Back to Work

A big thank you to you all for your forbearance over the last five months whilst Stephanie's Bespoke Care Service has been working at maximum capacity and unable to take on new clients; and special thanks to Julie at Ruby Slippers for stepping in and providing excellent care.

We are now back to work and over the next few weeks we shall be resuming our role with existing clients. Feel free to contact us in the new year with regards to your home care needs.

Councils putting stricter limits on elderly care

By Jane HughesHealth correspondent, BBC News

Most councils are imposing unreasonably short time limits on care for the elderly at home, according to the UK Homecare Association.

In a survey, it found that an estimated 75% of councils expected carers to complete visits to elderly people in less than half an hour.

Ten per cent imposed time limits of 15 minutes.

The Association of Directors of Adult Social Services said it illustrated the financial pressures on the system.

Around 640,000 carers visit people in their homes across the UK on a daily basis, helping them with basic tasks like dressing, washing, and heating up meals.

But as budgets tighten, increasing numbers are being told to clockwatch; having time limits set on visits.

In its survey, the UK Homecare Association heard from 739 companies providing care at people's homes, representing 90% of all local authority areas.

Dignity compromised

Many said even when staff were carrying out the most intimate of personal care, they were given such strict time limits that it became difficult to protect people's dignity; a third had issued formal warnings about the problem to councils.

And six per cent said carers were sometimes under so much pressure that they feared people's safety could be compromised.

Many companies providing home care complained of councils driving down the prices they were prepared to pay for care, to the point where quality was affected and some carers were leaving the profession.

The UK Homecare Association suggested that excessively short time limits on visits might amount to institutional abuse.

Its chief executive, Bridget Warr, called on governments across the UK to ensure that everyone was able to get high quality care, and that enough funding was available.

"We need to consign visit times that risk the dignity and safety of elderly and vulnerable people to the past," she said.

The UK's largest home care provider, Saga, said the findings highlighted the need to change the way social care is paid for in the UK.

"Care is not just about old people - it's about families and loved ones," said Ros Altmann, Saga's director general.

"At the moment all these people are being let down."

The Association of Directors of Adult Social Services said until a sustainable funding solution was found things were unlikely to change.

Their president, Sarah Pickup, denied that price was the overriding priority.

"Inevitably in the current climate, commissioners are concerned about price," she said, "but that is not the same as saying it is general practice to put price above quality.

The government is expected to announce its plans for the system of providing care for elderly people and other vulnerable adults in England in the next few days.

The Department of Health said it had provided £7.2bn extra for adult social care services over the next three years.

"Commissioning care by the minute is unacceptable," said the Care Services Minister, Paul Burstow.

"The focus must always be on providing high quality, timely and dignified care - not on the time it takes to deliver it."

Twelve Months On for Stephanie's Bespoke Care Service

On 20 June 2011, we launched Stephanie's Bespoke Care Service blog. Here we are, twelve months on, with the 47th posting.

They say that the first twelve months are the most challenging for any new enterprise. Well, I am pleased to report that the last twelve months for Stephanie's Bespoke Care Service has run like clockwork and that the usual challenges for small enterprises have not materialised for us. Save for Sarah, who left us earlier this year, we still have the same committed  team of carers. The 'co-operative model' has served us well, enabling each carer to develop their special practices whilst providing a seamless service. Importantly, I can report that we have provided 100% 'on-time' service to clients, including extra cover and emergency attendance.

When setting up the service there was always the concern that some eventuality may not have been covered. It is usually the last thing that anyone thinks of that can de-rail the provision of care for those living at home. During the last twelve months we have handled emergency call-outs, hospital admissions, problems with Health Trust provision of equipment (especially from the wheel chair service) and unscheduled visits from health care professionals. Interestingly, on each occasion, our systems, care plans and staff resources have proved more than adequate to provide a 'silver care service'. Additionally, we have maintained the 'dedicated carer' principle, advanced in continuation training, and maintained and improved the standards of care.

