Hip fracture patients `get sub-standard treatment'

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The Independent Online

Health Editor

Thousands of elderly people who break their hips receive sub-standard care, with long delays before treatment from inexperienced surgeons and poor pain control, according to a study.

The Audit Commission assessed the care provided by for elderly patients with hip fractures in nine hospitals across the country, and found patients' recovery was hindered by poor planning and co-ordination of their care, pre- and post-operatively, and in rehabilitation.

Each year, 57,000 people break their hips and most district general hospitals will see, on average, one patient a day with this condition. Most will be female; 90 per cent of them are over 65 and three-quarters are over 75. With an ageing population, the number of fractures will double in 20 years if current trends continue. The cost to the health service of caring for the patients is about pounds 250m a year.

Andrew Foster, Controller of the Audit Commission, said: "Although there are some examples of good practice, there are more things going wrong at every stage [in hip fracture] than we've found in previous studies for similar things."

He said it was not a failure of individual managers, doctors, nurses or social workers, but a failure to adopt a "coherent strategy" for dealing with hip fracture, and to view the condition from the patients' point of view. Initially, many patients were having to wait in A&E departments for up to 10 hours before admission to a ward. Almost 20 per cent of patients waited for more than five hours.

David Browning, associate director of the commission, said: "These are frail, elderly women in most cases, probably in shock. They are lying immobile on hard trolleys and there is a danger of pressure sores."

Although orthopaedic surgeons agree that the best outcome of a hip fracture repair is the result of prompt surgery, up to 40 per cent wait two to three days, often going without food - in case surgery is scheduled at short notice - and receiving less than optimum attention to pain control. The main problems are lack of theatre time and shortage of orthopaedic surgeons, according to the report.

Another worrying trend was the number of junior surgeons and anaesthetists who carried out the surgery, Mr Foster said. "One in 10 operations were carried out by an unsupervised SHO [senior house officer] surgeon and anaesthetist together.It is a serious operation involving big bolts being pushed through frail, crumbly bones. It needs to be done well."

Once the patient was ready for discharge further problems were identified largely because of failure to plan discharge early enough, and co-ordinate the various services - nursing care, physiotherapy, and social services. The report concludes with examples of best practice, and recommends that purchasing authorities (health authorities, GP fundholders etc) draw up detailed contracts of minimum expectations for the care and management of hip fracture patients by hospitals.

Mr Foster said comprehensive and well-co-ordinated care was needed to help elderly patients recover after hip operations, and in many cases their needs were not adequately met. He urged hospital managers to "take the lead in establishing robust arrangements for planning and delivering the care elderly people need".

Harriet Harman, Labour's health spokeswoman, said the improvements in care that the report recommends are made harder to achieve in a fragmented, competitive NHS. "Their call is for more planning and more co-operation in order to improve their care of these vulnerable patients. The Government is driving the NHS in the opposite direction."

8 United They Stand, Co-ordinating Care for Elderly Patients with Hip Fractures, HMSO; pounds 10.00.