By 2050, one in four people in the UK will be over 65. The ageing population is already a challenge
to the National Health Service and social care services, both under pressure to cut costs.
This film examines the reality behind the headlines that surround the health and wellbeing
of the most vulnerable group in society.
Something like 60% of admissions to hospital are in people over 65, about two thirds of the bed days
are in people over 65, and we know from the research that some of those admissions are preventable.
And they could be prevented by managing people better who have long term medical conditions
so that they stay well and don’t deteriorate, they could also be prevented sometimes when
people do become ill by responding more quickly to their concerns and maintaining them at home.
And we know we’re not going to solve the problems of the NHS unless we do start delivering
more care closer to home as the population ages.
So how do we define an unnecessary hospital admission for an older person,
whether they live in their own home or a residential home?
In the immediate situation that’s an older person who has an illness which from the medical
point of view can probably be dealt with quite adequately in for an example a domestic setting,
with community health resources - but cannot be unless there is the adequacy of social care
immediately available and the social care and the health care working collectively together.
So that could be an immediately avoidable hospital admission.
My view is that there is a lot of emphasis on trying to keep people at home, and I think that’s
quite legitimate if it’s based on the needs of the individual, but too often it’s based in the
needs of the system and the budget. So what I would say is what we want is the right service
for a person at the right time in their life.
It can be difficult to identify what the right thing is because older people are a hugely diverse group.
When Mum goes into hospital, you know like, if she’s had a fall and they’ve taken her,
the surroundings really disturb her because she doesn’t recognise the sounds and what’s
going on around and she gets very distressed.
I’m living here on my own, but at least, it’s mine. I don’t want to be in hospital.
I don’t want him in hospital, they think I do, I don’t. But when it gets serious, I have to.
These are just a few voices from the 10 million British people who are currently aged over 65.
Including three million who are over 80. The majority of them continue to live independently.
Yet increasing age inevitably brings its problems.
We are carrying a much larger burden of ill health in the community than we were perhaps
20 years ago, because we have many more people who are the elderly old, who have many
health problems including frailty, which is not a diagnosis, it is just a state of health
The ageing population is increasingly reliant on quality care, either in a residential setting
or at home. Home carers in particular, with the right training, can play a vital role in helping
to prevent unnecessary hospital admissions.
The home carer is in a unique position to be able to pick up when somebody is beginning to
get more frail, beginning to - maybe beginning to become ill, maybe beginning to develop dementia
and so on. And it’s really crucial that people have the training and the confidence to
actually take the right action when that happens.
People don’t necessarily you know want to spend a disproportionate amount of their time in hospital,
therefore if you can have home carers playing a key role, and they’re trained in that, in identifying
you know early warning signs that people are actually becoming more confused, or becoming
increasingly more frail, we can put in additional support to help people stay at home.
When we’re talking about home care staff, who are vital in terms of maintaining people’s independence
at home, again there’s an issue about their skills, about the support they get from their own
organisation, but also the access to health care inputs when required. So if you’re a home care
worker and you find that someone’s having problems with their medication, or they’re falling,
or they’re becoming confused, you need that rapid access to input from community nursing,
from general practitioners, if you’re going to enable people to remain safe at home.
Better prevention programmes, and innovations like telehealth, are beginning to make staying at
home in later life safer and more realistic. The result is that when people finally go into
care homes, they are often very frail and ill.
It’s important to remember that many years ago care homes were not places where people with
very severe frailty went. And in fact if you go back to the 70’s, you’ll find care homes with
large car parks, because lots of the residents still had their own cars. We’re now in a scenario
where care homes are delivering very very high levels of care to people with multiple morbidities
and some serious health issues. So I think the world has changed in terms of the population
of care homes but the health care system has not caught up with that.
People in care homes are among the ill-est people in our society really. They only go into
care homes because they’re very frail, vulnerable, often on multiple medications, they often have
conditions like dementia or falls or immobility. And we know that care homes have been a bit of
a black hole for health care input really. People in long term care often get much less access to
not just GP input but other community health services like chiropody or dieticians
or physiotherapists than they would in their own homes. So they get a raw deal. But they are on
the list of general practitioners, and general practitioners, or commissioning groups,
need to start providing more services for those people. And it will be win win as well,
because often they end up in hospital because their medical problems haven’t been well managed.