Of the most satisfying aspects of the service, the first has been our client feedback. Kathleen, our first client reports total satisfaction and tells us that "she is the envy of her less fortunate friends". It is wonderful to receive such praise and is credit to the small team of carers who attend her on a daily basis. The other significant joy has been the functionality of the team - meeting regularly, exchanging appropriate information, sharing experience and feeling supported.

And the next twelve months? Well, on the basis that we seem to have navigated the perfect course to date, hopefully to continue providing a valued, bespoke service to our clients, their families and the extended team of care professionals.

Government delays threatening future of homes

By John Bingham, Social Affairs Editor, Telegraph

Private operators are under renewed pressure after the report showed that the fees they receive from councils to look after elderly people have risen slower than inflation for the third year in a row.

Age UK said the figures from the health analysts Laing & Buisson showed that care for the elderly was now being “cut to the bone” and warned that the crisis is “deepening by the day”.

A promised Government white paper on overhauling the care system has been repeatedly delayed. It is now expected in the next few weeks.

Meanwhile behind-the-scenes cross party talks intended to thrash out a new way to fund care for Britain’s ageing population, following a landmark report by the economist Andrew Dilnot last year, are believed to have stalled.

Laing & Buisson said the delays were making councils, which have seen their own funding cut sharply, reluctant to increase what they pay to care homes by more.

Its report, the only study of its kind in the care sector, showed that councils have upped their fees by an average of just 1.6 per cent in the current financial year.

Inflation is currently running at 2.8 per cent and homes estimate they would have need an average increase of about 2.5 per cent just to meet their costs.

The report adds that the rises might have been smaller had it not been for a series of legal challenges.

The small rise in fees represents an improvement on last year for the battered sector, which was described as the “worst ever” for care homes.

But overall, homes have seen a real-terms cut of almost five per cent over the last three years, the report found.

It means that homes are more likely to charge middle class residents who do not qualify for state support even more.

Only people with assets, including their home, worth less than £23,500 qualify for any state support with their care in old age.

A recent study by the Labour Party showed homes are already hiking charges to better-off residents by up to £12,000 a year to subsidise those who receive free care.

Laing & Buisson also found dramatic variations in the amount different councils are prepared to pay, with a handful of councils paying as little as £274 a week per person for residential care while others pay a minimum of more than £700 a week.

Justin Merritt operations director of Laing & Buisson said: “With the continued delay of word from the Government on the reformation of social care funding and its considered response to the Dilnot report, it’s hardly surprising that councils have been reluctant to budge on baseline fees.

“Initial promises were that the coalition government would have something to say in the spring.

“We’re now half way through June – to paraphrase the old saying, just how long is this piece of spring?

“This persistent chipping away at operators’ margins certainly risks damaging the long term health of the sector.

“If the Government is not careful it could face a situation where just as it is geared up to address the problem of how to support an ageing population, one of the options in which to achieve this aim may no longer be in a position to do so.”

Martin Green, chief executive of English Community Care Association, said: “The care system is in crisis because local authorities are refusing to pay the true costs of care, yet still expecting to get high quality services and the Government is guilty of shameful complacency in refusing to find a solution to the long-term care funding crisis”.

But Sarah Pickup, president of the Association of Directors Adult Social Services, said councils are having to freeze pay for their own staff making it harder for councillors to increase fees elsewhere.

“The independent sector is a place where the chickens are going to come home to roost if the funding situation isn’t resolved,” she added.

Caroline Abrahams, of Age UK said: “These cuts will inevitably affect the range and quality of care available for England’s frailest and poorest care home residents.

“As we continue to wait for the long delayed White Paper and funding report, the crisis in social care deepens by the day.”

Oliver Thomas, UK Director of Bupa Care Homes, said: “We know there’s a £1.7 billion shortfall – politicians must agree how the system can be sustainably financed and should listen to charities, providers and councils when we unanimously call for the funding shortfall to be urgently plugged.”

A spokesman for the Department of Health said: "As this report says, councils are paying higher fees to care providers this year.

"Ultimately, the amount of money councils pay to care homes is determined in contracts between councils and providers, though councils should take into account the actual cost of providing care.

"In the Spending Review, we recognised the pressures on the adult social care system, and allocated an additional £7.2 billion over the next three years.

