Community institutional care for frail elderly people

Time to structure professional responsibility

Responsibility for the medical management of elderly people in community institutional care (residential or nursing) remains poorly defined. It currently rests by default rather than by design on the heavily burdened shoulders of general practitioners. The number of patients in private or voluntary homes in Britain has risen from 18 200 in 1983 to 148 500 in 1994.1 The management of frail elderly people in nursing homes has also been regarded as beyond the scope of the general medical services contract and as a non-core activity.2

To add to this uncertainty, the role of geriatricians has undergone major changes. Increasing responsibilities for acute services have meant less time for continuing care and community care generally. These changes are partly due to the reduction of NHS long term beds, the withdrawal from acute admission duties by some medical specialities, and the lack of understanding and appreciation of geriatric care in the contracting process. The white paper Choice and Opportunity envisages, perhaps optimistically, new entrants into the community care market for health care.3 Generally, the lack of national benchmark standards has contributed to these difficulties. Some aspects of these issues have been addressed in Standards of Medical Care for Older People, a widely endorsed report from the British Geriatric Society.4

The poorly defined areas of responsibility mean that patients falling between primary and secondary health care and social services may easily be forgotten. The very essence of the craft of geriatric medicine is endangered, with professional knowledge and leadership in long term care5 becoming so dissipated that training and development are threatened, making the future one of reinvention rather than evolution. The present haphazard approach to community institutional medical care is provoking idiosyncratic solutions, ranging from establishing naively planned community geriatrician posts to recruiting unaccountable visiting medical officers. Private contractual arrangements between care homes and general practitioners, aimed at recognising the workload of care homes, cannot supplement the obligation of general medical services to individual patients. These contracts are liable to raise conflicts of interest, are professionally unaccountable, and obfuscate health service continuing healthcare responsibilities. We outline five options.

1. Visiting medical officers could be appointed specifically to provide the medical management of nursing homes. Some visiting medical officers have been established, but their relationships with primary and secondary care and their accountability are largely unresolved.

2. Geriatric medical and psychiatric outreach services could be set up. Hospital departments would become responsible for the routine surveillance and management of people in nursing homes. Out of hours and emergency cover would be provided by primary care emergency consortiums. This would relieve general practitioners of their present burden. However, it would require a significant shift of resources to secondary care and become a major commitment for hospital departments.

3. Shared medical care could be established. Routine care would remain the responsibility of the general practitioner, but hospital staff would have an increased role to support and facilitate care through visiting and advice. Though attractive in some ways, this option would not address the real problems of the workload in primary care. Furthermore, legal liabilities when differing opinions exist would need careful exploration.

4. Integrated medical care could be organised. Primary care would retain responsibility, with service payments for medical assessments on admission and for reviews. Geriatric services would provide structured support through the development of care management programmes. This model seems to allow the strengths of general practice to be maintained while defining and developing specialist responsibility. It would also provide a work sensitive solution for remunerating general practitioners.

5. Health maintenance organisations could be set up. Nursing homes would become American-style health maintenance organisations employing their own medical staff on their own terms. The cadre of doctors for this option is not obvious, and the potential for poor standards is worrying.

The fourth option has many attractions and complements the recommendations of the Burgner report for a single registration and inspection system.6 Burgner's important caveat—flexibility of provision—implies the need for preadmission assessments, which must have a medical component, to stream patients into appropriate settings in terms of their needs, the skills of staff, and supportive infrastructure. Streaming categories of community institutions would permit postadmission medical care of varying complexity. On the one hand, primary care would retain its traditional responsibility for care of frail elderly people whose condition is stable and who need little more than social and personal care. On the other hand, proactive specialist supervision would be given to the most heavily disabled people with chronically unstable multiple and complex disease.

Between the extremes of dependency lie the greatest difficulties and medical burden. The assessment of patients in nursing home care should be structured. Assessment should offer patients an assured care plan responsive to their needs and change. The minimum dataset resident assessment protocols provide the most comprehensive and sophisticated approach, having been refined in several countries.7 This system offers an opportunity for integration between primary care, secondary care, and other appropriate disciplines, including the deployment of the gerontological nurse specialists proposed by Johnson and Hoyes.8

Managed care programmes can be applied to many medical issues after admission to institutional care. Criticism that managed care violates clinical freedom should be viewed in the light of the advances in the management of conditions such as diabetes and asthma through disease management.Outcomes based management in long term care, as in other areas of health care, should be pursued as a means to quality and value assurance.9

Because of their data collection and compatibility with computerisation, minimum dataset resident assessment protocols make rational disease management in this diverse population possible. These proposals build on existing strengths of primary and secondary care and promote the establishment of genuine joint working and responsibility between health, social services, and care providers.