PAPER B

Continuing Care Needs and Public Health

For the purposes of this briefing paper the following definitions have been used to inform the evidence given below:

Continuing Care (or long term care) is a general term that describes the care that people need over an extended period of time, as a result of disability, accident or illness to address physical and/or mental health needs. It may require services from the NHS and/or social care. Continuing care may be provided in a range of settings from an NHS hospital to the patient’s own home.

Continuing Care Eligibility Criteria, Hampshire & IW Strategic Health Authority, June 2006

Public Health has been defined as “the science and art of preventing disease, prolonging life and promoting health through the organised efforts and informed choices of society, organisations, public and private, communities and individuals.”

A person receiving continuing care is likely to have complex and specialised health and social care needs which may be due to:

o Complex, intense or unpredictable health care needs and with the need for continuity of specialised care

A rapidly deteriorating or unstable medical, physical or mental health condition requiring regular supervision by specialist staff

The individual being in the final stages of a terminal illness and likely to die in the near future. Whilst not being prescriptive ‘near future’ will be around 4-8 weeks.

These circumstances have a number of implications for public health interventions:

The scope of traditional public health preventative programmes will be limited for the majority of individuals in continuing care, although for some people very slow-stream rehabilitation may offer scope for improving health status over a period of time and in due course lead to them no longer requiring continuing care. The focus of care is more likely to relate to maximising well-being and quality of life and will be delivered by specialist staff who will need to incorporate a public health approach into their care plans, rather than an intervention being provided by the core public health team.

Many of the patients receiving continuing care will be older people and their care will be guided by the National Service Framework for Older People, a number of these standards link closely to public health approaches:

Standard 1 - Rooting out age discrimination

Standard 2 - Person-centred care

Standard 6 - Falls prevention

Standard 8 - Promotion of health and active life in older age

The NSF has recently been updated with the publication of A New Ambition for Older Age. This identifies three priorities:

o Dignity in Care

o Joined up care

o Healthy ageing

Two areas are specifically highlighted below, demonstrating how other staff groups have a key role in promoting health and well-being in continuing care settings and the importance of working in partnership to deliver the public health agenda.

Nutrition in continuing care settings

The Dignity in Care programme highlights the need to ensure older people’s nutritional needs are carefully considered, including provision of assistance with eating and drinking. Maintaining good nutritional intake and adequate hydration are essential to enabling individuals to maximise their health potential. Under-nutrition can have a significant impact on recovery from illness, injury or surgery in older people with links to higher rates of wound infection, increased risk of general infection, pressure sores and heart failure, as well as increased likelihood of adverse psychological reactions. Being underweight can lead to increased risk of osteoporosis and fracture, impairment of muscle function, impaired respiratory drive and decreased cardiac function, compromised immunity, impaired body heat production with increased risk of hypothermia and associated risk of falls and injury, increased likelihood of inpatient admission and longer inpatient episodes. Malnutrition has been associated with increased mortality risk. A systematic approach to identifying malnutrition on admission to hospital is currently being introduced with the use of a tool called the Malnutrition Universal Screening Tool (MUST).

Research indicates the value of older people having company whilst eating, of having pleasant surroundings and being able to exercise choice over their food. There is much that staff in residential care settings can do to make meal times a pleasant and sociable occasion. Research has identified benefits from establishing family-style mealtimes for older people in residential care settings, with improvements in both psychosocial function and calorie intake, the latter being particularly influenced by having companionship at mealtimes.

The Food Standards Agency published Nutrient and Food Based Guidelines for UK Institutions in October 2006. This document provides advice and sample menus for residential and nursing homes, based on the nutritional needs of people aged 75 and over with the aim of supporting wider care standards and to provide the basis for commissioning and monitoring of services. As well as promoting the general principles of healthy nutritional intake recommended for the population as a whole, the guidance includes advice specific to the needs of older people such as ensuring adequate intake of a range of essential micronutrients, including Vitamin D, essential for effective absorption of calcium. Additional guidance for meeting the needs of people who have specific disease-related nutritional needs are available from the National Association of Care Caterers.

Just as the role of school catering staff in promoting public health is currently being developed and promoted, so too, the key public health role of catering staff working in care settings also needs to be acknowledged and supported through training and development. The Isle of Wight Healthy Eating Alliance has recognised the importance of this role by establishing a separate category for good practice in promoting good nutrition in care homes within its annual Healthy Eating Awards to be presented in early December.

Falls prevention in residential and nursing homes

The need to reduce the risk of falls was identified by a dedicated standard within the National Service framework for Older People. The care home setting is especially important for falls prevention programmes as 60% of people in care homes are likely to fall each year. Staff working in residential and nursing homes have a key role in preventing falls and the Falls Prevention Co-ordinator of the Public Health Team has been providing training to staff in these settings to enable them to understand the factors that increase risk of falls and to identify action they might take to minimise the risk of falling among the individuals they care for. A presentation giving more information about this work programme will be given to the Commission by the Falls Prevention Co-ordinator.

Dr Paul Bingham

Director of Public Health