Reshaping Care for Older People: ‘A look into the rear-view
mirror’
–discussion paper based on further insights from national data
May 2013
Peter Knight BSc JIT Programme Lead on Partnership Information
Summary
This discussion paper presents a retrospective analysis of trends on a selection of
national measures which have relevance to Re-shaping Care for Older People in
Scotland. It also weaves in additional analyses of the data in a way which takes
account of the demographic shifts which have occurred during the past decade. The
paper discusses some of the factors which are likely to have influenced the trends.
With an eye on future changes to come, the report adds further insight and
awareness about the magnitude and direction of changes which have already
occurred in the care and support of older people in Scotland. In conclusion it draws
attention to some of the key issues referred to in this paper and which the JIT is
addressing with stakeholders.
Introduction
By 2009 a set of analyses including forward projections of age related emergency
admissions to hospital and potential social care needs were sharply heightening
awareness of the full potential impact of population change in Scotland on health and
care for older people. It was evident from the analyses, which were presented at a
series of meetings of Scotland’s leaders in the health and social care field in early
2009, that change was essential. The conclusion was reinforced by an emerging and
largely unprecedented fiscal climate. With this backdrop serving as context, the Reshaping Care for Older People Programme was established, providing a national
framework for changes that would be necessary in the short, medium and longer
term. The Change Fund was introduced in 2011/12, providing the catalyst for a
cohesive response from partnerships engaging in what is essentially a whole system
transformation programme.
.
This report looks at some of the trends in national measures up to the establishment
of the Re-shaping Care programme and more recently. What these trends reveal is
that there is no fixed status quo, looking back – change has been a continuous
presence. To illustrate this, the analyses presented here not only show the actual
trends based on the published figures for each year shown but also show a
‘projected trend’ which are the values obtained by applying the 2003 (or 2002/03)
rate to the population aged 65+ in each year thereafter. This provides a way of
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seeing how far the actual trend has diverged from the trend which would have
occurred had population change been the only factor at play.
The specific aspects of care included in these analyses are:



long stay care home residents;
local authority home care (and Telecare);
and, for people admitted as an emergency to Scotland's general acute
hospitals: beddays used and admission numbers.
Care and support of older people is multi-faceted and each element of the analyses
shown here adds to our overall understanding. Setting the different elements
alongside each other has the additional benefit that it is possible to reflect how the
different trends differ. All the analyses are based on routinely collected national data
and have the potential to be replicated locally.
The information provided here is relatively high level and it is beyond the scope of
the paper to give a comprehensive account, with appropriate evidence, of all the
factors behind the trends. Reference is made in the text however to key factors
which have reasonable credibility and which are likely to have at least contributed in
some respect to the direction of the trends.
Demographic context
The backdrop to this paper is the changing demographics in Scotland and the way
these bear upon health and care. Both health and (social) care needs are very
influenced by age, with a greater need for care and support, in general, in later life.
Population projections show that the population structure of Scotland is getting older
and that this feature is going to accelerate during the next few decades. As is shown
in the table the growth in numbers of people aged 65 or over, or 75 or over, which
occurred in the decade up to 2011 is expected to be superceded by an even greater
rise in numbers in those age groups in the current decade and decade after that.
Actual and projected change in population aged 65+ and 75+, Scotland
65+
75+
In ten year period:
Actual increase
2001 to 2011
Projected increase 2010 to 2020
Projected increase 2020 to 2030
thousands
85.2
195.3
249.8
52.5
92.9
157.1
source: GRO Scotland
About the analyses
Each of the analyses in this paper uses the same general approach: the trend in the
actual activity in the period from 2003 to 2011 is presented, alongside a calculated
‘projected trend’. The projected trend shows what the trend would been if nothing
had changed (or if changes had cancelled out) since the start of the period (i.e. 2003
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or 2002/03), apart from the known changes which had occurred in the size and
structure of the 65+ population. The difference between the two sets of figures (i.e.
actual and projected) in each chart show the net effect of changes in service
delivered, adjusted for changes in population structure, since 2003.
Note that in all the bar charts below the y-axis scales do not start at zero.
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Care home residents
The actual number of older people resident long term in care homes at the census
point at the end of March has stayed fairly level since 2003 (Chart 1). Because of the
growth in the 65+ population this means that the proportion (or rate) of older people
supported long term in care homes has actually gone down in the period. The
projected numbers shown on the chart provide some measure of this difference.
