Mind your language; they"re not "bed blockers" but older people

The NHS is faced with a rising tide of demand for care combined with a tight rein on both NHS and social care finances. The impact of these pressures is seen across the health and care system. It manifests itself obviously in delayed transfers out of hospitals.

Year on year these delays are rising, with more people staying in hospital when they don’t need to be there. It has an impact on the care of some of the frailest and most vulnerable people and is the subject of continued attention from the media, healthcare regulators and politicians.

When media and commentators discuss this issue it’s only a matter of time before a certain horrible term is used – “bed blocker”.

The phrase “blocked bed” originated in the UK in the late 50s, driven by hospital clinicians’ concerns about a lack of beds. Its use grew between 1961 and 1967, when the elderly population increased by 14% while bed numbers remained static. In 1986 “bed blocking” made its first appearance in a British Medical Journal headline. Although it was not accepted as a medical term, by the 90s it was being widely used by health economists as a marker of inefficiency.

The term persists to this day, despite many efforts to move away from it, such as the Department of Health’s redefinition of delayed discharge and delayed transfer in April 2001.

Surely the time has come to remember to whom bed blocking is referring. These “blockers” are often older people, who are frail and vulnerable and who would like nothing more than to return home to their families. The phrase “bed blocker” puts all the emphasis, and blame, on the individual. The reality is that it is the system that has failed to move quickly enough to put together the right package of care to enable the person in the bed to return home.

Language matters. How we talk about people reflects how we treat them and, in the health service, how we engage them in the care they receive. When we stop talking about people as people and instead use the language of the system (units, targets, blockers) we risk undermining the compassionate care the health service was created for and has delivered for almost 70 years.

I rarely hear anyone who works in the health and care sector use this phrase. Those working with and caring for people see the individual. They know their individual stories and what matters to them.

There is a quiet revolution under way in the NHS. It’s increasingly recognised that people should no longer be seen as passive recipients of their care but as participants in both the decision making process and the care they experience.

This is the right thing to do and what people want. But it is also a response to people’s changing health needs. With more and more people managing long-term conditions, sometimes more than one at a time, the old “patch ‘em up, ship ‘em out” approach is a thing of the past. The health service needs to work with people to manage their own care, and this means understanding their individual circumstances, wants and needs. To do this well also means looking beyond the health service towards their family life and other institutions like local government, schools and community groups.

The NHS Confederation brought together experts from across health and care to form a commission on improving urgent care for older people. In Sheffield, new processes discharge many more patients home, to be assessed there rather than in a mock environment in the ward. A saving of more than 30,000 bed days was recorded there over the first year and people report better experiences of care.

North east London foundation trust and the London Ambulance Service have together provided a home-based emergency assessment and care package for people who fall, resulting in only one in 20 recipients being admitted to hospital within 48 hours. There are similar examples in Derbyshire, Oldham, Greater Manchester, Norfolk, Aintree and right across the country.

The NHS has a way to go in making sure these examples make up a default approach. But the term “bed blocking” is unhelpful and arguably one of the most inappropriate terms in the healthcare lexicon. Let’s consign it to the dustbin and focus on what we know works both for the individual and the health and care system.

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Mind your language; they"re not "bed blockers" but older people

Guideline Critics Shift Attacks From Beta Blockers To Statins

With the release today of updated European and US guidelines the ongoing controversy regarding beta-blockers appears to be resolved. But that doesn’t necessarily mean there will be an outbreak of guideline peace and harmony. The critics who helped ignite the controversy over beta blockers now say new statin recommendations contained in the guidelines are based on deeply flawed evidence.

The previous incarnation of the European guideline on perioperative evaluation and treatment of people undergoing noncardiac surgery was the subject of intense criticism due to the scandal discrediting Don Poldermans, a Dutch researcher widely published in the field. To address the current uncertainty US and European medical societies earlier today released updated versions of these guidelines.

“Given the recent publication of several large-scale trials, including POISE-II, and new risk calculators, as well as the controversy regarding the use of beta blockers related to the DECREASE trials, the writing committee felt it was necessary to reevaluate all of the data on cardiovascular care for the patient undergoing noncardiac surgery,” said US Writing Committee Chair Lee Fleisher, in a press release.

Regarding beta-blockers the US and European guidelines now do not recommend routine use in patients who undergo non-cardiac surgery, though people who are already taking beta-blockers should continue taking them. (Previously the European guideline but not the US guideline did support routine use of beta-blockers.) Both guidelines state that beta blocker therapy may be initiated prior to surgery in carefully selected higher risk patients.

Statin Recommendation Comes Under Fire

Both the new European and US guidelines say that preoperative initiation of statin therapy may be considered in patients undergoing vascular surgery and that people already taking statins should continue taking them. Now some of the same critics who attacked the reliability of the beta blocker guideline say that this recommendation is not supported by the evidence.

The new recommendation is based on several observational studies and one randomized controlled trial. (Two other randomized trials were not considered because they were performed by Poldermans’ group and have been discredited.) The  critics, UK cardiologists and researchers Darrel Francis and Graham Cole, say that the one  trial by Durazzo et al has fatal flaws that make it completely unreliable. (Durazzo, it may be worth noting, had been a frequent co-author of Polderman’s and had been a co-author of several of the controversial or retracted studies.)

