Are acute care pathways fit for our
ageing population?
How do we need to improve?
David Oliver
ECIST Conference.
Birmingham 4 October 2012
To Cover
• I: Why ageing, health and care for older people are in the
news? “the perfect storm”
• II: Population ageing in England
• III: Implications for population health
• IV: Implications for (hospital) services
• “Older people R Us”
• V: Quality in acute services for older people
• VI: How could we get better? – a quick steer
– A) Systems/ “end-to-end” pathways
– B) Within hospitals
I: Why ageing, health and care
have a higher profile now than
ever?
2012 – care for older people in
England: A “perfect storm”
• And a once-in-ageneration
opportunity to effect
lasting change
2012: “Perfect Storm” e.g.
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Ombudsman “Care and Compassion”
Patients’ Association C.A.R.E. campaign
CQC DANI Inspections
Age UK/NHS Confed. “Delivering Dignity” commission
Dementia Strategy/PM Dementia Challenge
Various reports on care for people with Dementia
Social care funding/reform
Age equality duty in Equality Act
26% cuts in local government support grant – impact on social
care provision.
£ 15-20bn “Nicholson Challenge”
– Older patients with complex needs as key to delivery
RCP “Hospitals on the Edge” report
Francis Report….
Equality Act
“our hospitals are struggling to cope with the
challenges of an ageing population and
rising hospital admissions” RCP 2012 (See
also future hospitals commission)
• “A fewer third general and acute
hospital beds than 25 years ago
but last decade has seen 37%
increase in emergency
admissions”
• “Hospitals have coped by reducing
length of stay but this fall has
flattened and is now increasing for
over 85s”
• “2/3 of patients admitted to hospital
are over 65 and many have
dementia, frailty or complex
needs….buildings, services and
staff are not equipped to deal with
them”
II: Population Ageing in England
Over the last 50 years, trend has moved from a ‘rectangularisation’
to an a ‘elongation’ (from “old” to “older”) Number over 80 has
doubled in past two decades (See BMJ 2010 “oldest old double”)
Around 18% of all
deaths were
before 65 in 2006
– the same
proportion as in
1991
Distribution of death England 1841 - 2006
100%
90%
1981
1991
80%
1941
70%
2001
60%
50%
1841
2006
40%
30%
20%
10%
0%
1
5
9
13
17
21
25
Source: mortality.org, originally ONS
29
33
37
41
45
49
53
57
61
65
69
73
77
81
85
89
93
97 101 105 109
9
ONS Projections
(146% increase in over 90s & 85% in over 80s in next 20
years)
Services?
Workforce?
Pensions?
Unpaid care?
Inequalities persist
Inequalities persist
The success story of population
ageing: A cause for celebration?
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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
III: What ageing really means for
health and wellbeing:
A balanced view.
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 acutely ill or
dependent on care
Wider Determinants: Potential for
multiple disadvantages. Role of
local government, benefits,
housing etc?
Proportion of older people more ill,
dependent? e.g.
• 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
• Census
– 40% of 65 to 74 “good health”, 37% “fairly good”
– Over 85, 60% F and 70% M “good or fairly good”
• Cognitive function and ageing study (Brayne et al)
• c. 1.3 M (15%) of people over 65 disabled, with 62%
needing care at some point daily and 21% continuous
care
• So most older people are not disabled, dependent..
• Or in hospitals or nursing/residential homes
But.....The result of increasing life expectancy on
population prevalence of illness..
• People now either survive with one or more
long-term conditions ( & multiple medications)
• Live long enough to..
• ..develop conditions of ageing
– e.g. dementia (800,000), osteoporosis,
cataracts
• Become frail
• Develop functional, sensory, cognitive
impairment
• Become disabled or dependent to some degree
• So reliant on formal or informal care or multiple
services and contacts with multiple staff
Multimorbidity in Scotland
(Scottish School of Primary Care Barnett et al Lancet May
2012)
– 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
Most people with any long term condition have
multiple conditions in Scotland
(Scottish School of Primary Care)
e.g. Only 18% with
COPD just have
COPD
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
100%
% of services used
80%
60%
40%
20%
0%
Number of people
GP consultations
Practice Nurse
appointments
Outpatient and A&E
attendances
Type of service
26
Source: 2005 General Household Survey.
No LTC
Non-limiting LTC
9 April, 2015
Limiting LTC
Inpatient bed days
Reported prevalence of disability clearly rises with age. We also need to
understand how the severity of disability varies with age.
Disability distribution over age
100%
90%
Individuals without
a disability,
including limiting
long standing
illness
80%
70%
60%
50%
40%
30%
Individuals with a
disability, including
limiting long
standing illness
20%
10%
0%
0-15
27
16-24
25-34
35-44
45-54
55-59
Source: Family Resources Survey 2007
60-64
65-74
75-84
85+
Frailty –
(only around 6% of over 65s but very high
proportion of service use and predicts poor outcomes)
[Weight loss, exhaustion, weakness, slow walking
speed, diminished physical activity] (Fried Criteria)]
..”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, incontinence, delirium or
general failure to thrive . A small insult can result
in catastrophic loss of function”
Rockwood Age Ageing 2004
i.e. Poor Functional Reserve
IV: What this means for
services
Especially Hospital Inpatient Care
People over 65 (England)...
• 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)
• [Average patient 81 and 43% over 85 in Intermediate Care Services]
• 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)
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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
• 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)
• Most over admissions over 70 have some functional
impairment and some need for MDT rehab (Hubbard
2005)
• 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
Older people in hospital
• Majority of inpatients and bed days
• The older you are the longer your stay
• Emergency readmissions highest in over
75s and rising fastest
• Older people more likely to be moved
repeatedly during hospitalisation
• Kings Fund 2011 Continuity of care for older
people in hospital
IV: Are services age-proof and fit
for purpose?
