Getting Health Services Right for an Ageing
Population. What else do we need to do?
David Oliver
Partners 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
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”)
Around 18% of
Distribution of death England 1841 - 2006
all deaths were
before 65 in
2006 – the same
proportion as in
1991
100%
90%
1981
1991
80%
1941
70%
2001
60%
50%
1841
2006
40%
30%
20%
10%
0%
1
5
9
13
17
21
Source: mortality.org, originally ONS
25
29
33
37
41
45
49
53
57
61
65
69
73
77
81
85
89
93
97 101 105 109
5
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?
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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
Unhelpful/apocalyptic language?
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“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
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Not just medical model of “absence of disease”
Control over daily life
Wider Determinants: Potential for
multiple disadvantages. Role of
Personal care and
local government, benefits,
housing etc?
appearance
Food and drink
Accommodation
(cleanliness and
comfort)
Personal safety
Social Participation
Occupation/Activity
Dignity (in care) once
you are vulnerable or
dependent
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 longterm 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
Multimorbidity in Scotland
(Scottish School of Primary Care)
– 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
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
19
Source: 2005 General Household Survey.
No LTC
Non-limiting LTC
20 March, 2016
Limiting LTC
Inpatient bed days
Societal Cost of Dementia in UK
[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]
Alzheimer’s Disease International, 2009
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
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
22
16-24
25-34
35-44
45-54
55-59
Source: Family Resources Survey 2007
60-64
65-74
75-84
85+
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)
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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
(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.
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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)
3,000
Minimum: 1,145
Maximum: 2,805
2,500
Mean: 1,881
Median: 1,821
2,000
1,500
1,000
500
0
PCTs
NB Excludes admissions where PCT is unknown; mid-2009 PCO population estimates used
CPA Review (part of equality act
consultation)
CPA Review
www.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)
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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