A discussion of the NSF was published in the BMJ
earlier this year by Professor Sir Grimley Evans. This note reflects
the feelings of the author not necessarily Bro Taf Health Authority
policy.
His concern is that the National Service
Framework for Older People serves a political agenda, and that
agenda, unchanged over 50 years, is to keep old people out of
hospital.
He goes on: It is believed that care in proper
hospitals is too expensive for old people. This partly reflects a
preoccupation with cost per institutional day (money that might be
saved by closing something down) rather than with cost per satisfied
patient (money properly invested). But savings from putting old
people in cheap, ill resourced accommodation are rapidly lost in
unnecessarily prolonged lengths of stay, not to mention human
misery.
These fantasies are fed by studies of
“inappropriate” use of hospital beds by older people. The definition
of inappropriate is contentious, and the term is too readily
attached to the patient rather than the treatment. Certainly some
older people stay in hospital longer than they want because of the
complexities and under-funding of social service care. There are
probably many more old people who would benefit from acute hospital
admissions that they are denied. The clearest expression of the
agenda is the framework’s performance indicator, that demands an
annual increase in acute admission rates for people aged over 75 of
less than 2%. No evidence is offered to suggest that this percentage
will match clinical need. The proposal is institutionalized ageism.
However, the most worrying feature of the
framework is its proposal for developments in intermediate care. An
extra 5,000 intermediate care beds are to be created. The spirits of
geriatricians with long memories will droop. In the 1960s there were
many intermediate care beds outside acute hospitals, into which “bed
blocking” old people were transferred in the hope that somehow they
would disappear from the system.
He goes on to say: Geriatricians of those days
spent their lives getting such beds closed and their staff resources
transferred to acute hospitals to provide the specialist
rehabilitative care that older people need to get safely and
expeditiously home. Specialist geriatric rehabilitation units are
crucial elements of comprehensive acute hospital services but are
expensive. In medical care, as in anything else, you get what you
pay for. It is convenient for managers to confuse convalescence
(spontaneous recovery) with the more expensive rehabilitation that
is necessary to make non-spontaneous recovery happen.
Those geriatricians who have contrived to defend
specialist rehabilitation units against the cutbacks of the past 20
years may now have to fight to prevent their being downgraded to
intermediate care. Indeed, managers may seek to close rehabilitation
units to free money for purchasing intermediate care beds in private
sector nursing homes. Those “extra” beds will have to come from
somewhere.
Worse yet is the implication, for which there is
no justifying evidence, that older patients could be sent directly
to intermediate care, bypassing the skilled diagnostic evaluation
that the complexities of disease and disability in old age require.
This must not be allowed to happen, at least until the unconvincing
and over-bureaucratic proposals for a single assessment process have
been properly evaluated as adequate for the purpose.
On the other hand the proposals for hospital
geriatric services will encourage any laggard trust where such
services are not already in place. The framework gives clear and
robust guidelines for the treatment and prevention of stroke, and
its performance indicators will capture important elements of good
care. Many deaths and much disability will be prevented if the
guidance is matched by resources. The proposals for mental health
follow conventional wisdom, and an increase in surgical
interventions to reduce disability will be welcome.
Ref (web)
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This study was set up to test the hypothesis that
radiography of the lumbar spine in patients with low back pain is
not associated with improved clinical outcomes or satisfaction with
care.
It was a randomised un-blinded controlled trial
in 52 general practices in Nottingham and surroundings.
An adaptation of the Sickness Impact Profile,
visual analogue scale for pain, health status, EuroQol, satisfaction
with care, use of primary and secondary care services, and reporting
of low back pain at three and nine months after randomisation were
studied.
The intervention group were more likely to report
low back pain at three months (relative risk 1.26, 95% confidence
interval 1.00 to 1.60) and had a lower overall health status score
and borderline higher Roland and pain scores. A higher proportion of
participants consulted their doctor in the three months after
radiography (1.62, 1.33 to 1.97).
Satisfaction with care was greater in the group
receiving radiography at nine but not three months after
randomisation. Overall, 80% of participants in both groups at three
and nine months would have radiography if the choice was available.
An abnormal finding on radiography made no difference to the
outcome, as measured by the Sickness Impact Profile score.
Radiography of the lumbar spine in primary care
patients with low back pain of at least six weeks’ duration is not
associated with improved patient functioning, severity of pain, or
overall health status but is associated with an increase in doctor
workload.
Guidelines on the management of low back pain in primary care
should be consistent about not recommending radiography of the
lumbar spine in patients with low back pain in the absence of
indicators for serious spinal disease, even if it has persisted for
at least six weeks. Patients receiving radiography are more
satisfied with the care they received. The challenge for primary
care is to increase satisfaction without recourse to radiography
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