Getting Health Services Right for an Ageing Population. What else do we need to do?

David OliverPartners in care conference,

Manchester 7 Feb 2010

What I will cover• I: The success story of population ageing and our

unhelpful & polarised attitudes to it• II: What it means for population health and

wellbeing (the good and the “challenging”)?• III: What it means for health services?• IV: Are our services geared up to the new reality?• V: How we need to change?• You can all have all the slides and I do answer emails• What I won’t cover much until question time:

Relevant Health Policy in England

I: Population ageing in England

Population Ageing England• Life Expectancy 1901

– 49 F, 45 M– 1.3 M over 65 (5% of population)

• Life Expectancy 2008– 82 F, 77 M, 50% living to 80– 8.1. M over 65 (19% of population)– 5% over 80

• Life expectancy at 70 is now 17 years for men and 19 for women (“seventy is the new sixty”)

• Start of the NHS in 1948, 48% died before 65• Now its <18%• Still major inequalities in (healthy) life expectancy

at 65

5

We continue to live longer on average, but over the last 50 years, the trend has moved from a ‘rectangularisation’ (from young to old) to an a ‘elongation’ (from old to older) of the age distribution in the population. Number over 80 has doubled in past decade (See BMJ 2010 “oldest old double”)

Source: mortality.org, originally ONS

Distribution of death England 1841 - 2006

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97 101 105 109

1841

1941

19811991

2001

2006

Around 18% of all deaths were before 65 in 2006 – the same proportion as in 1991

ONS Projections (e.g. 146% increase in over 90s and 85% increase in

over 80s in next 20 years)

The success story of population ageing: A cause for celebration?

• Better social conditions, housing, nutrition• Better work-place safety• Higher wealth• Better child and maternal health• Better public health• Better preventative health interventions• Better curative medical treatment• Better management for long term conditions• Better potential for individuals to flourish and have a

long and active life

Unhelpful/apocalyptic language?

• “The Elderly”??• “Time-bomb”• “Crisis”• “Tsunami”• “Burden”• Distasteful jokes on email forwards...• Ageist language used by doctors and nurses• “Challenge” surely a better word?

Perceptions and stereotypes of ageing (Clinicians are not immune…lots of objective evidence)

• “It is commonly believed that older people lead a rather gloomy existence characterised by social isolation, neglect from their family, beset with health problems and suffering considerable emotional stress” ...Most pernicious is the assumption of “passivity and dependence”...with older people “Incapable of running their own lives and as passive recipients of services”

• Christina Victor. The Social Context of Ageing

II: What ageing really means for population health and wellbeing

A balanced view instead of polarised reality gap of elite ageing versus

victimhood and “the elderly”

Satisfaction with life

• English Longitudinal Study of Ageing, more than half of over 10,000 over 50s tracked since 2002 experienced increase in wellbeing with age

• US National Academy of Sciences Study, (314,000) Overall enjoyment of life declined through early adulthood, beginning to rise again at c 50 and peaking in 70s and 80s

• Health, poverty and social-connectedness all independent influencers

How older people define wellbeing Not just medical model of “absence of disease”

• Control over daily life• Personal care and

appearance• Food and drink• Accommodation

(cleanliness and comfort)• Personal safety• Social Participation• Occupation/Activity• Dignity (in care) once you

are vulnerable or dependent

Wider Determinants: Potential for multiple disadvantages. Role of local government, benefits, housing etc?

Dignity in Older Europeans Project (Woolhead) 400

older people. (Themes mirrored in 500 under 65s)• Dignity of identity

– Maintain self respect– Undermined by disrespectful address or labelling– Attitudes of staff or family– Neglect of appearances and clothing– Exposure– Lack of privacy in personal care and mixed wards– Toileting– Nutrition (and assistance with feeding and drinking)– Care when suffering or dying (See also “Dying to be heard” or VOICES survey)

• Human Rights– Importance of being treated as an equal, regardless of age– Fighting discrimination– Choose how you live and how you die (including advanced decisions)

• Autonomy– Retain independent control over lives for as long as possible– Even where need for nursing home, can still be kept clean and tidy

Family Carers’ priorities?e.g. RC.Psych Audit of Dementia Care in General Hospitals 2011

• Care planning and support in relation to the dementia (i.e. not just the acute condition) from admission to discharge

• Care of patients with acute confusion• Maintaining dignity in care• Maintenance of patient ability• Communication and collaboration: staff and patients/

carers• Information exchange• End-of-life care• Ward environment

• Mirrors Patients’ Association C.A.R.E campaign

A note of caution...• False and unhelpful distinction between “basic” or

“essential” care• And medical/diagnostic• Falls, immobility, confusion, incontinence, end of

life care, nutrition, dementia, pain, discharge planning etc...