Specifically they indicate what would have happened had the long term resident rate
remained constant from 2003 onwards. By the latest time point on the chart (2011)
the actual number of residents is 17% below the projected number based on the
2003 rate.
The difference between the actual and the projected is a reflection of changes which
must have occurred in the period. It is probable that a number of factors account for
the difference: for example, changing thresholds regarding the necessity of
admission to a care home and changing preferences of older people (and their
families) could affect the rate. The availability of a wider basket of options (eg see
Home Care below and note 1 of the Appendix) which enable people to live longer in
their own homes may be a critical factor.
Chart 1
Trend in Care Home residents aged 65+ in Scotland:
actual vs projected numbers
40000
N of residents 65+
35000
30000
Projected
25000
Actual
20000
15000
2003 2004 2005 2006 2007 2008 2009 2010 2011
Year
Home care
Between 2003 and 2005 the total number of people provided with local authority
funded home care rose in Scotland, in line with the demographic changes in the
population aged 65+ (Chart 2). After 2005 there was a sustained year-on-year
reduction in the number of individuals receiving home care, through to 2011. In the
same period the projected number (based, as before, on the 2003 rate) rose steadily
year-on-year and the net effect, the difference between the projected and the actual,
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has grown each year. By 2011 the actual number receiving home care is 19% below
the projected number.
A range of factors may have contributed to this trend including changes in the
application of local eligibility criteria or a move away from the use of low intensity
home care with substitution by other forms of care and support (e.g. Telecare – see
below).
Chart 2
Home care clients 65+
N of clients 65+
70000
60000
Projected
50000
Actual
40000
30000
2003 2004 2005 2006 2007 2008 2009 2010 2011
Year
A somewhat contrasting trend is found with the number of people provided with
intensive home care (i.e. 10+ hours home care). Here the trend in the actual
numbers receiving these intensive level packages of home care is higher (+13% in
2011) than the projected trend (Chart 3). This means that a greater number of
people are provided with 10 or more hours of home care than would be expected on
the basis of population change alone since 2003.
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Chart 3
An analysis of the total hours of home care provided by local authorities reveals a
similar divergence between actual and projected. In 2011 the actual hours provided
are 20% higher than the projected (Chart 4). (Note that this analysis differs in some
respects from the other analyses presented. The hours of home care relate to clients
of all ages. The projection method used is slightly different from the method used
elsewhere – see note 2 of the Appendix)
Chart 4
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Drawing these analyses together, it is evident that there has been a steeper than
projected rise in hours of home care provided in the period from 2003, whilst the
overall number of clients receiving home care has fallen in the same period. This
suggests that while the ageing of the population brings with it the likelihood of higher
demand for care and support, in terms of the allocation of home care resources local
authorities have increasingly focussed on people with higher needs.
Viewed alongside the trend information on long term care home resident numbers it
may be that the relatively static number of care home residents is in part a flip side of
the higher-than-expected rise in home care provided. Thus it may be that these
trends are the reflection of a greater emphasis towards care and support at home
even for people with higher levels of care need.
Looking ahead, the community/home based improvement and development
initiatives which are emerging or underway, including re-ablement and intermediate
care (including further flexibility in the use of care homes), and the application of
self-directed support, will lead to even more marked changes in these trends.
Telecare provision
As a corollary to the analyses above it is also relevant to look at the emerging figures
on telecare provision by local authorities. Telecare is strongly orientated towards the
prevention end of the care and support spectrum and has become a significant
feature in delivery of support in an integrated system. Although trend data are not
available nationally we know there has been a growing provision of telecare in recent
years, in part supported by Scottish Government initiatives and funding and with the
active support of the Joint Improvement Team (JIT) through the national Telecare
Programme.
We do know from the 2011 figures that telecare (mainly community alarms) is now
provided to most people who receive home care and to an even larger number of
older people who do not receive home care (Chart 5). The likely extension of the use
of telehealthcare in the future as part of a wider integrated care and support package
for people with long-term conditions and/or at risk of falling is another reason for
assuming that the trends of the past decade discussed earlier may not reflect future
trends.
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Chart 5
Local authority services: Telecare & home care
Scotland 2011
Telecare no home
care
21%
Home care+Telecare
54%
25%
Other home care
clients
Although constrained by the single year of data available, it is interesting to note that
the dark bar (the ‘actual’) in the 2011 column in Chart 2 would double in height were
it to include also the Telecare-only clients.