Are older people a “disadvantaged
majority”?
Lots of good services to celebrate and
learn from and many satisfied patients
and families so balance required...
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 & adherence to good
practice processes evidenced to deliver these
• Safety
• Experience of patients and carers
• Efficiency. Ensuring value for money, costeffective treatment, minimising unwarranted
variation/ensuring consistency, tackling
inefficiencies at interfaces between agencies
• (Fair/non-discriminatory)
• (Joined-up/integrated/continuity)
• Integration and discrimination are whole other
talks
Outcomes & adherence to evidencebased best practice
• 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
• NHS Confederation “Acute Awareness” report on dementia
• NCEPOD report on peri-operative care for people over 80
• “Age UK “still hungry to be heard” report
• Work on anti-psychotic prescriptions in Dementia
• Quest for Quality Report on health inputs in nursing and
residential homes and Failing the Frail Audit
• National audit of intermediate care
• Consistent picture of gaps and variation in even most
basic assessments and interventions
Safety/adverse events e.g.
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Falls (275,000 in English hospitals last year)
Emergency readmissions/unsafe discharge
Hospital mortality rates largely concern older people
Drug errors (prescribing, administration, supervision)
– (CHUMS study)
Hospital acquired infections
Pressure sores
DVT
Protection of vulnerable adults
Delirium? Immobility? Dependence? Incontinence?
Experience (patients, 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 2012
• Francis Report on Mid-Staffs...
• Common issues: Dignity, nutrition, communication,
respect, information, continence, privacy, discharge from
hospital, end of life care, pain relief, dementia care,
attitudes
“Many geriatricians think ageism is rife in NHS, poll
suggests
Nearly half blame institutional ageism for poor treatment of
older patients”
Guardian 2009 (BGS/Help the Aged Report)
2/3 geriatricians felt service institutionally ageist. 2/3 had witnessed
ageist/discriminatory behaviour.
“Right bed,
wrong
patients”
“Seeing the
person in the
bed”
Health Service Journal
(2008) Sixty not out:
managers' survey, Health
Service Journal 118 (10
January 2008) : 28‐30.
1000 health service
managers felt that older
people and those with
mental illness were the
worse served
Attitudes and behaviours
“whose
interests
matter?”
Arbitrary decisions made on age
alone
Older people denied
investigation, diagnosis and
treatment relative to younger
people
Services for conditions common
in old age poorly prioritised
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
• We will not achieve the £15-20bn efficiency
challenge without looking at older people inc.
those with dementia and complex needs
– Big spend, Big Variation, Poor integration, Double
Running, Care Gaps etc
National Hip Fracture
Database
From “An atlas of variations in social
care”
Audit commission value for
money at health and social
care interface 2011
From Kings Fund report 2012 on
Emergency Bed use in Older People
Audit commission value for
money at health and social
care interface 2011
From national audit of intermediate
care 2012
Delayed transfers of care from
acute hospitals.
Number of Delayed Days during the month by reason
30,000
A) Awaiting completion of
assessment
B) Awaiting public funding
25,000
Total Delayed Days
C) Awaiting further non-acute
Dii) Awaiting nursing home
placement or availability
Di) Awaiting residential home
placement or availability
E) Awaiting care package in own
home
F) Awaiting community equipment
and adaptations
G) Patient or family choice
20,000
15,000
10,000
5,000
H) Disputes
0
Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- M Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar10 10 10 10 10 11 11 11 11 ay- 11 11 11 11 11 11 11 12 12 12
11
Month
I) Housing – patients not covered
by NHS and Community Care Act
V (a): How do we get better? An
early steer..
(Solutions would be a whole other talk..)
Across Systems and Pathways…
Joined up commissioning and
provision in localities. Utopia?
Dystopia? Something in between?
From King’s Fund Report “Older
People and Emergency Bed Use”
Focus
For today
A different approach? Continuity of Care Model a
better conception (also requires right workforce, skills,
capacity and resource in right part of system)
Care in long term social
care/supported housing
setting or for those in
receipt of social services
Tertiary prevention
Clinicians need to engage
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With pathway redesign
Across organisational boundaries
Stop “working in silos”
Even if it means changing job plans and
working practices
• And get over the LTC vs Acute Care false
dichotomy
How do we get better?
Within Hospital?
Lots of guidance..e.g.
The Silver Book
My stuff..e.g.
Benefits of CGA (Ellis and
Langhorne)
• 22 trials. 10,000 + participants, 6 countries
• Patients more likely to be living at home at end of
scheduled follow up (OR 1.16)
• And at median follow up of 12 months (OR 1.25)
• Compared to general medical care
• Less likely to be living in residential/nursing care (OR
0.78)
• Less likely to die or experience deterioration(OR 0.76)
• More likely to experience improved cognition (Mean
difference 0.08)
• Specialist wards had better outcomes than teams for
Apply the
same
principles
within
hospital
Let’s “get with the programme”
• Properly trained clinicians
• With right skills and attitudes for the patients who
actually come through the door
• Early skilled senior assessment by MDT including
skilled, interested, committed consultant
• No more “acopia”/”social admission”/”bed blocker”/”right
bed wrong patients”/”medically discharged”
“inappropriate” etc etc
• Functional problems have reversible diagnoses
• Front door turnaround where appropriate
• Assertive discharge planning from day one and every (7)
day
• Configuration of bed-base and numbers of specialists,
supported by MDT professionals
We have a once in a generation opportunity
to transform care. Lets not waste it.
• Thank You
• David.Oliver@dh.gsi.gov.uk