National framework could transform care for older people in England

EDITOR—Grimley Evans and Tallis criticise the national service framework for older people.1 I agree with them that the policy to reduce emergency admissions to hospital only among the over 75s is ageist. Application of the framework's age discrimination standard means that this high level performance measure will have to be changed to an age standardised measure.

The framework model for intermediate care services requires there to be comprehensive assessment, active rehabilitation, and medical leadership involving both hospital specialists and general practitioners. There will be no return to 1960s-style convalescence and other forms of marginalising older people.

On research strategy, the national framework supports the recommendations of the research and development strategic review to establish a national research advisory network for older people and for a directed programme of research; this has already commissioned a £1.2m programme to evaluate intermediate care.

On information provision, the framework will ensure scrutiny by patients and the public of all age based policies. It will also ensure the involvement of older people in patient forums, the local strategic partnerships, and the development of personal care plans that reflect individual needs, circumstances, and priorities.

The single assessment process will not replace medical diagnoses and decision making but will ensure that a single patient record is built up over time and shared among healthcare and social-care professionals, to replace the current inefficient and fragmented records systems.

Milestones for implementation of the falls standard are longer than those for some other parts of the framework as evidence is emerging about how best to organise this key component of services. Achieving organised services for the prevention and management of falls will be a great advance in the care of older people.

An inclusive approach was used throughout the development of the national service framework. The success of the approach is one reason why the framework has been so well received; it provides a historic opportunity for transforming health and social care for older people in England.

Proposals for intermediate care are reinventing workhouse wards

EDITOR—Grimley Evans and Tallis draw attention to the proposed development of intermediate care and its retrogressive nature.1 The rationale given for the implementation of intermediate care in the national service framework for older people is perplexing and inadequate.2

The framework states, firstly, that old people do not want to be in hospital. But if acute treatment is needed then hospital is often the best place to be. Secondly, it says that unplanned admissions might be avoided by prevention and rehabilitation. But intermediate care is not rehabilitation. Thirdly, it says that old people stay in hospital too long. This may well be true, but shunting sick people to another institution is not the solution.

The selective use of scientific evidence made by the framework to “support” intermediate care is remarkable. By its own admission “evaluative evidence of intermediate care schemes is scarce.” Evidence for the benefits of hospital at home is cited as being a Cochrane/NHS Centre for Reviews and Dissemination systematic review but is not in either archive. Evidence on hospital at home is available in the Cochrane Library,3 but as the systematic review concludes that “there is insufficient evidence to assess the effects of hospital-at-home on patient outcomes or the cost to the health service” it was presumably deemed inadmissible.

A Cochrane review of the effects of intermediate nurse-led inpatient beds is planned (see Cochrane Library protocols) but has not yet been completed. A non-systematic review concluded, perhaps not surprisingly, that “methodological limitations render firm conclusions difficult.”4

The secretary of state for health decided that there should be intermediate care beds, and the national service framework had to come up with a post hoc justification for them. As with any new technology, it is sensible for it to be evaluated before being widely used in the NHS—that is what NHS research and development is for. In his rapid response on bmj.com (bmj.com/cgi/eletters/322/7290/807#EL3; above letter here in printed journal) Philp shows touching faith in intermediate care, asserting that it will be done properly. But in the absence of any decent evidence, how can he know how it should be done?

A return to the ethos of the workhouse wards (diagnostic failures, inadequate treatment and rehabilitation, long stays, complications), only recently removed from our NHS, seems quite probable but will clearly cost more than before. Acting as a mouthpiece for ministers seems to mean forfeiting scientific integrity—surely too high a price to pay.

Problems with mental health are important too

EDITOR—It is unfortunate that Grimley Evans and Tallis concentrate only on the physical problems of old age.1 What of the “unworried unwell”—those with dementia? Years of socially oriented policy to deal with the problems of dementia may well have greatly improved the lot of carers. They have been of less help to patients themselves.

