, 2015).

As Stewart continues, whilst providing palliative care, doctors collaborate with chaplains and hospice nurses and make home visits when supporting terminal patients in their decision to die at home and helping them to exercise some autonomy over where he or she dies.  This is done to ensure that patients die with dignity.

Conclusion

Elderly care is a complex and challenging issue. Assisted living, day care, long term care, residential care, home care and hospice care - all involve many processes and many different professionals. In Britain, the central theme that runs through all elderly care arrangements and practices is the challenge of finding a fine balance between helping an elderly person exercise his or her independence and providing care when it is needed, sometimes without the patient’s consent.

Dignity is another key term that reflects the needs of an aging patient. It is important to ensure that a patient is treated with dignity, especially in those situations when he or she suffers form dementia. Being able to make choices related to the end on life matters in another area where dignity is an important issue.

Healthcare practitioners in the UK are encouraged to work in partnership with other professionals such as social workers and are required to have an up-to-date knowledge of legal matters associated with the care of elderly patients.

Acknowledgment

This research was supported by the grant awarded by Russian Science Foundation (project №16-18-00016)

This research was conducted at the Tomsk Polytechnic University with financial support from the Ministry of Education and Science of the Russian Federation as part of the major research project "Evaluation and improvement of the social, economic and emotional well-being of older people," the contract ¹ 14.Z50.31.0029.

References

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