"We will shortly be publishing the Care and Support White Paper, and a progress report on funding, which will transform care and support."

http://www.telegraph.co.uk/health/healthnews/9350169/Elderly-care-Government-delays-threatening-future-of-homes-report-warns.html

Elderly Care Costs

Almost 200,000 more pensioners will be forced to pay all the costs of their care in coming years after a “stealth” cut to Government funding for the elderly, new research predicts.

By John Bingham, Social Affairs Editor, Daily Telegraph

A study carried out by Age UK for The Daily Telegraph predicts that the cost to families of funding old-age care will more than double in the next 13 years, far outstripping the taxpayer’s contribution.

The number of people in England who do not qualify for any state support would spiral to 670,000 unless dramatic steps are taken, the study estimates. At the same time the wealth threshold for qualifying for Government support has risen more slowly than inflation for several years, according to Age UK.

Campaigners said that this amounts to a “stealth” cut in funding for old age care.

Michelle Mitchell, director general of Age UK said: “Over the years support for care services has been eroded to the point where the system is in crisis. “This means that more and more of the burden of paying for care has been pushed onto older people and their families without any wider discussion about the fairest way of funding these essential services. "This is why we need leadership from the Government to frame an urgent debate on radical reform of the care system.”

The charity calculates that the number of people in England forced to pay for all of their elderly care needs is set to rise from around 490,000 now to 530,000 by 2015. It would then increase to an estimated 670,000 people a decade later. That would see the bill to families spiral from £8.4 billion at present to £17.5 billion in the same period.

The steep rise is a result not only of the ageing population but also the fact that more and more people now approaching retirement own their own homes, meaning that they would be judged too well-off to qualify for any support. A White Paper setting out how care for the elderly is to be overhauled to cope with the looming crisis is due to be published later this summer.

Separately, the major political parties have been holding unprecedented cross-party talks in an attempt to seek agreement on a new way of paying for elderly care. Last year a Government Commission chaired by the economist Andrew Dilnot proposed capping the amount anyone would pay at £35,000. He also proposed raising the threshold, so that only those with assets worth more than £100,000 would have to make a contribution to their care costs. Currently the figure is just under £23,500.

Age UK estimates that although this figure has risen by almost £3,000 in the last seven years, when the rising cost of living is taken into account that equates to a fall of £2,200 in real terms. Dr Ros Altmann, director general of Saga, said: “This is another stealth tax on the middle income pensioners who have saved.

“This is the worst means test in our whole system ... There are more and more people needing care and less and less money being allocated to them so the squeezed middle is being squeezed again.“These are people who have worked hard. The very well-off will probably be able to afford it but it is the decent middle classes who may have put money into a pension but nobody told them they needed it for care as well. “Those who have saved for their future don’t mind paying something for care but what is so desperately unfair about the current system is to lose everything."

Liz Kendall, the shadow minister for older people, who is involved in the cross-party talks, said: “This analysis strengthens the urgent case for reforming our broken care system. “Thousands of people are already paying the price for a system that has now reached crisis point. “It is not only that more people are paying more but that the charges they face for home care and residential care vary hugely across the country so people face a postcode lottery through no fault of their own.”

A Department of Health spokeswoman said: “The main reason for these figures is an ageing population which will mean more and more people will need care and support in years to come. “But we are committing an extra £7.2 billion to social care over the next four years to make sure councils have enough to maintain the current levels of access and eligibility. “We are working to reform social care and we will publish our plans very shortly.”

Homecare for elderly 'disgraceful', report finds

Standard of care provided to elderly in their homes has been described as disgraceful in report by consumer group Which?

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A geriatrician holds the hand of an elderly woman with arthritis. Photograph: Corbis

Older people are suffering "disgraceful" home care, including missed medication and confinement to soiled beds, an undercover investigation has revealed.

Researchers for the Which? consumer group reported missed visits, food out out of reach and vulnerable people left without a way of getting to the bathroom.

Which? asked 30 people or their carers to keep diaries over the course of a week in January detailing their experiences of home care, also known as domiciliary care, by paid workers.