Few older people recognise the importance of late onset memory impairment. Even if they do they are unlikely to be referred to a specialist at an early stage in their illness, unlike those with other priority illnesses such as cancer, cardiovascular disease, and stroke.

Those who are fortunate enough to be referred see specialists hidebound in practice by health authorities continuing to resist the evidence base for treatment with cholinesterase inhibitors.2 People with dementia “shouldn't be” in acute medical wards,3 and bed blocking prevents admission to psychiatric inpatient care for assessment and to improve associated problems. Instead, they are channelled down the care slope through residential care, nursing home care, and nursing home care for elderly mentally infirm people.

In these environments care leaves a great deal to be desired.4 The policy of closing NHS beds has simply helped to fund the largest institutional care base in the country's history,5 yet a substantial proportion of people in institutions need not be there.5

The national service framework, and similar work in Scotland, must provide an opportunity to improve the health care of people with dementia if these problems are to be addressed. Grimley Evans and Tallis are right to point out that no “in group” of civil servants should prevent this happening.

Framework's recognition of importance of stroke has substantial implications

EDITOR—The national service framework for older people, discussed by Grimley Evans and Tallis,1 recognises that stroke is a medical emergency and that patients will usually require urgent hospital admission. This will have substantial implications for the prehospital management of patients with acute stroke, which are not discussed in the document about the framework.

People who have had a stroke are more likely to survive and recover more function if admitted promptly to a hospital based stroke unit in an integrated stroke service.2 Thrombolysis with intravenous alteplase is licensed for use within three hours of acute stroke in the United States and may receive licensing approval in Europe. Even within the first three hours the beneficial effects decline with increasing time to treatment.3

The median time from the onset of stroke to admission to hospital in the United Kingdom is 5.6 hours,4 which compares unfavourably with the 2.6 hours in the United States.5 Around 40% of patients with acute stroke in the United Kingdom make an emergency telephone call by dialling 999 (reaching hospital in a median of 2 hours); another 40% call their general practitioner (taking a median of 10 hours).4

Patients with acute stroke are mostly categorised by ambulance dispatchers in the United Kingdom as having a category B (non-life threatening) illness and are not transported to hospital with maximum haste. The failure to categorise stroke as a category A emergency, plus delays in accident and emergency departments before admission to an acute stroke unit, delay the delivery of skilled care and mean that most hospitals cannot participate in trials of treatments for acute stroke.

The widespread introduction of coronary care units and category A status for patients with suspected myocardial infarction provided the infrastructure that led to the evaluation and introduction of thrombolysis and revascularisation treatments. Similar investment by the NHS in acute stroke units and category A status for suspected acute stroke is necessary.

Paramedics need to be able to diagnose stroke rapidly and accurately and take patients quickly to hospitals with acute stroke units. Stroke recognition instruments have been validated in the United States for this purpose. In collaboration with the Northumbria Ambulance Service we have developed such an instrument (the face, arm, and speech test) for paramedics in the United Kingdom, which is presently undergoing validation.

The national service framework emphasises the urgency of acute stroke, but these recommendations will require substantial investment in public education, admission protocols, and the paramedical services to reduce unnecessary delays.

Framework will have considerable effect on primary care

EDITOR—Grimley Evans and Tallis's editorial talks about the effect that the national service framework for older people will have on hospital based care but does not mention the effect on primary care. 1 2 Chapter 5 of the framework (on stroke) is largely concerned with the acute care and rehabilitation in secondary care of patients with a stroke or transient ischaemic attack. After only a passing mention of secondary prevention in the text, a key milestone is that by 2004 “every general practice can identify people who have had a stroke.”

No reference is made to the particular difficulties of identifying a cohort of patients who have previously had a stroke. Unlike with coronary heart disease, when patients are likely to have been prescribed a symptomatic treatment (for instance, a nitrate) in the past, it can be hard to identify patients who have had a stroke.3 This can lead to great inaccuracy in a practice's stroke register, as can be seen from our experiences.

