The social care crisis continues placing burdens on hospitals and bringing distress to vulnerable patients. This is evident is a number of ways, one of which is that too many people with dementia are not receiving the support that is appropriate to their needs, they end up in very busy Accident and Emergency Departments.
On Tuesday, 20 August 2019, the Daily Mail ran a story about the extent of the challenge in their article Hospitals treat 1,000 dementia patients a day because basic social care is so poor. Despite the fact that their headline then used the outdated term ‘casualty’ to describe Emergency Departments the article is an interesting one. It contains the news that emergency hospital admissions of dementia sufferers have now reached almost 1000-a-day, a dramatic rise of a third over the last four years. The increasing numbers of elderly people in the population combined with real funding pressure on social care systems, capacity problems in care home and residential units, make this a real challenge. We know that the longer an elderly patient stays in hospital the more their physical condition can deteriorate. Emergency physicians are keen to help support find a solution to this issue.
These latest figures simply highlight what we already experience on a daily basis. The demographic bulge in the population has been forecast for years and it is with us now. It is estimated that by 2021 more than one million people will have dementia in the United Kingdom, which is likely to make this situation even more challenging to resolve.
The problems can be found in all three domains of the system. First of all, there is care in the community, where dementia patients are looked after in their homes either by professional carers or their own relatives. This is undoubtedly the most suitable form of care, because those with dementia can be comforted by familiar surroundings. The problem is that the provision of care in the community has been under relentless pressure, enduring an overall cut in funding of 10 per cent in the last eight years, just at a time when the elderly population is growing.
The second domain is nursing and residential care, which is affected by the twin strains of funding challenges and rising costs. Moreover, support in this sector for patients with dementia has recently been hit by the over-stretching of GP services who also face a workforce shortage, as of course do we in emergency medicine. There are pockets of good practice where work is underway with care homes to help manage their patients without the need to admit them to their local Emergency Department. This best practice needs to be replicated across the country.
The hospitals themselves are the third domain in the care system, but here again there are funding issues. The demands on the NHS system are such that we emergency doctors end up having to practice what is called “corridor medicine”, that is treatment of patients on trolleys parked outside the main hospital wards in crowded Emergency Departments. For people with dementia, who are already disorientated, that is a particularly inappropriate and disorientating form of care.
There is a real opportunity here because in my view many emergency admissions could be avoided if effective care were provided in the home or the residential unit. For example, urinary and chest infections, which combined with malnutrition or dehydration are a source of significant morbidity. Better investment in the community and social care will help identify such conditions early and indeed prevent admission in a significant proportion.
Dementia is rising at a steady rate, as life expectancy lengthens and other life-threatening ailments – like outcomes from heart disease improve. There is an urgent need for more carers, more NHS staff and more hospital beds. Every part of the system, from local authority community care to Emergency Departments, needs greater investment. This call for greater investment may be unpopular given the recent funding settlement for the NHS plan but it is needed because the increase in funding provided amounts to an additional 3.1 per cent-a-year for the next 5 years as noted by independent observers, whereas throughout its history the NHS has on average had annual funding increases of 3.4 per cent. Given the scale of the problem, the proposed rise is likely to be insufficient.
Despite the challenges we medical staff always do our best to put the patients at ease. We do that by providing constant reassurance, which can be a difficult task where dementia is concerned because of the problems with communication. NHS staff have access to better training to improve our ability to communicate, helped by a range of Cognitive Assessment Tools, which we must ensure we use consistently. At the same time, we must work on trying to find out the causes of debilitation and provide early treatment.
This may involve a swift return to the community if nothing more is needed than a course of anti-biotics, but often, in the case of a moderate illness, a short stay in hospital is required. Then there are the harder instances, like a major fracture or a severe infection. Throughout, our aim must be to provide the best possible quality of care, treating every patient with dignity. At times, a high degree of sensitivity is required in discussing the patient’s condition if the prognosis is bleak. In developing an end-of-life plan and the RCEM has developed excellent guidance in this regard. It is vital to learn from and work with families about the patient’s own wishes to ensure that futile interventions and resuscitation are prevented.
We need to shine a light on this issue affecting so many families in the UK. The essence of this message is that more investment in Social Care is needed to help relieve the pressure on busy emergency departments. This is an issue already picked up as a key one in the NHS Long term Plan (for England), which aims to achieve greater integration of health and social care and tackle some of the issues identified in this blog. The devolved nations also have it high on their agenda to tackle. The key to the future in this vital area will be an adequate funding settlement for Social Care this coming Autumn.
Dr Taj Hassan