Our elderly merit medical care that acknowledges they have an array of specific needs Nursing homes staffed by specialists and categorised according to the particular, diverse needs of patients they care for are the best way forward after Leas Cross, writes Prof Séamus Cowman.
The care and attention we bestow on our elderly is a measure of the values we hold as a society. Following on from the nursing home charges debacle, the Leas Cross report and scandal has created a public awareness of the health services management of our most vulnerable elderly people. This level of scrutiny will lead to a more discerning approach by families to standards of health delivery to their elderly members.
At another level, the Leas Cross report is a statement about all parties involved in the management and delivery of services. The public, in particular the families of elderly residents, is asking for accountability.
Delivering accountability is straight forward for the professions of nursing and medicine - they are accountable to the public under statutory regulation, and there are fitness-to-practice procedures in place through which each individual is accountable for their own actions.
However, the nursing system in which these professionals work is devoid of any formal regulation by which accountability can be obtained. Accountability is diffuse though some type of quasi reporting system between the Health Service Executive (HSE), proprietors of nursing homes and an ineffective inspectorial process, all of which is now regarded as systemic failure.
Most often, poor standards of care are reflected in the appearance of patients with complications of bed rest. There are no excuses acceptable for poor nursing and medical care.
We do have a good evidence base for preventing bed rest complications. The research tells us that one in five patients has some form of pressure sore and 60 per cent of all pressure sores occur in hospital. For elderly patients, the risk of dying is three times greater for those with a pressure sore. Also the burden of pressure sores on the health services is significant. The hospital stay of patients with a pressure sore is three times longer and the estimated cost of a grade four pressure sore is €119,000.
In moving forward from Leas Cross, radical reform is required of the current system. The regulation of nursing homes must be established on a statutory basis with legislation that provides for public accountability. Given demographic trends and the future increase in elderly people, a national body overseeing care of the elderly should be established to support the legislation. The legislation must set the requirements for a robust and vigilant nursing homes inspection system with processes relating to standards of care bench marked against best practice
Nursing homes should be categorised by the type of services they are capable of delivering. Patient-need and levels of dependency must be central to the process of categorising nursing homes. This will correct the existing assumption and anomaly that all nursing homes are capable of caring for all types of patient diagnosis.
Just as the formal hospital system operates on a specialist model at every level, similarly care of the elderly must be regarded as a specialist service. This would result in nursing homes that would specialise in the confused elderly or elderly patients with stroke or immobile frail elderly or elderly with intellectual disability etc.
This is the only way forward that will ensure a match between the skills of the nursing and medical staff and the patient's needs. It will also facilitate ongoing staff development linked to the specialist needs of the patient. All nurse and doctors who provide care to elderly people must be required to undertake some form of education in care of the elderly. Gerontological nursing is an area that can now be studied right up to post graduate MSc level.
A greater level of appropriate clinical specialist nursing expertise in caring for the elderly must be located in areas of long-stay care. Clinical nurse specialists in tissue viability are key in preventing pressure sores. In this regard, it is noted that 76 per cent of such clinical nurses are employed in teaching hospitals, with only 7 per cent in long-stay facilities.
The establishment of a stronger and more robust system of nursing home service delivery will inevitably require greater resources. The proportion of people aged 65 years and over in Ireland is currently 11.5 per cent of the population and is set to grow to 14 per cent by 2011.
Given the population trend towards an increased number of elderly in future years, the State must examine new and creative ways of supporting the private sector in maintaining regulated and publicly accountable services.
At the end of day, an investment in care of the elderly is an investment in all of our futures.
Séamus Cowman is professor of nursing at the Royal College of Surgeons in Ireland.