Dr Colin Currie, Chair, Hip Fracture Audit Database Special Interest Group, Fragility Fracture Network;
Clinical Lead (Geriatric Medicine), 2007-2013, UK National Hip Fracture Database will be presenting at the upcoming 3rd Annual Hip Fracture Management Conference, taking place on the 3rd and 4th December 2014 at the Sydney Harbour Marriott.
Dr Currie joined us to share some interesting insights into the limited availability of support and rehabilitation in the community that results in large numbers of older people being unnecessarily admitted permanently to a care home following a hip fracture.
“I dimly recall a hip fracture-related publication of long ago. In it, a large proportion of a series of older Australian women who were interviewed said they would rather die than be institutionalised as a result of a hip fracture (1).
At that time, probably back in the 1970’s, Australia had among the highest rates of institutionalised over- 65’s in the world; and of course I am aware that this has been addressed – if only on grounds of cost.
But the anxiety hasn’t gone away, with loss of home, independence and all that goes with that being seen – not unreasonably – as a fate worse than death.
A few years back, in chance meetings on the London-Edinburgh train, three or four Scotland-based acquaintances with parents or parents-in-law in England told me indignantly how – only a few weeks following a hip fracture – their relatives had been dispatched to permanent nursing home care.
I was doing the London-Edinburgh commute weekly because I was working part-time in Downing Street. As an adviser on health and social care of older people I had access to an immense amount of data on the outcomes – including care home admission – of unscheduled hospital admissions of over-75s and over-85s in England: with hip fracture accounting for a significant proportion of them. The indignation expressed in a very short personal series from the East Coast line was justified.
The rates of permanent institutionalisation following hip fracture vary quite alarmingly. And that is not a reflection of any credible variation in clinical need at population level. Instead – simply and brutally – it reflects a post-code lottery in community support and rehabilitation for older people who have broken a hip.
I had more than the numbers to go on. The Downing Street job allowed me to indulge in a little light anthropology: visiting some of the few places where, on the evidence available, such services seemed to work well. That was a revelation. (2).
In the two best-performing locations, top-line community services had established a kind of protective ownership of the frail elderly at home. All necessary care was provided for them there by teams who knew them well and, when acute hospital admission was inevitable, it could be cut short by early discharge home with immediately available support and rehabilitation. And the same could be done even if you were unknown to the local team before your acute admission.
Care home admissions from acute hospital care had fallen sharply in both places. Anecdotally, hip fracture patients featured largely among those who had benefited.
Why isn’t a post-code lottery like this recognised as a national scandal? Whoever is paying the bills, unnecessary admission to permanent care home care is very expensive. And, in strictly humanitarian terms, such admissions are an outrage. Don’t even the strictest of high court judges consider all the alternatives before imposing a life-time custodial sentence?
Is there anything we can do about it? Well, knowing more about it would be a start. The next big challenge for hip fracture audit in the UK is to document post-acute care far better and demonstrate – ideally using case-mix adjustment – the unjustifiable variance in care home outcomes; to identify good practice; and then to use the power of audit, clinical governance and political pressure to address the vast, costly and avoidable injustice of ‘a fate worse than death’ resulting from poor care after a hip fracture”.
Author: Dr Colin Currie, Chair, Hip Fracture Audit Database Special Interest Group, Fragility Fracture Network; Clinical Lead (Geriatric Medicine), 2007-2013, UK National Hip Fracture Database.
To find out more about the event programme and to register, please visit the 3rd Annual Hip Fracture Management Conference website.