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

Elderly care system under review

Elderly care system is a 'dog's breakfast', minister Paul Burstow admits

The current system of organising care for the elderly and disabled is a “dog’s breakfast” and in urgent need of reform, the minister responsible for it admitted yesterday.

Elderly care system is a 'dog's breakfast', minister Paul Burstow admits Photo: Alamy

By John Bingham, Social Affairs Editor

6:00AM GMT 02 Mar 2012   Telegraph

Paul Burstow said the social care system is no longer “fit for purpose” and is based on a complex and overlapping set of regulations dating back to the Tudor poor laws, which were reformed in the 1830s.

The Coalition is due to unveil its plans for reform in a white paper in April, to replace a patchwork system of overlapping entitlements and care standards in different areas.

But the white paper will not deal with the crucial issue of how to fund care for the elderly, which is the subject of separate cross-party talks taking place behind closed doors.

Similar talks designed to explore the possibility of creating a national care system based on the model of the NHS broke down in acrimony before the 2010 election.

This time even details of when and how many meetings have taken place have not been disclosed. A “progress report” is due to be released with the white paper.

During a live discussion on the social networking website “Gransnet” Mr Burstow heard a cataologue of examples of poor care and took questions on the need for an overhaul.

He responded: “I think social care law in this country is a complete dog's breakfast, and is the product of piecemeal change over the last 60 years.

“Our social care law looks back to the poor law and is not fit for purpose.”

He rejected predictions that most people would have to have private health insurance in 10 years instead of relying on the NHS but hinted that it might be necessary for people to have insurance to pay for personal care in their old age.

“I do think that there is a need for more people to wake up to the truth, even the nasty little secret, about social care: it's not free, and never has been,” he wrote.

“I know this comes as a shock to an awful lot of people, who think it's just like the NHS and think it will be free when you need it.

“The sad thing is that too many of us fail to plan for the time when we might be frailer, and as a result of that, put ourselves at greater risk … we have to have conversations earlier that are about how we plan for our long-term care needs, just like we have to have those conversations about pensions and other aspects of financial planning.”

He also said it was unacceptable that some elderly people are “not treated as a human being” while needing care and adding: “We need to ban age discrimination in our health and care system.”

Last night Michelle Mitchell, director-general of Age UK said: “In every sphere of life from hospital to social care or simply buying insurance, older people face daily discrimination.

“Ageism is the most common form of discrimination in the UK.

“It’s time to stop treating older people as second class citizens because of their age and recognise the valuable contribution that people in later life can and do make.”

Liz Kendall, the shadow minister for older people said: "The care system has reached breaking point. Fewer and fewer older people are getting the help they need as eight out of 10 councils are now providing care only for those with substantial or critical needs.

"And charges are soaring - for home care, residential care and meals on wheels - leaving many families struggling to know how they will cope.

"Paul Burstow should own up to the fact that more than £1 billion has been cut from local council budgets for older people's care since his Government came to power.

"We need urgent action to tackle the immediate care crisis and put in place a better, fairer system of funding for the future.

"That's why Labour has called for cross party talks on this issue and is pressing for legislation in this Parliament. I hope the Government