Ensuring dignity, respect and standards of care for older people

None of us could remain unmoved by the harrowing details revealed in the recent Parliamentary and Health Service Ombudsman (PHSO, 2011) report regarding care of older people. Lack of care, dignity, privacy and a lack of insight into the specific needs of older people were all present. The focus appeared to be on inpatients, and one can speculate regarding the factors in this environment that could contribute to such poor care. 

For those of us who work in hospitals, and visit adults to assess and improve their diabetes care, it has been noticeable that many inpatients seem increasingly ill with complex medical needs, many of whom are older people. Often staffing levels do not match the resources needed for such care, and additional staffing is not available due to financial constraints. People are often moved several times during their hospital stay, which must reduce familiarity by staff of their patients’ needs, as well as being disruptive and distressing for the individuals themselves – and certainly disorientating if they are moved at night. All of these factors can combine to reduce patient safety and confidence in care provision. 

So what is the relevance of this to diabetes care? Many of the people with diabetes who we support go into hospitals, and many are either older people or frail elderly. Clearly, their needs could be unmet because they are old, but also because of additional specific problems, such as cognitive changes due to age, comorbidities and diabetes-related complications. Although well documented in the literature, these specific problems are not always recognised in hospital or community settings where older people do not have access to specialist diabetes teams – and many do not. This includes those who are housebound or live in institutionalised care. 

So what can we as nurses working in diabetes do to prevent or avoid similar tragedies for older people with diabetes? We know that our specialist resources are limited and are at risk of being further reduced, so one place to begin is to ensure that our diabetes services are as effectively and efficiently organised as possible. Key to that organisation is effective teamwork, which is demonstrated by leadership, team members knowing their role and having the skills and competencies to perform safely, with honesty and trust among the team to achieve the vision of the patient at the centre of care. This collaboration is essential to provide an integrated service, which works for the person with diabetes across primary, community and hospital care, with access to specialists and generalists at defined stages. Without effective teamwork, the support and safety of people with diabetes will be compromised, and scarce resources could be squandered with the resultant tragedies as seen in the Ombudsman report (PHSO, 2011). 

The topic of teamwork is explored further in this supplement by Joy Williams, whose article on page 109 discusses how effective teamwork can improve the care of older people with diabetes, by identifying barriers to teamworking, recognition of an effective team, and how health care must be delivered within current resources.

Another important way of reducing the risk of suboptimal care is to have agreed protocols or clinical guidelines to protect the vulnerable older person with diabetes, and improve quality of care. In their article on page 102, Fiona Kirkland and Professor Alan Sinclair identify the barriers to the delivery of high-quality care in care homes, and the need for good clinical practice guidelines for care home residents with diabetes. The authors hope that through the discussion of the Good Clinical Practice Guidelines for Care Home Residents (Diabetes UK, 2010), and recognition of the inequities of diabetes care, that “such barriers will be diminished, thus reducing the consequences of poor diabetes management and improving quality of life for older people with diabetes”.

My hope is that in addition to these guidelines, by improving our service organisation through teamwork and making best use of our resources we can reduce the risk of our patients’ voices only being heard through an ombudsman’s report.