Emergency hospital inpatients: Occupied beddays
The benefits to older people of avoiding emergency admission to hospital, except
where it really is clinically necessary, have been widely discussed. Emergency
hospital inpatient stays are also known to account for the largest single area of
expenditure on the care and support of older people. There is an existing HEAT
target designed to lead to reduced hospital bedday rates by people aged 75 and
over, thus focussing specifically on the age group most likely to use hospital inpatient
beds. For consistency with the earlier analyses in this paper, the analyses below
look at the 65+ age group but the general conclusions also apply to the 75+ age
group.
The trend in the use of hospital inpatient beds following emergency admission since
2003/04 is, in general, rising until 2008/09 (Chart 6). As mentioned earlier, the Reshaping Care programme was launched in 2009 and building on the earlier initiatives
within the long term conditions programme added a sharper focus to efforts to
change the direction of this trend. By 2010/11 the number of beddays had fallen to
its lowest level since 2003/4.
Using a similar approach to the method used on the social care data, the 2002/03
rate of beddays has been applied to the population in each of the subsequent years
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to give projected values up to 2010/11. As is evident from the chart, if the increase in
beddays had kept in step with the increasingly older population after 2002/03, the
additional bed requirement would have been substantial. In fact even up until
2008/09 the number of beddays based on the 2002/03 projection is higher than the
actual beddays used. From 2009/10 onwards, the gap between the projected beds
and the actual beds has grown substantially, with a difference of 11% by 2010/11.
Chart 6
Hospital emergency admission 65+:
occupied beddays
3300000
beddays
3000000
Projected
beddays
2700000
2400000
Actual
beddays
2100000
3
4
5
6
7
8
9
0
1
2/0 03/0 04/0 05/0 06/0 07/0 08/0 09/1 10/1
0
20 20
20 20 20 20 20
20 20
There are likely to be many reasons for a growing divergence between actual and
projected. Partnerships have worked hard to avoid unnecessary delays in moving
people on from hospital once their care and treatment is complete and there has
been a well documented reduction in the number of delayed discharges. This
success in partnership working will undoubtedly have made a contribution. There is
also evidence from surveys of a long term improvement in healthy life expectancy in
the population at large which might well have had some impact. After 2008/09
however, where a tipping point occurs in the trend, it is likely that the Re-shaping
Care and long term conditions programmes, in combination with associated HEAT
targets, will have been essential factors.
For Scotland as a whole the challenge remains to sustain and improve upon these
trends. This would allow resources to be released to deliver on the longer term aims
of the Re-shaping Care programme – to enable older people to live well at home as
independently as possible. The projections which are referred to in the first sentence
of the introduction showed that the demographic changes could lead to a need for
more and more hospital beds in Scotland unless alternative care and support,
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including anticipatory and preventative measures, can be developed. This conclusion
is still as valid today as it was in 2009. Even in the short spell since 2008/09 had the
bedday rate per 1000 population aged 65+ continued at the 2008/09 level to 2010/11
almost 500 beds more would have been required in Scotland’s hospitals.
Numbers of emergency admissions
The HEAT targets rightly focus on bed days because of the consensus around the
potentially detrimental effect for older people associated with prolonged stays in
hospital, higher risk of long term care and the associated costs. It is also important
however to retain interest in the number of emergency admissions: although many
emergency admissions are entirely appropriate, the process of emergency
admission to hospital is potentially disruptive for the patient and their families and the
front-end costs of emergency care are significant.
A year on year rise in the number of emergency admissions of older people has
been observed since 2003 but is especially evident from 2006/07 onwards. In
2006/07 the gap between the actual and the projected volume increased markedly
and has been sustained since then (Chart 7). In 2010/11 the actual number of
admissions was nearly 7% higher than the projected number. Emergency
admissions, arriving through A&E or directly referred into hospital, continue to
challenge the flow through acute care.
Chart 7
Hospital emergency admissions 65+
emergency admissions
240000
220000
200000
Actual
admissions
180000
160000
Projected
admissions
140000
120000
/03 /04 /05 /06 /07 /08 /09 /10 /11
02 003 004 005 006 007 008 009 010
0
2
2
2
2
2
2
2
2
2
Year
Other analyses (not shown here) show that a much bigger percentage rise has
occurred in admissions which result in short stays in hospital (e.g. 1 day or less) than
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the percentage rise in admissions which result in longer lengths of stay. There are
likely to be a mix of reasons for this pattern including:






more older people with complex and multiple conditions managed in the
community;
changing thresholds for emergency admission for specific conditions;
influence of algorithm driven referrals for chest pain, stroke/ TIA and
breathlessness, availability of senior decision makers;
access to diagnostics;
access to ambulatory alternatives to emergency admission; and
unintended consequences of other targets such as the four-hour A&E
standard.
