More than a sum of parts.

Pauline has a number of conditions. She has a heart condition, hypertension, osteoarthritis in her hips, continence and mobility problems. She is having her problems treated. The trouble is she’s having them treated in different hospitals by different consultants. Pauline is 86 and her memory is not what it was. She has difficulty with attention and calculation and short-term memory. In my view, Pauline needs to have an assessment at a memory clinic; her cognitive problems make it difficult for her to keep track of her appointments, take her medication and comply with medical advice. I have concerns about her receiving integrated care because that needs managing. Someone needs to have a holistic overview of Pauline’s health and to work with her to balance the costs and benefits of each treatment. The diuretics prescribed by the cardiologist can affect continence. They can also cause dizziness and postural hypotension. Pauline says sometimes she forgets them for a few days then takes them in a batch to sort out leg swelling. The falls caused by rushing to the toilet, dizziness and arthritic pain affecting gait cause Pauline to become fearful and less mobile. Then she gets stiffer and everything becomes too much. Pauline is widowed and has no children. She lives alone and is vulnerable, like many older people. Doris has glaucoma and a confirmed diagnosis of dementia. She has osteoarthritis, diabetes, osteoporosis, hypertension and a number of other conditions. Doris is under the care of a number of specialists and visits three London hospitals to see different consultants. She isn’t really sure about which medications she’s supposed to be taking or what care she’s supposed to be receiving. “It’s all a bit of a muddle,” she explains. When I ask Doris’s daughter-in-law Kate if she can shed some light on Doris’s history and treatments she produces an indexed A4 binder. There’s a summary sheet of Doris’s conditions, consultants and medications. There are sections for the letters from consultants and therapists. I notice there’s a new section for community nursing. Unfortunately, in most cases, healthcare services expect patients to remember, organise and manage complex healthcare information. We expect patients to remember what tests they’ve had, where they’ve had them and what the results were. We expect them to know and follow recommendations on diet and exercise and to know what medications they are on. This can prove challenging even when a person has only one condition and is cognitively intact. As we age we are at increased risk of having more than one condition and the incidence of cognitive impairment rises with age. It can all become a bit of a muddle. Muddles are dangerous. They can result in fragmented care, in medication that is not optimised, in tests being repeated and treatment delayed. Our patients deserve better, but if we’re not careful things will get worse. There are fresh risks that threaten to further fragment care. The marketisation and commodification of healthcare open the healthcare ‘market’ to multiple providers. This means a person with just one condition such as respiratory disease may receive oxygen from one provider, rehabilitation from another, primary care from another and acute care from another (Morgan, 2012). Older people are at the greatest risk of harm due to fragmentation of care, as they are more likely to have multiple conditions, live alone and to have some level of cognitive impairment. We need to get smarter quickly. Two actions would improve care, increase safety and cut costs. The first is to learn from the problems the US has experienced with its market-led healthcare system. In the US, choice is not unlimited and the concept of ‘any willing provider’ is not absolute; patient safety is paramount. In the US, disease management programmes mandate that one provider provides all aspects of a patients care in relation to a particular disease. So the person with respiratory disease will have oxygen, therapy, primary and secondary care supplied by one provider (Morgan, 2012). This reduces risks and improves care. The second is to use technology to enable us to maintain effective records. We can now store large amounts of information on microchips. Providing patients with electronic records that could be presented and updated on each and every healthcare encounter is entirely possible. These could be in the form of a medical card or a device with a microchip that is worn as a bracelet or a pendant that contains up to date accurate information about the person’s health. Our population is ageing and greater numbers of people have multiple conditions (Office for National Statistics, 2012). It is not possible to provide every person with long term conditions with support from community matrons and not every older person has a family who can support them. We need to work together to ensure that patients receive the best possible care. We need systems and processes to to do this. Simple solutions such as those outlined could make a big difference in the difficult times that lie ahead. BJCN