Norman Irons: Action needed to improve the ERI’s care of the elderly

Today I am visiting an old friend who has just been discharged from the ERI after six months. He has undergone several operations, survived in the high dependency/intensive care unit, and been saved by the hospital when his life appeared to be ebbing away. His treatment and care was exemplary.

So much is so good in NHS Lothian and indeed NHS Scotland. Yet, as the Evening News highlighted last week there is one area in which patient care often falls below the standard that any of us would expect. The News reported the results of an inspection by Healthcare Improvements Scotland (HIS). In June 2011, Nicola Sturgeon (then Health Secretary) tasked HIS with carrying out a programme of inspections “to provide assurance that the care of older people in acute  hospitals is of a high standard”.

Unfortunately, the results of the HIS inspection at the ERI during this August really failed to provide that reassurance. Here it should be acknowledged that the subjective responses to a patient survey indicate that, overall, patients were positive about the care and help which they received. Yet the objective assessment of treatment and care of the elderly was far below the standard which we would accept for ourselves or our relatives. Consider the following short account by the HIS team.

“We saw two patients with dry mouths who had not received mouth care. Their mouths were dry and crusted and, as a result they found it difficult to speak to us.” Can you imagine the discomfort these patients suffered from thirst and dehydration?

Care of the elderly is not a new problem and there will never be a perfect solution, but patients, relatives and the wider community have received promises in the past; especially about elderly people in an acute hospital environment.

I raised my personal concerns about this seven years ago after the death of my mother in the ERI. At first there was a failure to acknowledge that the system was failing but, with widespread coverage by the Evening News, other families reported similar  failings. NHS Lothian was forced to act and, to its credit, set up a very powerful group to investigate and report on Older People’s Services.

Chaired by Anne Jarvie, formerly Scotland’s Chief Nursing Officer and including another six specialists/practitioners in care of the elderly, this External Reference Group recommended a total of 43 separate actions to address the issues raised. Now I accept that in an imperfect world with limited resources one would not expect a response to every action recommended. Nevertheless I would, and the people of Lothian should, reasonably expect that there would be such a shake-up of attitudes, care and procedures that the most serious problems would never arise again.

Yet here we are, six years on, with independent inspections reporting adversely on precisely the same issues of respect for the individual, nutritional care and hydration; and the prevention of pressure ulcers (bedsore to you and me). These inspections only covered three days yet they identified 23 areas for improvement, including 17 which are mandatory.

It is impossible in this short article to list all of the deficiencies identified, but some are well worthy of reporting verbatim because they illustrate such dramatic evidence in the failure of the procedures. Here is an example: “A patient had no nutritional risk assessment carried out on admission. The patient was being weighed daily. We had to calculate the total weight loss and bring to ward staff’s attention that the patient had lost 10kg in weight over a week. Staff were unaware of this and were not reviewing or calculating the total weight loss.” Ten kilograms is more than one-and-a-half stone; but no one noticed?

Here is another example: “On two separate occasions, patients with visual impairments (one patient was partially sighted, one patient was blind), were not assisted to find their cutlery or it was placed out of reach. We saw the partially sighted patient eating her meal with her fingers as their cutlery was out of sight under their plate. We had to ask staff to help this patient. The patient who was blind was not handed their cutlery when the meal tray was delivered. We intervened to help this patient find their cutlery.”

And of course, the News reported the ludicrous circumstance where the patient with left arm in a plaster had soup given to them but the bowl was out of reach of their right hand. And the pathetic instance of a patient trying to drink from a water jug because the glass was out of reach? What can be done to improve the situation?

Well, as I have noted above the HIS identified 23 areas for improvement and, obviously, the new chief executive of NHS Lothian should be acting urgently to deal with this. All the recommendations are important but personally I believe that the six headline improvements to “Nutritional Care and Hydration” must rank highest.

Of all of them, however, one recommendation sticks out: “NHS Lothian must review the way mealtimes are managed on the wards and make sure that all non-essential activity (clinical and non-clinical) is stopped during patient mealtime”. In short, the emphasis at mealtimes must be on attention to patient’s nutrition and hydration. Someone on each ward must be made responsible for this. If it requires extra resources, so be it. The elderly are the least able to articulate their problems or often afraid to “make a nuisance of themselves”

I said at the beginning that so much is so good in NHS Lothian. It is a pity that its performance is spoiled for want of a few simple actions. Anne Jarvie recommended that NHS Lothian should appoint a Champion for Older People. That was six years ago. Today we need one more than ever.

• Norman Irons is a former Lord Provost of Edinburgh

Protected mealtimes policy

NHS Dumfries and Galloway introduced a “protected mealtimes” policy in 2007 aimed at avoiding unnecessary interruptions when patients were being served meals.

Visitors are urged to play their part by avoiding mealtimes but the health authority insists “there are times when relatives/carers are welcome to attend the ward during mealtimes, for example if they are helping patients to eat”. Non-essential staff activity is discouraged including: ward rounds, medication rounds (unless medicines are required), routine recording of pulse and blood, pressure in stable patients, routine blood tests, routine heart tests, routine assessment and treatments, routine investigations.

This approach has been praised by Doug Anthoney,

Age Scotland campaigns officer.