One elderly woman was left alone in the dark for hours unable to find food or drink. Another was left without a walking frame, leaving her unable to get to the bathroom, while one man was not given vital diabetes medication, the watchdog said.

Which? declined to name the agencies involved, saying it wants to protect people who gave feedback.

One unnamed daughter reported: "They missed a day just after Christmas. They incorrectly entered into their database the days we didn't need care. I covered but mum didn't contact me until early evening, by which time she needed a lot of cleaning up. You wonder about the elderly with no relatives."

A son said: "There are times when dad, who is diabetic, hasn't had his insulin on time and it's vital medication. When I voiced my concerns to the care agency I was just told to find another agency."

Another daughter told the watchdog: "She can't see her sandwiches to eat them and hasn't touched her drinks as she can't see those either. I can't express how angry I feel at the carers. There is a printed note on the front door about putting a light on at 4pm as well as a note from me in the kitchen beside the care book. It is also in the care plan. What more can I do?"

Others did identify good service, with one son saying: "My mum's carer does things without being asked, such as tidying up, and will do extra things like brushing her shoes. Mum says she's a real carer."

However, a separate Which? survey found one of the most common complaints was missed and rushed visits, with relatives often left to step in.

Almost half of respondents (47%) able to answer a question about visits said at least one had been missed in the past six months, while 62% of those had not been warned in advance.

Which? said "in many cases" diarists reported a good service was provided only after complaining, with some family members being forced to make numerous phone calls and to have a "constant battle" with agencies.

The Which? executive director of Which?, Richard Lloyd, said: "The government can no longer claim to be shocked as report after report highlights the pitiful state of care for older people. If they are serious about ensuring vulnerable people are treated with dignity, then we must see real action because every day they delay is another day older people risk being neglected."

The chief executive of the Care Quality Commission (CQC), Cynthia Bower, said: "Homecare is one of the most difficult areas of care to monitor because it is delivered behind closed doors which is why, starting next month, CQC will be carrying out a themed inspection programme of 250 providers of domiciliary care services.

"We will be focusing on dignity and respect, the safeguarding of people in vulnerable circumstances and how well-supported and trained homecare staff are to undertake these most important care tasks.

"We will use a range of ways of checking up on these services, including going into people's homes, contacting people who use services and their families and talking to local groups who represent the users of homecare services."

The Age UK charity director general, Michelle Mitchell, said: "While many careworkers work hard to provide compassionate care, the underfunding of the social care system is resulting in a serious reduction of domiciliary care, which can put both the health and dignity of older people at risk.

"Good homecare must begin and end with the needs of individuals rather than focusing on a tick box of tasks to be completed within a set time."

A spokesman for the UK Homecare Association, Colin Angel, said the report highlighted "the disturbing consequences of the commissioning of homecare by local councils".

"To meet the current stringent public sector spending cuts councils are making significant attempts to reduce the price they pay for care," he said.

"Homecare agencies repeatedly tell us that councils also allow less time for care to increasingly frail and elderly people. This raises serious questions about the ability of people to receive dignified, effective care, a situation which must be addressed nationally."

David Rogers, chairman of the Local Government Association's wellbeing board, said there was too little money in the system "and without fundamental reform the situation is only going to get worse".

"Local authorities are doing all they can to find solutions that don't impact on the services they can deliver to elderly and vulnerable residents and despite a 28% funding cut from government, spending on adult services this year is expected to fall by just 2.5%, the lowest for any service area."

The minister for care services, Paul Burstow, said: "We are funding work to put in place the first ever training standards for care assistants to raise the bar on quality.

"The best councils are arranging care that concentrates on delivering the outcomes people have a right to expect. Kindness, compassion, dignity and respect must be central to care, whoever provides it and wherever it is provided."

All-metal hips need more corrective surgery

Tuesday March 13 2012

Data suggests some metal hips wear down faster than expected

“Experts are calling for controversial metal-on-metal hip implants to be banned,” according to The Guardian. The newspaper said that research has found “unequivocal evidence” of high failure rates of these hip implants, particularly among women.