• All require a proper diagnosis and treatment• And require skills and knowledge• Patients and their families might be happy with

personal nursing care but not realise that treatable problems are not being addressed

Proportion of older people less healthy/more dependent? • Health survey for England

– 1 in 3 over 65 reported no longstanding illness– 60% over 65 reported no illness limiting lifestyle– 1 in 2 women over 80 reported no limiting illness– Slight improvement over 30 years

• Census– 40% of 65 to 74 “good health”, 37% “fairly good”– Over 85, 60% F and 70% M “good or fairly good”– Small improvement over 30 years

• English Longitudinal Study of Ageing• Healthy Life Expectancy at 65 (2005): 15 years F, 13 years M.

• Cognitive function and ageing study (Brayne et al)• 1.3 M (15%) of people over 65 disabled, with 62% needing care at some point daily and 21% continuous care

• No reduction in proportion living with LTC but seeming reduction in those suffering limiting illness

But.....The result of increasing life expectancy on population prevalence of illness..

• People now either survive with one or more long-term conditions (often requiring multiple medications)

• Live long enough to develop conditions of ageing– E.g. dementia (800,000), osteoporosis, cataracts

etc • Live long enough to become frail• Live long enough to develop functional, sensory or

cognitive impairment• And potentially disabled or dependent to some

degree• So reliant on formal or informal care or multiple

services and contacts with multiple staff

– The majority of over-65s have 2 or more conditions, and the majority of over-75s have 3 or more conditions

– More people have 2 or more conditions than only have 1

Multimorbidity in Scotland (Scottish School of Primary Care)

19 20 April 2023

People with long-term conditions have high health service use (55% of all GP appointments, 68% of outpatient and A&E appointments and

77% of inpatient bed days and therefore 69% total health spend.People with limiting LTCs are the most intensive users of the most expensive services

0%

20%

40%

60%

80%

100%

Number of people GP consultations Practice Nurseappointments

Outpatient and A&Eattendances

Inpatient bed days

Type of service

% o

f ser

vice

s us

ed

No LTC Non-limiting LTC Limiting LTCSource: 2005 General Household Survey.

Societal Cost of Dementia in UK

Alzheimer’s Disease International, 2009

[Total NHS spend in England £122bn.

[Total spend on Dementia in Health and Social Care £8.2bn]

[Total spend on police and prisons £9.4bn]

Frailty[Muscle and weight loss, weakness, slow walking

speed, easy fatigue (Fried)]

..”Frailty is a failure to integrate responses in the face of stress. This is why diseases manifest themselves as the “geriatric giants”….functions …such as staying upright, maintaining balance and walking are more likely to fail, resulting in falls, immobility or delirium. A small insult can result in catastrophic loss of function”

Rockwood Age Ageing 2004

i.e. Poor Functional Reserve

22Source: Family Resources Survey 2007

Individuals with a disability, including

limiting long standing illness

Individuals without a disability,

including limiting long standing

illness

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-15 16-24 25-34 35-44 45-54 55-59 60-64 65-74 75-84 85+

Disability distribution over age

Reported prevalence of disability clearly rises with age. We also need to understand how the severity of disability varies with age.

III: What this in turn means for health and social care services. In particular,

general hospital casemix

“Older People R US”

People over 65...• 60% adult social care spend (£9bn)

– 1.25 M out of 1.7 m users

• 37% NHS Primary Care spend (£27bn)• 46% acute care spend (£ 27bn)• 12% NHS budget is on community health care

(largely older people) (c £12bn)• Often those interdependent on multiple services

(e.g. 60% of home care service users have been in hospital in previous year. 80% of delayed transfers are over 70)

• Population ageing means this trend will continue

Over 65s in hospital (England) (DH analysis of HES data)

• 60% admissions• 70% bed days• 85% delayed transfers• 65% emergency

readmissions• 75% deaths in hospital• 25% bed days are in

over 85s

High intensity users of hospital services have overlap of physical and

social vulnerabilities

Hospital Casemix (even more vulnerable and complex in long term social care –

where access to healthcare fairly poor – see “quest for quality” 2011)

• 1 in 4 adult beds occupied by someone with dementia (stay an average 7 days longer)

• Delirium affects 1 in 4 patients over 65 • Urinary incontinence 1 in 4 over 65• 1 in 4 over 65 have evidence of malnutrition• Falls and falls injuries account for more bed days than

MI and Stroke Combined• Falls = 35% safety incidents (median age 82)• Hip fracture is a good example

– Median Age 84, 12 month mortality 20-30%, 1 in 3 have dementia, 1 in 3 suffer delirium, 1 in 3 never return to former residence, 1 in 4 from care homes

IV: Are our services and systems consistently “age proof and fit for

purpose” – designed around the needs of the people who use them most?

Older people not so much “new consumers” but “disadvantaged

majority”?

Official values...

• “ comprehensive service available to all, free at the point of delivery and based on need and not age, gender, ethnicity etc”

• NHS Constitution 2008

• “unjustifiable age discrimination and unfair treatment have no place in a fair society which values all its members”

• Equality Act 2010

Prof Ken Rockwood 2005

• “If we design services for people with one thing wrong at once but people with many things wrong turn up, the fault lies not with the users but with the service, yet all too often these patients are labelled as inappropriate and presented as a problem”

Rt Hon Stephen Dorrell MP 2011 (HSJ)

• “Systems designed to treat occasional episodes of care for normally healthy people are being used to deliver care for people who have complex and long term conditions. The result is often that they are passed from silo to silo without the system having ability to co-ordinate different providers”

What do we mean by “quality” in treatment and care?

