Using population sub-segmentation to promote tailored end of life care in later life

Professor Martin Vernon is National Clinical Director for Older People and Person Centred Integrated Care at NHS England. He tweets @runnermandoc. Dr Dawn Moody is Associate National Clinical Director for Older People and Integrated Person-Centred Care for NHS England. She tweets @Moody_D_K. They will be speaking at the BGS Living and Dying Well with Frailty event today. Follow the conference via #bgsconf

Frailty is an especially problematic long term condition characterised by declining intrinsic capacity to deal with stressor events such as acute illness or physical accidents. When severe it significantly increases personal annual risk of reaching end of life. While occurring alongside human ageing, not everyone develops frailty and it is not solely confined to older people. NHS England estimates 20% of the population aged 90 and over remains fit and are therefore likely to be fortunate in ageing well. Conversely we estimate that up to 25% of people aged 65 to 69 are living with mild frailty in England which compared to their fit peer group places them at twice the annual risk of reaching end of life.  A further 5% of this age group is estimated to be living with moderate or severe frailty.

Supporting individuals to age well by preventing frailty where possible is of course a key priority. Of equal importance is to ensure that everyone is supported to be actively involved in planning their future care as they age. Doing this requires proactive identification of personal vulnerability to unanticipated decline in health through to the end of life.

Population growth makes this especially challenging. The World Bank estimates that between 1960 and 2015 the population proportion of people aged 65 and over rose from 5 to 8%[1]. This means the number of people in the world aged 65 and over rose from 249 million to 690 million. In the UK there are now 11.6 million people aged 65 or over[2]. By 2040 nearly 1 in 7 people will be aged over 75[3].

To tackle this, in 2017 the NHS in England became the first health system in the world to commence systematic identification of frailty by severity within the whole population of older people. This approach permits population sub-segmentation to proactively identify those with the greatest needs, to target and plan their care and support in ways which prioritise what matters most to them.

Why is this so important? Healthy ageing is of course something to celebrate for those achieving greater numbers of disability free life years. However currently greater numbers of people are reaching later life with multiple long term health conditions and/or increased levels of social care and support need. This poses significant challenges for health and social care systems. Global disease burden and cause of death has shifted from communicable (infectious) to non-communicable disease: from premature death caused by  infections to greater years lived with disability[4].

In 2010 the leading causes of disability adjusted life years were ischaemic heart disease, BGS eventlower respiratory infection and stroke. Rising levels of mental health and behavioural disorder, musculoskeletal disorder and diabetes are now expected to put health systems under even greater pressure[5]. By 2050 the worldwide prevalence of Alzheimer’s dementia is expected to quadruple from the estimated 26.6 million in 2006.

In shaping health and social care policy for future generations, it is therefore crucial to understand and define the populations of older people who are living added life years in either good or poor health. Current projections suggest that health and social care systems should prepare themselves for meeting the needs of older people whose leading causes of disability will be depression, hearing loss, musculoskeletal disease, dementia, falls chronic obstructive lung disease and diabetes mellitus[6]. This will have significant impacts on how we approach advance care planning and end of life care among older people in the coming decades. Our shared goal should be to ensure that every older person has timely opportunity to be involved in deciding about their end of life care based on what matters most to them.

Follow Living and Dying Well with Frailty event on today via #bgsconf

[1]http://data.worldbank.org/indicator/SP.POP.65UP.TO.ZS?end=2015&name_desc=false&start=1960&view=chart

[2]https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/bulletins/annualmidyearpopulationestimates/latest

[3] https://www.ons.gov.uk/peoplepopulationandcommunity

[4] http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(12)61689-4.pdf

[5] http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(12)61689-4.pdf

[6]http://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2015_Report.pdf

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