In an analysis published earlier this year, Cole, Francis, and co-authors wrote that the Durazzo study

…was a double-blind randomised trial of 100 patients undergoing vascular surgery, with a 45-day course of atorvastatin or placebo. It sought reduced perioperative events in the atorvastatin arm, which indeed was what was found: 8% versus 26% (p = 0.031) at 6 months [22].

This study has serious failings, which make it an unsound basis for recommending therapy. First, its sample size calculation is stated to have been based on a 22% event rate at 6 months in a previous paper [23]. In reality, the source article states that the rate was 12% at 6 months. Such a transcription error would cause a study to be approximately 4-fold undersized.

Second, the authors indicate that they designed their study to detect a relative risk reduction of 95%. This study design is not credible as no therapy has ever been so effective in preventing myocardial infarction. If the true effect size was, for example, half of this, this overestimate would have contributed a further ~ 4-fold undersizing of the study.

Third, the survival data published cannot be correct. The paper reports that of the 50 patients in each arm, none were lost to follow-up. Therefore, every patient surviving to each displayed time point should be exactly 2%. With this in mind, in the Kaplan–Meier graphs, almost all the numerical values in the survival follow-up figure contradict the graphical values shown.

Finally, for 50-patient groups with no loss to follow-up, event-free survival rates must again be multiples of 2%. They are quoted as 91.4% and 73.5%, values that are not possible.

Francis and Cole sent the following comment about the new guidelines:

We are very sad that over 100 world authorities were forced to sign the European guideline without all having had time to read the papers on which their recommendations were based, and without being able to openly voice dissent.

Their awful predicament is easiest to see for a therapeutic idea whose road has been very “bumpy” indeed: the perioperative course of statins. The outcome data of the key trial by Durazzo et al has for over 6 months been publically known to be impossible. This is buttressed by Don Poldermans’ now notorious DECREASE III and IV trials, whose own university’s investigation revealed extensive fictionalisation, and by meta-analyses whose events arose mostly or entirely amongst these extraordinary pieces of science.

There are important lessons to learn. First, guidelines must in future have the right to say that all the major trials have now been discredited, so there is no longer a recommendation. If we fail to recognise this, we have truly failed our patients.

Second, never again should we pretend that all the experts have agreed on recommendations. It was always unlikely, and in this case clearly ridiculous.

In an interview, Fleisher, the chair of the US guideline, defended the committee’s recommendation of statins. He said that the committee was aware of the limitations of the Durazzo study and that the recommendation was based on the totality of the evidence, including the observational studies. He agreed that there was a significant need for more high quality studies.

Guideline Critics Shift Attacks From Beta Blockers To Statins

Jeremy Hunt: Doctors should quit thinking of individuals as "bed blockers and bodies"

Mr Hunt wants hospitals to move away from the “rigid shift patterns” imposed as a result of the European Operating Time Directive to guarantee that medical professionals have the “flexibility” to care for their patients.

In a speech at St Guy’s and St Thomas’s hospital in London, Mr Hunt will relate some of the letters of complaint he receives every day from individuals.

He will to say: “A single letter I received last March was from a lady whose husband sadly passed away right after what can only be described as two many years of chaotic care.

“Her husband was passed all around the program from clinician to clinician, with no a single appearing to know anything at all of his demands or historical past.

“One more letter I got this month came from a man diagnosed with cancer of the throat, but also a suspected secondary cancer of the kidney. His consultant referred to him inside of earshot not by his title but as ‘head and neck …#157′.”

Mr Hunt will contact for a significant alter in the culture of the NHS. He will say: “Every patient is a person. A man or woman with a title. A man or woman with a household. Not just a physique harbouring a pathology not a diagnostic puzzle not a four-hour target or an 18 week difficulty not a value pressure – and most surely not ‘bed-blocker … #157″.

He praised Dr Granger’s Twitter campaign to motivate doctors to be far more courteous when speaking to their patients. He will say: “Dr Kate Granger has highlighted the importance of treating patients as men and women.

“She has started out the campaign #hellomynameis, which has turn out to be increasingly properly-identified based mostly on the basic but essential courtesy of introducing oneself when meeting sufferers for the very first time. We can all learn from that strategy.”

Last year, Mr Hunt announced that sufferers will be offered a named medical professional and nurse who will be listed above their bed and be accountable for their care for the duration of every single shift.

He now wants to go additional and introduce “entire remain” doctors, who are responsible for a patient’s properly-becoming throughout their keep in hospital.

From right now, the Care Good quality Commission will make “continuity of care” a single of its essential “indicators” when carrying out assessments.

Mr Hunt will say: “This technique has confirmed extremely profitable in nations the place it is adopted. Lengthy stays and costs can be reduced. With wise flexibilities, the concept have to certainly be to ingrain continuity of care as one of our crucial priorities for each and each NHS patient. I want each hospital in the nation to adopt keep-at-residence physicians.”

Jeremy Hunt: Doctors should quit thinking of individuals as "bed blockers and bodies"