Bundling together the analysis on beddays and actual admissions of older people
admitted as an emergency it is clear that whilst much is being achieved regarding
reduced hospital bed use the number of emergency admissions is still an
impediment to progress and continues to rise. With support from the Change Fund
many of the emerging initiatives in local partnerships have the reduction of
admissions or support for earlier discharge as intended outcomes. If partnerships
are able to achieve success with these initiatives, drawing upon the improvement
support of the Joint Improvement Team and others as required, they will have gone
a long way towards the re-shaping of care and support for older people which is
absolutely necessary for Scotland.
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Conclusions
1. The paper features key trends in a number of areas of activity in care and
support for older people. It presents new analyses using a method which
illustrates what the trends might have been had the increasing number of
older people, in this case people aged 65+, been the determining and only
factor which changed in the period covered. The bringing together here of
different measures and the use of the latter method means that we are able to
contrast the different activities and draw wider inferences than is possible
from a fragmented analysis of each measure individually.
2. The differences between the actual trends and the population driven trends
(‘projected’) shows the net impact of a mix of other factors including changing
local practice and policies. These changes have been achieved, in part at
least, from the continuing improvement initiatives which have been a feature
in Scotland, as well as the result of many individual local decisions. The
available data largely pre-date the impact of the Change Fund which should
drive further change.
3. One of the inferences suggested by the social care data is that there is a
partial correlation between the static or falling number of care home residents
at Scotland level, despite the rising number of older people since 2003, and
the trend in the number of hours of home care which have grown even more
than would be expected as a consequence of the expanding population.
While home care client numbers have fallen overall since 2005, there has
been a rise in the number receiving intensive levels of home care. Intensive
levels of home care are likely to be possible alternative form of care and
support to long term care home admission.
4. Orientated strongly towards the prevention end of the care and support
spectrum, Telecare provision has become a significant feature. The number of
people who were provided with Telecare support in 2011 outstrips the number
getting home care.
5. Convincing progress at Scotland level towards a reduced reliance on inpatient
beds for emergency care has been achieved since 2008/09. The presence of
a HEAT target in this regard will help partnerships focus on further progress in
the next few years. This is a sentinel area of focus within local Change Plans
and an area where the JIT is actively providing support.
6. A sustained rise in the number of older people being admitted as an
emergency continues to challenge acute care services. Much of the growth in
these admissions is for short spells in hospital. This key issue has been
identified as a specific area for JIT and others to focus improvement effort
with local partnerships, along with the on-going improvement work to reduce
delayed discharges.
PK JIT May 2013 (original version issued to partnerships in March 2013)
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APPENDIX
Technical notes (revised May 2013)
Calculation of projected numbers
In the case of the care home residents, home care clients (ie not the 10+ hours or
the care hours overall) and the hospital admissions projections the calculation
involved applying the age related rate at 2002/03 or 2003 to the estimated
population in each year. In the case of the 10+ hours home care and home care
hours it was not possible to use this method and an alternative approximation of
was used. Details are available on request.
1. The following observation is made by Scottish Government’s Analytical Services
Division which was responsible for collecting Care Home Information for much of the
period covered by the analysis: Introduction of standards by Care Commission resulted in
closure of small residential care homes unable to meet new standards. New Care Homes tend to be
large purpose built Nursing Homes. Evidenced by increasing size of care homes and shift towards
private sector (older people care homes.)
Care hours projection figures
2. In addition, the published home care hours data are not age-specific insofar as
they are able to be used in the general method used for projecting the 2003
rates. Because of this a different, less reliable, method for projecting the care
hours is adopted here. The projections for the care hours uses all ages data
adjusted each year by an estimate of the growth in the population at risk in that
year. The reliability of this method is uncertain. If better alternative methods are
identified these will be used in the future.
Data sources:
Care Home residents:
Home care & Telecare:
Emergency admissions:
Population:
ISDScotland/ASD
H&SC ASD
ISDScotland
NRS (GROScotland)
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