We are based in an urban, relatively deprived area of Birmingham with a higher than average proportion of patients aged over 65 (18%) and a list size of 5768. Our stroke register was previously maintained by opportunistic coding of consultations and summarising of hospital letters, a method used in many practices for their registers.4 We recently completed summarising and then computerising the medical histories of all of our patients and have noticed a large effect on our stroke register (table).

Before we reviewed our patients' notes 51 patients were recorded as having had a stroke or transient ischaemic attack. After the process 118 patients were so recorded. This final figure is similar to that found in community surveys.5 Summarising and computerising required roughly 600 hours of doctor time, 500 hours of nurse time, and over 800 hours of administration time (non-doctors were paid for their time).

We believe that our original register was not dissimilar to registers in other practices. Stroke care was not the impetus behind our summarising effort, and it might be argued that concentrating on patients aged over 65 would have been more efficient. Nevertheless, as we assume that our experience is not unique many cases of stroke will remain unidentified unless similar strategies are used elsewhere.

Until the problem of developing adequate stroke registers is tackled the management of most patients with stroke in primary care is likely to be unaffected by the national service framework for older people.

Authors' reply

EDITOR—Although Philp agrees that a policy to reduce emergency admissions to hospital only among the over 75s is ageist, he seems to think that this can be corrected by applying the national service framework's age discrimination standard, which will change a high level performance measure to an age standardised measure. This opaque formulation is the reverse of reassuring. Moreover, it will be interesting to know how either of these measures will be policed.

Equally unreassuring is Philp's assertion that there will be no return to 1960s-style intermediate care as a mode of marginalising older people. It certainly does not deal with the concerns articulated by Ebrahim that intermediate care may represent “a return to the ethos of the workhouse wards (diagnostic failures, inadequate treatment and rehabilitation, long stays, complications).” Connolly's letter is especially relevant here; diversion of elderly psychiatric patients from acute facilities and a socially oriented approach to dementia has already been disastrous for the medical care of such patients.

If there is not to be a repeat of the 1960s it will be essential to monitor closely how many older people “successfully” discharged from hospital into intermediate care, especially care purchased in the private sector, move sideways into permanent residence there rather than going back home. Can we rely on the necessary data being collected and made public? It is evident that the limited resources and even more limited person power available to deliver health care in the NHS will be spread even wider, and the creation of a new tier of service will be inefficient even if it does not result, as we anticipate, in serious inequities.

The emphasis on intermediate care was the result of the national service framework for older people being hijacked by the methodologically flawed national beds inquiry. The £1.2m programme to evaluate intermediate care looks pretty paltry compared with the huge sums earmarked for this evidence-free adventure dreamed up by policymakers remote from the real world and from the real challenges of providing technically up to date and humane care for desperately ill old people.

As for the single assessment process, Philp does little to assure us that this will not just become a bureaucratic nightmare, with many boxes being ticked and few people being helped. Besides, it is not clear what problem this single assessment process really will solve. (The most striking feature of the national service framework for older people is the lack of analysis of the reason why things have gone wrong hitherto.)

Jenkinson and Ford rightly emphasise the need for substantial investment in public education, admission protocols, and paramedical services in order to treat stroke with the urgency that it demands and deserves. Their own work in Northumbria is a model that could be adopted elsewhere. Such investment would be an interesting test of the rhetoric in the framework where there really is robust evidence to indicate the correct way forward.

McManus et al's point about the key role of primary care in implementation of the excellent stroke standard and of the resource implications that this has is entirely valid. Without the development of adequate stroke registers, secondary prevention and longer term follow up are going to remain as chaotic and inadequate as at present. Without the resources to support primary prevention measures in the primary care sector, the chances of achieving the targets of stroke reduction will be slender indeed.

It is too late now to change the national service framework for older people. The government should put its money where its rhetoric is and try to learn from some of the unexpected and uncomfortable experiences it is going to have with intermediate care so that the damage it causes may be limited; and civil servants should have less say in shaping the details of healthcare delivery. This framework could have a message for future national service frameworks: learning from experience is painful; learning from inexperience is even more painful as well as more expensive.