Medical issues include physical and mental wellbeing. Well over 70% of care home residents
have some form of cognitive impairment, ranging from depression and confusion to dementia.
Care homes are really centres of excellence for end of life care and for dementia. Places where
frail older people who can no longer manage themselves at home can be supported to live
and to end their lives. They’re also places where people can go for respite care
and for re-ablement and rehabilitation.
No matter where older people live, or the state of their mental or physical health,
the main reason for admissions to A&E remains some sort of crisis.
At the moment that an older person is as it were turning up at the front door of a hospital,
looking like in their view or their GP’s view that they need to be admitted to hospital,
actually there are few safe alternatives. But for some individuals, getting prompt diagnosis,
and getting a rapid response team combining health and social care, supporting people at home,
is definitely an option. The key to that is a very rapid assessment diagnostically at the front door
of the hospital. Which is where we need to collaborate. So if you can get that clarity,
so you can then have a sense of what’s actually going to happen to this individual in the next
day or two, what’s likely, then you can arrange care around them. That’s important, though it’s
not going to be the majority of older people that arrive at hospital.
When older people need hospital, they need hospital just as much as younger people.
So they should never be denied admission when that’s the right thing for their needs.
But the other thing is, when people are in beds, they sometimes stay too long, and that’s partly
about having enough step down services when people leave hospital, but it’s also if you manage
people better in hospital, they’ll often stay for a shorter time. So we avoid letting them become
immobile, we avoid moving them four times, we avoid causing confusion and having them lose
function while they are in hospital and often their length of stay will be shorter if we do the
right thing across the whole pathway of care.
Government initiatives such as the 2012 Health and Social Care Act, and legislation on care
and support, emphasise the need for integrated working between health and social care.
But ongoing research into integrated working and unnecessary hospital admissions amongst
older people, has so far not shown a reduction in emergency admissions.
It has however shown up other potential benefits.
There was a reduction in planned hospital admissions and a reduction in outpatient usage.
So as a result, the overall costs of hospital care for people who were receiving
the integrated care were actually slightly lower.
It’s not just about money, it’s about better outcomes for individuals.
The things that really seemed to work are where patients - people can take some control of their
health, so they become more empowered. For example patient education in people with chronic
obstructive pulmonary disease, which is a long term respiratory condition, can reduce admissions
by 40%. And there are very few interventions that we could put in as a health service that would be
as effective as that. And we know that things like rehabilitation after somebody’s had an admission,
can be really effective as well. So for example in some of the heart failure research where they’ve
seen their best results, patients have been able to access a specialist nurse, they’ve had education,
they’ve learned how to look after their own condition, they know where to go, where to seek
help if their condition deteriorates, so you’ve got a number of smaller interventions in
there building up to one big one, and perhaps it’s there that we’ll see the biggest hits.
The jury may still be out on the best ways to reduce unnecessary hospital admissions amongst
older people, but the challenge remains. Are the health and social care sectors
ready and able to join forces to face up to it?
We know what’s coming, we shouldn’t pretend we don’t know what’s coming. Are we preparing for it?
I don’t see any evidence of that. I worry enormously that the current squeeze on everything
means that some small home care providers are going out of business, we’re going to be losing
quite a lot of the skills and expertise, and as the numbers increase we actually going to be
less and less well equipped to deliver the services that are needed. And I don’t think
we should be tolerating that.
I think the debate about the medical model and the social care model has become increasingly
redundant, conceptually and definitely in practice. So I think that we - whilst we have
different bodies of expertise and to some extent work within different paradigms, the reality is
that we need to coalesce around the needs of older people. And where that’s done actually,
people don’t necessarily always agree. But what they do is they cooperate to do the job properly.
Our life is most impacted as clinicians when social care is struggling. It’s exactly the same
for social care professionals. Their life gets more difficult when the doctors are unresponsive.
We do have the knowledge actually within the systems of care and the professionals and
others involved. It would be good to have a period of less meddling, and less reorganisation,
so we actually have the time to get together and turn these things into viable solutions.
I think we can do it.