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Elderly people at home who cannot cope
388
Elderly people at home who cannot cope SiR,—The procedure for admission under section 47 of the National Assistance Act 1948 incorporates safeguards that are probably better than those existing under the Mental Health Act. The comments of Dr Tregaskis and Dr Mayberry (July 6, p 47) appear to deal largely with abuses of the Act. Let us examine what happens in practice to see if the patient’s rights are neglected. The patient’s own doctor is involved and he is concerned to promote the best interests of his patient. He can obtain advice from a consultant geriatrician and often does. Indeed, consultant geriatricians are one of the sources of referral for section 47. A social worker is involved, and they are stalwarts in the protection of individual rights. The public health physician acts as an independent medical assessor and not as a law enforcement officer. Sometimes he has to resist pressure for inappropriate admission from geriatricians or even solicitors. Not all patients require geriatric care but when admission to a geriatric ward is needed, this can only be achieved if the consultant agrees and, therefore, a further independent person is involved in the consideration of the patient’s needs. Finally, the procedure is reviewed by lay magistrates advised by a legally trained clerk. Evidence to the magistrates has to be given on oath. If rubberstamping does occur, that is no fault of the legislation-and there is no reason why the group suggested in Tregaskis and Mayberry’s recommendation 2 should not also descend to rubber-stamping. Many physicians have found that magistrates undertake a searching and sensitive review of the application. On one occasion, the inquiry lasted all morning and other cases listed for hearing had to be postponed. As with the Mental Health Act, the plea for advocacy should be resisted as it tends to create an impression that the patient is being charged with an offence. It is alleged that the "proper officer" is usually a junior medical officer. Where is the evidence for this? Good public health practice requires that the application is either made, or supervised, by a physician of some ten years’ standing. He should ensure that there is consultation with relatives and/or solicitor before admission. The patient should be visited after admission and consultations started with others as to future placement, including the possibility of returning home. The question of treatment is outside the remit of the Act. Admission cannot be based on refusal of treatment and anyone who presumes to treat compulsorily is acting in ignorance and illegally. There is no danger that section 47 will be used for the benefit of others or to compensate a shortfall in local services, unless the social worker and doctors conspire to commit perjury. The fact that 91 % of people admitted were dead within a year proves nothing. The group under consideration is a pre-selected, high-risk one. My impression, gained after admitting about 15 patients over a period of years, is that most would have died within 3 months if they had not been helped. Section 47, like electroconvulsive therapy, forceps delivery, and antidepressants can be a great help to patients if not abused. It is an excellent piece of legislation provided by Parliament in recognition of the frailty of the human race and the need to preserve the dignity of mankind. The emergency powers were introduced on the suggestion of Sir Alfred Broughton, an MP and general practitioner, who was anxious to ensure that our old people were not left to die in lonely squalor, and their bodies gnawed by rats while advocates engaged in costly, eloquent, but irrelevant, submissions. Bingley Health Centre, Bradford BD16 2TL, UK
the safety of the person in question
nor
the public health is
compromised. The Committee of Inquiry into the future of public health recommended (para 5.6) that the public health consultant should no longer be required to implement section 47. I hope that when the Act is reviewed this recommendation will be considered and that the implementation of section 47 is passed on to a designated social worker or a consultant geriatrician from a different district. Hampstead Health Authority, 21 Pond Street, London NW3 2PN, UK
M. R. BAHL
Recognising disability SiR,—Your July 20 editorial rightly points out that doctors are ill trained to recognise disability. We were concerned about the apparent lack of this skill in staff in accident and emergency
departments. Nurses and doctors in these departments and on the wards a questionnaire whenever they felt that someone had considered discharging a patient without taking account of the short-term disability produced by the presenting acute illness or injury. 117 forms were completed. In 98 cases, after the form had been discussed with the doctor concerned, discharge was judged inappropriate. In 54 such cases, the discharge was proposed by ward doctors and in 44 cases by doctors in accident and emergency departments. Nurses prevented inappropriate discharge in 79 of the 98 cases. Inappropriate discharge could be attributed to five main factors (more than one factor was attributed to some patients). (i) Pressure on beds (49 patients) was the commonest reason given by the specialty registrars, some of whom admitted that they had tried to discharge people who they knew could not walk. (ii) Failure to ask about home circumstances happened in 27 patients-eg, attempting to discharge a 24-year-old man, with freshly applied bilateral above-knee plaster-of Paris casts and instruction not to bear weight, who lived alone. (iii) Whether a person could perform important activities of daily living, such as walking was not established in 22 patients. (iv) In 17 patients, staff failed to enlist the help of other health-care professionals, such as district nurse, meals on wheels, or home help. (v) The role and availability of other health care professions was misunderstood (6). After this small study hospital staff realised that discharge arrangements on acute medical and surgical wards could be improved. The use of a team including a doctor, social worker, nurse, and other staff, and weekly meetings (as is done routinely in departments of medicine for the elderly) quickly identifies patients with disabilities. This enables prompt involvement of other healthcare staff and results in earlier discharge and improved bed use. Recognition of disability is not a desirable optional extra; it is an integral feature of good clinical practice. The training of medical students and junior doctors should include regular secondment to such multidisciplinary teams.