In recent months there has great deal of scrutiny about the safety of some types of metal-on-metal hip replacements, with concerns they wear out much faster than implants featuring plastic and ceramic parts. To examine the issue researchers working on behalf of the National Joint Registry in England and Wales analysed data on 402,051 hip surgeries performed using implants attached to the thigh bone by a metal stem, including 31,171 metal-on-metal implants. Researchers found that these had higher failure rates than other types of hip replacement, with an overall five-year failure rate of 6.2%. Those with larger ‘heads’ (the part of the implant fitting into the hip joint socket) had a higher failure rate than those with smaller heads, as did hip implants in women.

This study provides more information on the longer-term performance of metal-on-metal hip replacements, and supports claims that they do not last as long as other types of hip implants.

The use of this type of implant in England and Wales is reported to have dropped dramatically since 2008, and the ongoing concerns seem likely to reduce its use further. Overall, this study supports the recent recommendations by UK health regulators. It states that people with large-headed metal-on-metal implants should be monitored carefully over time to identify whether their implants are wearing down at a faster rate.

Where did the story come from?

The study was carried out by researchers from the Universities of Bristol and Exeter, and the Centre for Hip Surgery at the Wrightington Hospital in Lancashire. It was performed on behalf of the National Joint Registry of England and Wales, which also funded the research.

The study was published in the peer-reviewed medical journal The Lancet.

This story is covered in a balanced way by the Guardian.

What kind of research was this?

In recent months there has been some concern over the use of certain all-metal hip implants, particularly over whether they wear down at a faster rate compared to other types of implants.

Hip implants come in a variety of different sizes and materials, but the debate has centred on large-headed ‘metal-on-metal’ implants. These implants are designed so that both the ball replacing the top of the thigh bone and the artificial socket placed in the pelvis are made from metal.

This research was a registry study looking at data on hip implants collected in the National Joint Registry of England and Wales, which records all hip and knee replacement surgeries. This includes the first operation to install the implant, and any revision operations carried out to replace or remove part of the original implant.

Just like with natural bone, metal hip implants experience wear and tear and can eventually deteriorate. This means any implant may eventually need revision surgery, although analysing the revision rate gives an estimate of how often and how soon implants fail early. While the revision rate is an important indicator of the outcomes of hip replacement, it should be noted that not all hip implants that do not function well or cause pain will be replaced.

The researchers say that due to their resistance to wear, large diameter metal-on-metal hip stemmed implants have become popular. ‘Large diameter’ refers to the size of the ‘head’ part of the implant that sits in the hip socket section of the implant. Stemmed means the head is attached to an elongated stem that sits inside the top of the high bone and holds the head in place.

The study’s authors note that there have been concerns about the high failure rate of one particular brand of metal-on-metal hip stemmed implant called ASR, which was withdrawn from use in 2010. Given this withdrawal and fresh concerns about other types of metal-on-metal implants, the researchers aimed to look at whether general metal-on-metal hip stemmed implants fail any more regularly than other implants (ceramic-on-ceramic or metal-on-polythene). They also looked at whether large diameter implants lasted any longer than implants with smaller diameter heads.

This type of registry analysis is useful for monitoring the long-term performance of devices once they are in use. It can help to identify any problems that are occurring with the implants. Ideally, data on the comparative performance of different implants would come from randomised controlled trials, but the researchers report that there are few such studies available.

What did the research involve?

The researchers looked at 402,051 first total-hip replacements using a stemmed implant carried out in England and Wales between April 2003 and September 2011. They then identified any revision operations carried out to these hip implants to allow them to determine how long it took before a revision operation was needed for each type.

The researchers did not include data on ASR implants in their analysis, because they are already known to have much higher revision rates than other brands and have already been withdrawn from the market. The researchers also only included data on hip replacements that had sufficient data recorded to allow them to identify which operations were revisions of which earlier hip replacements. This allowed them to analyse data on 82% of all first total-hip replacements using a stemmed implant performed in the study period.

The researchers tried to make sure the hip implant operations being compared were as similar as possible. For example, they only included those where the implants were not ‘cemented’ in, and where the operation was being performed in ‘typical’ patients.

Typical patients were defined as those whose hip replacement was needed due to osteoarthritis only, and who were generally healthy or with only mild illness at the time of primary surgery as defined using a recognised measure of pre-operative health. The researchers also took into account the age of the patient, and looked at men and women separately.

