Comfort-seeking in trolley numbers instead of problem sensing in the care of older people
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Welcome to trolley season. It's the annual activity where the only metric that matters is keeping the numbers at a level where the numbers do not explode across the media as breaking news. Towards the end of October, the annual flex commences. Talk of winter initiatives starts rolling out despite the reality that trolleys are a year-round reality.
As a person who teaches and researches healthcare management, it is often challenging for me to keep up with the new buzzwords and plans. However, this year, something new has been introduced that requires all our attention and understanding.
The HSE issued a communication outlining its latest plan focused on 'flexing the model', a new process to discharge older people to nursing homes that began at the end of October. It also stated there would be revised instructions about access to "aids and appliances" for all public and private nursing homes. The related outcomes from this flex note that it would reduce "unnecessary conveyancing" in acute hospitals, increase "older adult's experience of care", and reduce "length of stay" of older people on trolleys and in acute hospitals overall.
On first reading all of this, you could think we could seek comfort in the proposed flex. Our population is advancing in age. According to a recent report from the Organization for Economic Cooperation and Development (OECD), life expectancy in Ireland is 82.4 years, 2.1 years above the OECD average. The Central Statistics Office says the population of over 80s is set to rise dramatically, increasing from 128,000 in 2011 to 484,000 by 2046.
We all know that we have ongoing capacity challenges in our hospitals nationwide. The OECD says Ireland has 2.9 hospital beds per 1,000 population, less than the average of 4.3. At 90%, Ireland has the highest bed occupancy rate in the OECD.
There is clear agreement within the academic literature that hospital admission is considered a health risk for frail older patients. There is now overwhelming evidence that an older person, even having a short stay in hospital, increases their risk of impacting their daily living activities.
Older people have different healthcare requirements. The Irish healthcare system needs to adapt to meet these requirements, mainly as the demand increases. The health and social care system has started a process of adapting to support the care of older people.
There are now pathways developed from the front door of emergency departments to support older people to integrated care teams and hubs in the community. Supporting how these teams work together is ongoing. There is a need to change ways of working and enable ongoing education and training to support these shifts. Central to this will be the need for ongoing workforce recruitment and retention in the community.
The literature around comfort-seeking advanced by Professor Mary Dixon Woods and colleagues at Cambridge University is defined as the "activity of seeking reassurance from the data available, and by the inability or unwillingness to seek out information that might challenge the sense that all is well". We could easily take comfort that there is lots of activity in the care of older people.
Notably, the idea of convalescence in a nursing home seems like a good policy flex that we could seek comfort in considering the pressures in our hospital. But it's important to distinguish what convalescence is and how it's different from rehabilitation. In researching this article, I found convalescence defined as the need to "rest and recover". Rehabilitation, in contrast, involves active interventions that can include input from a range of health and social care disciplines, such as occupational therapists, physiotherapists, and speech and language therapists. They aim to support a person back to participating in their life.
Nursing homes do not have the capacity or the staff to provide rehabilitation at the scale in which a flex to nursing home is being proposed this winter. While the HSE is allocating an increase of "aids and appliances" to nursing homes, there is no health and social care workforce being allocated to support the use of these aids. Comfort seeking in allocating additional “aids and appliances” is a dismal metric of success.
Professor Dixon Woods argues that organisations need to move away from "comfort seeking" and advance "problem-sensing". This involves actively seeking out weaknesses in our systems relating to quality and patient experiences. This flex to nursing homes raises a number of problems that all policymakers and managers should be responding to.
Sending older adults directly to nursing homes in response to a trolley crisis will not meet their needs. Not giving an older person the time and right to decide and consent to their care goes against the recently commenced Assisted Decision-Making (Capacity) Act 2015.
Older People overcrowded in emergency departments with frailty or dementia should not be punished for poor capacity building in our system. We as a society must demand a shift in better care for older people. We have to ensure that the resources that are there are being used to support rehabilitation, and that the will and preference of older people is central rather than comfort seeking in a trolley metric.