completed
Accident and Emergency Department, and Department of Medicine for the Central Middlesex Hospital, Park Royal, London NW10 7NS, UK
Elderly,
S. S. TACHAKRA A. C. D. CAYLEY
P. BURROWES
Cervical SiR,—Dr Tregaskis and Dr Mayberry stress that section 47 of the National Assistance Act should be reviewed. Their recommendations are supported. The definition of section 47 is "removal to suitable premises of persons in need of care and attention". The person concerned refuses all medical, nursing, and social support. The application of this legislation is painful but is in the interest of the patient/client. In most cases intervention by the "proper officer" is preceded by visits from a district nurse, social worker, general practitioner, and a consultant geriatrician or psychogeriatrician. The proper officer (who is usually a consultant in public health medicine and not a "junior member" of a local public health department) acts as referee and ensures that neither
cancer:
need to look and
recognise
SiR,—There has been an increasing consensus on the conservative management of mild cytological abnormalities. A recent workshop convened by the National Cervical Screening Programme National Coordinating Network’ concluded that mild dyskaryosis should be managed by a repeat smear at six months and if the abnormality persists should then be referred for colposcopy. This is a view we support on scientific evidence, until prospective studies further clarify the situation. But advocates of immediate referral for mild cytological abnormalities have always argued that this will lead to the detection of occult invasive lesions at the earliest opportunity. Other workers have drawn attention to the occurrence of invasive cervical lesions in patients with smears suggestive of a
Elderly people at home who cannot cope SiR,—The procedure for admission under section 47 of the National Assistance Act 1948 incorporates safeguards that are probably better than those existing under the Mental Health Act. The comments of Dr Tregaskis and Dr Mayberry (July 6, p 47) appear to deal largely with abuses of the Act. Let us examine what happens in practice to see if the patient’s rights are neglected. The patient’s own doctor is involved and he is concerned to promote the best interests of his patient. He can obtain advice from a consultant geriatrician and often does. Indeed, consultant geriatricians are one of the sources of referral for section 47. A social worker is involved, and they are stalwarts in the protection of individual rights. The public health physician acts as an independent medical assessor and not as a law enforcement officer. Sometimes he has to resist pressure for inappropriate admission from geriatricians or even solicitors. Not all patients require geriatric care but when admission to a geriatric ward is needed, this can only be achieved if the consultant agrees and, therefore, a further independent person is involved in the consideration of the patient’s needs. Finally, the procedure is reviewed by lay magistrates advised by a legally trained clerk. Evidence to the magistrates has to be given on oath. If rubberstamping does occur, that is no fault of the legislation-and there is no reason why the group suggested in Tregaskis and Mayberry’s recommendation 2 should not also descend to rubber-stamping. Many physicians have found that magistrates undertake a searching and sensitive review of the application. On one occasion, the inquiry lasted all morning and other cases listed for hearing had to be postponed. As with the Mental Health Act, the plea for advocacy should be resisted as it tends to create an impression that the patient is being charged with an offence. It is alleged that the "proper officer" is usually a junior medical officer. Where is the evidence for this? Good public health practice requires that the application is either made, or supervised, by a physician of some ten years’ standing. He should ensure that there is consultation with relatives and/or solicitor before admission. The patient should be visited after admission and consultations started with others as to future placement, including the possibility of returning home. The question of treatment is outside the remit of the Act. Admission cannot be based on refusal of treatment and anyone who presumes to treat compulsorily is acting in ignorance and illegally. There is no danger that section 47 will be used for the benefit of others or to compensate a shortfall in local services, unless the social worker and doctors conspire to commit perjury. The fact that 91 % of people admitted were dead within a year proves nothing. The group under consideration is a pre-selected, high-risk one. My impression, gained after admitting about 15 patients over a period of years, is that most would have died within 3 months if they had not been helped. Section 47, like electroconvulsive therapy, forceps delivery, and antidepressants can be a great help to patients if not abused. It is an excellent piece of legislation provided by Parliament in recognition of the frailty of the human race and the need to preserve the dignity of mankind. The emergency powers were introduced on the suggestion of Sir Alfred Broughton, an MP and general practitioner, who was anxious to ensure that our old people were not left to die in lonely squalor, and their bodies gnawed by rats while advocates engaged in costly, eloquent, but irrelevant, submissions. Bingley Health Centre, Bradford BD16 2TL, UK
