David Oliver is a Consultant Geriatrician in Berkshire and a visiting Professor in Medicine of Older People at City University, London. He is President Elect of the British Geriatrics Society. He writes on the King’s Fund blog about their paper, launched today.
By 2030, one in 5 people in England will be over 65 and at that age, men will on average live till 88 and women till 91. This population ageing shouldn’t constantly be catastrophised with language like “burden” “timebomb” or “tsunami”. In fact, it represents a victory for improved societal conditions and for modern healthcare – preventative and curative. Indeed, well into older age, most people report high levels of happiness, health and wellbeing and even over 80, only half say they live with life limiting long-term conditions.
However, despite the “upside” of population ageing, we need to be realistic about its inevitable implications for health and care services.As people age, they are progressively likely to experience:
- Multiple long-term conditions (with most over 75s having at least 3)
- Including common age-related conditions such as dementia, bone fragility, heart failure and incontinence
- Disability in the form of impaired mobility, visual or hearing impairment
This in turn means they are more likely to require:
- Support from multiple services and professionals, with transitions between them (risking disjointed care)
- Personal care (either formal or informal)
- Equipment to support them at home
- Hospitalisation, when required
- Rehabilitation after acute illness
- Long term care in care homes
- Planning and support for end of life care
- Multiple medications – with potential for side effects and interactions
And of course, in health and care services facing severe financial challenges, activity is driven disproportionately by older patients. If we want to solve the efficiency challenge, we will not do so without addressing the care of older people with complex needs.
In view of all this, the care of older people is on the national policy radar as never before. Commendable initiatives have included the government response to the Francis Report, the Equality Act, the new-wave CQC Inspection regimes, the Dementia Strategy and Challenge, the Integration Pioneers, the Better Care Fund and the Review of Emergency Services. The Department of Health is also about to announce the “No-one left alone” strategy (formerly the “vulnerable older peoples plan”) focussing very much on the role of GPs in providing continuity of care for people over 75.
In all this, there is the risk of repeating the mistake of short-term, non-sustainable initatives with non-recurring money – what I call “serial projectitis”. Another risk is the perpetuation of “silo thinking” – where public health, primary care long-term conditions management, urgent care and social care all develop separate strategies or programmes, driven by separate policy levers nationally.
We need is an acknowledgement that every component of care is interdependent on every other. High quality support outside hospital can prevent admission. High quality care within hospital can improve long-term outcomes and reduce disability or readmission. Better post-acute rehab can reduce care home placement.
In our new Kings Fund Paper Making Health and Care Systems Fit for an Ageing Population we have acknowledged this by providing one single practical resource for local service leaders wishing to look at their whole “end-to-end” pathway of care across every component and setting. We have set out in each section the current state of play, where we need to get to, the evidence for “what good looks like”, some key resources for practice and, crucially, practical examples of local service innovations being delivered right now.
The paper is set out under 10 components of care (without over-specifying who provides them or where they are provided). These are
- Healthy Active Ageing and Supporting Independence
- Living well with simple or stable long term conditions
- Living well with complex co-morbidities, dementia or frailty
- Rapid support in crisis as close to home as possible
- Good acute hospital care when needed
- Good discharge planning and post-discharge support
- Good rehabilitation and re-ablement after acute illness or injury
- High quality nursing and residential care for those who need it
- Choice, control and support towards the end of life
- Integration to provide person-centred co-ordinated care
We hope this provides a template for local service leaders to walk the pathway of care in their own patch in England and in the devolved nations. We hope it will be a useful tool in re-designing services – by ensuring that services are delivered to the highest quality, that transitions and interfaces between them work better, and that we avoid “double running” or duplication of effort. There is plenty we can do to improve our offer for our oldest citizens and plenty of excellent practice ready to spread and adopt.
I want this paper to be a useful resource for fellow BGS members to let their own organisations know “what good looks like” in setting out a vision for a high quality service and to have the tools to engage effectively with local partners in primary, community and social care and the wider community.