• Effectiveness. Outcomes plus adherence to recognised good practice which can deliver these and closing care gaps

• Safety• Experience of patients and carers, including person-centred

care• Efficiency. Ensuring value for money and minimising

unwarranted variation/ensuring consistency

• [Fairness/lack of discrimination]• [Joined-up-ness/Integration/Seamlessness……a topic for

another day]

Outcomes and proven interventions/services to deliver them e.g.

• RCP national audits on falls and bone health x 4 (latest “falling standards, broken promises”, 2011)

• National Hip Fracture Database and Annual Reports• RCP national continence audit• RCPsych audit of dementia care in general hospitals and NHS

Confederation “Acute Awareness” report• NCEPOD report on peri-operative care for people over 80 “an

age old problem”• Age UK “hungry to be heard” report• Steele et al BMJ 2008 on self-reported quality of care

indicators for primary care in 8,400 people • Work on anti-psychotic prescriptions in Dementia• Quest for Quality Report on health inputs in long term care

Safety e.g.

• Falls (275,000 in english hospitals last year)• Emergency readmissions• Hospital mortality rates largely concern older people• Drug errors (prescribing, administration, supervision)

– (CHUMS study)• Hospital acquired infections• Pressure sores• DVT• Protection of vulnerable adults

Experience (of patients and carers) e.g.• 2008 All parliamentary enquiry into older people in

health and social care– “A disturbing picture, requiring an entire culture change”

• NHS Ombudsman’s report “care and compassion” 2011• Patients association report• Care Quality Commission Dignity and Nutrition

Inspections 2011• Various reports on dementia care in general hospitals

2010/11• VOICES survey on end of life care • Reports on using multiple services/transitions • Common issues: Dignity, nutrition, communication, respect,

information, continence, privacy, discharge from hospital, end of life care, pain relief, dementia care, attitudes

Efficiency

• Major unwarranted variations• e.g. hospital admission and length of stay for

various groups and conditions• Care home placement• Delays, barriers etc at interfaces between

agencies/care settings

National Hip Fracture Database

3 fold variation (Similar story on bed days,

readmissions, nursing home placements etc) Variation in the number of emergency admissions of 65+ patients per 10,000 population,

2009/10 (England)

0

500

1,000

1,500

2,000

2,500

3,000

PCTs

NB Excludes admissions where PCT is unknown; mid-2009 PCO population estimates used

Minimum: 1,145Maximum: 2,805

Mean: 1,881Median: 1,821

CPA Review (part of equality act consultation)

CPA Reviewwww.cpa.org.uk/reading/age_discrimination.pdf

• Services often differentiated by age with major differences in resource, access, referral etc

• Decisions made arbitrarily on chronological age• Older people receive systematically worse diagnosis,

treatment, specialist referral etc than younger with same condition

• Common conditions of ageing are relatively neglected when compared to conditions of youth and mid-life

• Older people with frailty and functional impairment go undiagnosed and labelled as “acopia” “social admission” etc

• Attitudes, culture, basic care, communication etc...

Rt Hon Peter Aldous MP. Westminster Hall Debate on NHS care of older people 27th

October 2011• “I do not like saying this, but there is a sense of

déjà vu here….The CQC findings are similar to those in the 1998 report, “Not because they are old”, and there are parallels with the Patients’ Association study of two years ago. It is as if each new revelation creates a sense of outrage, and then nothing happens. We all have an obligation to ensure that this time is different.”

Death by awareness?...• “I’m drowning here and you’re describing the water”• Melvin Udall. As good as it gets

• We have more than enough evidence on:– What older people want– What good practice looks like– What isn’t good enough– The reasons behind it

• Need to move from awareness to intention to concerted effective action

V: How do we get better? Solutions, Solutions, Solutions

Constructive, effective, realistic

Constructive Solutions – no one “silver bullet”

• “For every complex human problem there is a solution which is simple, obvious and wrong”

• H L Mencken

• We need to tackle the problem from several angles...

• Stop reducing everything to training and accountability of nurses

Solutions (we need them all)• Systematic involvement of older people and carers as partners• Training, education, workforce, revalidation• Clinical & managerial leadership, ward to board to college• Good practice guidance and models• Dissemination and implementation• Effective regulation, inspection and follow up• Everybody “owning” the care of older people including doctors/AHPs etc• System outcomes, incentives and rules• Transparent data on performance and quality• Targeted campaigns and strategies (e.g. end of life, dementia)• Greater focus on prevention and proactive long term conditions

management to keep older people well and independent• More integrated services• Advocacy and momentum from charities etc• Social care reform• Law (Equality Act, Human Rights etc)

We have a once in a generation opportunity transform care. Lets not waste it.

• Thank You• David.Oliver@dh.gsi.gov.uk