the safety of the person in question
nor
the public health is
compromised. The Committee of Inquiry into the future of public health recommended (para 5.6) that the public health consultant should no longer be required to implement section 47. I hope that when the Act is reviewed this recommendation will be considered and that the implementation of section 47 is passed on to a designated social worker or a consultant geriatrician from a different district. Hampstead Health Authority, 21 Pond Street, London NW3 2PN, UK
M. R. BAHL
Recognising disability SiR,—Your July 20 editorial rightly points out that doctors are ill trained to recognise disability. We were concerned about the apparent lack of this skill in staff in accident and emergency
departments. Nurses and doctors in these departments and on the wards a questionnaire whenever they felt that someone had considered discharging a patient without taking account of the short-term disability produced by the presenting acute illness or injury. 117 forms were completed. In 98 cases, after the form had been discussed with the doctor concerned, discharge was judged inappropriate. In 54 such cases, the discharge was proposed by ward doctors and in 44 cases by doctors in accident and emergency departments. Nurses prevented inappropriate discharge in 79 of the 98 cases. Inappropriate discharge could be attributed to five main factors (more than one factor was attributed to some patients). (i) Pressure on beds (49 patients) was the commonest reason given by the specialty registrars, some of whom admitted that they had tried to discharge people who they knew could not walk. (ii) Failure to ask about home circumstances happened in 27 patients-eg, attempting to discharge a 24-year-old man, with freshly applied bilateral above-knee plaster-of Paris casts and instruction not to bear weight, who lived alone. (iii) Whether a person could perform important activities of daily living, such as walking was not established in 22 patients. (iv) In 17 patients, staff failed to enlist the help of other health-care professionals, such as district nurse, meals on wheels, or home help. (v) The role and availability of other health care professions was misunderstood (6). After this small study hospital staff realised that discharge arrangements on acute medical and surgical wards could be improved. The use of a team including a doctor, social worker, nurse, and other staff, and weekly meetings (as is done routinely in departments of medicine for the elderly) quickly identifies patients with disabilities. This enables prompt involvement of other healthcare staff and results in earlier discharge and improved bed use. Recognition of disability is not a desirable optional extra; it is an integral feature of good clinical practice. The training of medical students and junior doctors should include regular secondment to such multidisciplinary teams.
completed
Accident and Emergency Department, and Department of Medicine for the Central Middlesex Hospital, Park Royal, London NW10 7NS, UK
Elderly,
S. S. TACHAKRA A. C. D. CAYLEY
P. BURROWES
Cervical SiR,—Dr Tregaskis and Dr Mayberry stress that section 47 of the National Assistance Act should be reviewed. Their recommendations are supported. The definition of section 47 is "removal to suitable premises of persons in need of care and attention". The person concerned refuses all medical, nursing, and social support. The application of this legislation is painful but is in the interest of the patient/client. In most cases intervention by the "proper officer" is preceded by visits from a district nurse, social worker, general practitioner, and a consultant geriatrician or psychogeriatrician. The proper officer (who is usually a consultant in public health medicine and not a "junior member" of a local public health department) acts as referee and ensures that neither
cancer:
need to look and
recognise
SiR,—There has been an increasing consensus on the conservative management of mild cytological abnormalities. A recent workshop convened by the National Cervical Screening Programme National Coordinating Network’ concluded that mild dyskaryosis should be managed by a repeat smear at six months and if the abnormality persists should then be referred for colposcopy. This is a view we support on scientific evidence, until prospective studies further clarify the situation. But advocates of immediate referral for mild cytological abnormalities have always argued that this will lead to the detection of occult invasive lesions at the earliest opportunity. Other workers have drawn attention to the occurrence of invasive cervical lesions in patients with smears suggestive of a