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Editor's blog Thursday 11 November 2010: Help! The aged!

There is a bitter irony that a day devoted to raising awareness of the sacrifices of previous generations in war, a report reveals that people of the main demographic we consider are at significant risk from healthcare.

An Age-Old Problem is the depressing new report from the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD), out today.

The study looks at elderly patients who died in hospital within 30 days of undergoing surgery. Only one-third were judged to have received good care. NCEPOD is calling for specialist elderly care and consultant input at all stages of the patient pathway.

It's always a bit galling when they system makes such spectacularly bad and wholly predictable errors around the healthcare of older people as the study reveals. (One of the predictable gigs in my old job editing a management journal was the regularity of annual studies and surveys revealing how widespread malnutrition was among the elderly in hospitals, even if not present at admission. It gets depressing reprinting the same article year on year, and feeling that it is making little difference - it's one reason I'm quite fond of national targets).

It's hard to avoid concluding that we don't really give very much of a damn about elderly people in hospital.

Perhaps all elderly people going into hospital should take a cute animal, which need to be given comparable care. There would be a proper national scandal if neglect were happening to cute doggies, or pussy-cats.

The vulnerable elderly are potentially not cute. They may have dementia, or at least be confused and disoriented. They almost certainly have a lot of need.

And what we ought to bear in mind is that in not that many years' time, 'they' will be us. So let's sort this out, eh?

What the NCEPOD report says
Report author and NCEPOD Clinical Co-ordinator in Surgery Mr Ian Martin explained that specialist elderly care teams reviewed less than one third of patients (225/965) before surgery. “Most patients were admitted as emergencies by very junior doctors without timely input of senior care of the elderly clinicians. There is still a long way to go to ensure good practice and appropriate care – this is despite our advice in 1999 and recommendations in the 2001 National Service Framework (NSF) calling for specialists to be involved at every stage of elderly care”.

The NCEPOD study also found little evidence of a well-resourced acute pain service, which they consider essential for modern secondary health care. 71 hospitals appeared to have no acute pain service

Key findings
• Just over 1/3 of patients surveyed (38%, 295/786) received good care.
• Poor nutrition and serious associated illness were very common in the group studied.
• In over two-thirds of cases (67.7%, 653/965), patients were not reviewed by specialists in Medicine for the Care of Older People.
• Clinically significant delays occurred in 1 in 5 patients between admission and their operation.
• 1/4 of hospitals had no acute pain service.

Key recommendations
• In elderly patients needing urgent surgery careful attention should be given to improving fluid status, reducing unnecessary drug treatment and anticipating nutritional support.
• Elderly patients undergoing surgery need access to routine daily clinical review from specialists in elderly care.
• Delays in surgery, which lead to poor outcome, should be subject to rigorous audit and rectified.
• Pain and its management should have a high priority to avoid patient suffering.

NCEPOD Chairman Mr Bertie Leigh added, “Our report describes problems that are going to become more and more prevalent. The numbers of people aged over 85 will double in the next ten years, and we must rise to the challenge that this presents.

“Elderly people tend to be more vulnerable than younger patients, and require a style of medicine that is sensitive to their many and varied needs. But, our advisors found that far too many people were not getting that pattern of care. Again and again, I read of cases where doctors were insufficiently trained to understand the subtle and complex needs presented by elderly patients.”

There is a very smart ‘urban myths debunked’ pop-up on the NCEPOD website, whose text is worth reproducing in full.

NCEPOD are often reported as stating that surgery must never be performed at night when in fact this is not the case. Our recommendations highlight concerns about surgery being performed out of hours by junior staff with too little supervision during the procedure and lack of medical support when the patient had returned to the ward.

NCEPOD considers that all the appropriate resources and appropriately trained personnel should be available in order for surgery to take place whatever the time. It is acknowledged that patterns of work will vary, dependent upon local arrangements, available resources and in particular consultant availability and appropriate job planning.

It is important to recognise however, that the competence level of staff in both surgery and anaesthesia must be appropriate not only for the complexity of the surgery, but also for the general health in terms of co-morbidities of the individual patient.

It must also be recognised, that trainees should only perform duties under appropriate levels of supervision, and that consultant trainers should also be sufficiently fresh and well rested to be able to perform their supervisory role.