What were the basic results?

The researchers found that metal-on-metal hip implants were used in 8% of the 402,051 first total hip replacements using a stemmed implant. This equated to 31,171 replacements. Use of these types of implants peaked around 2008 but then reduced sharply after this.

Overall, metal-on-metal implants required revision due to failure more quickly than other implants, with a 6.2% needing revision within five years of implantation. The size of the head of the metal on metal implant affected the failure rate in men and women, with larger heads failing earlier. Overall, each 1mm increase in head size increased the risk of revision over time by about 2% (hazard ratio [HR] 1.020 in men, 95% confidence interval [CI] 1.004 to 1.037; HR in women 1.019, 95% CI 1.001 to 1.038).

In men aged 60 years, the five-year revision rate was 3.2% for 28mm head metal-on-metal implants, and 5.1% for 52mm head implants. In younger women, the five-year revision rate was 6.1% for 46mm head metal-on-metal implants, compared with 1.6% for 28mm head metal-on-polyethylene implants.
Revision rates for metal-on-metal implants were higher for women than men, even with implants with the same head size. For example, a 36mm head metal-on-metal implant in women aged 60 had a five-year revision rate of 5.1% compared to 3.7% among men of the same age and implant head size.

However, larger head sizes were more durable for ceramic-on-ceramic hip implants. In men aged 60 years, the five-year revision rate was 3.3% with 28mm head ceramic-on-ceramic implants, and 2.0% with 40mm head ceramic-on-ceramic implants.

Age also had an effect on implant survival for women, with younger women receiving hip implants more likely to have revisions.

The most common reasons for revisions were loosening and pain, and these were more common in people who had metal-on-metal implants.

How did the researchers interpret the results?

The researchers concluded that metal-on-metal stemmed hip implants have a higher failure rate than other options, and should no longer be implanted. They say that all patients with these types of implants should be carefully monitored, particularly young women whose hip implants have large diameter heads. They say that their findings support the continued use of large diameter ceramic-on-ceramic bearings as they seem to perform well.

Conclusion

Metal-on-metal hip implants have been under intense scrutiny in recent months, and this analysis provides useful data on how often they require revision and how they compare to implants made of other materials. Overall, this research indicates that metal-on-metal hip implants have higher revision rates (rates of replacement) than other types of hip implants in England and Wales.

As with all such studies, there is the possibility that factors other than the implant type differed between the groups being compared, and that these other factors may influence the results. The researchers tried to minimise the risk of this by:

• comparing similar operations in similar patients
• looking at men and women separately
• looking at the effect of age and implant head size

However, there are other factors such as activity levels that could still be having an effect.

As the data used in this study came from a surgical registry, not a lot of information was available about factors such as body mass index (BMI) or activity levels. These two factors could potentially influence the stress implants are placed under and therefore the wear that they display. The researchers say that in their opinion there is no obvious reason to suppose that these factors would vary to a large extent between people receiving the different large head metal and ceramic hip implants.

Due to these inherent limitations with observational research it is difficult to conclude that the differences seen are definitely due to the implants alone. The advantage of this registry data is that a large number of people were assessed. Furthermore, this is not a selected subsample of people receiving hip implants but all patients from different surgeons and using different implants. The researchers say that these strengths and the consistency of their findings support the suggestion that these findings do represent the true effects of the implant types.

Overall, these findings do seem to suggest that metal-on-metal hips do require revisions more frequently than other types of hip implants. This study reports that since 2008 there has been a dramatic reduction in the use of metal-on-metal hip implants in England and Wales. Overall it found that most hip replacements analysed in the study period (92% between April 2003 and September 2011) did not use metal-on-metal implants. It seems likely that based on this study their use may decline further. It is important to bear in mind that the overall five-year revision rates with metal-on-metal hips is 6.2%, so the majority of these implants have not needed revision in this time. This study supports the authors’ suggestion and MHRA recommendation that people with these implants should be monitored carefully over time, to identify when such revisions might be required.

Analysis by Bazian : reproduced from NHS Choices