In the first of three comment pieces on the Commission on Hospital Care for Frail Older People, Julienne Meyer and John Myatt explore the issues facing older people, and what the NHS can learn from the Commission on Residential Care
Older people with frailty, dementia and complex comorbidities are now the “core business” of the acute general hospital. Two-thirds of NHS clients are aged 65 and over but they receive only two-fifths of total expenditure.
‘NHS and care sector staff need to work in partnership to help find solutions across the health, social care and housing system’
The majority of costs inevitably lie at the end of people’s lives. Around one in three people over 65 admitted acutely to hospital are in fact in their last year of life. Older people often present in hospital with additional challenges to their acute care problems.
Of people aged over 70 admitted to an acute hospital, 50 per cent have cognitive impairment, 27 per cent have delirium, and 24 per cent have possible major depression. These challenges are likely to increase over time, as the population ages.
More from the commission
To help address the issues associated with the continued ageing of our population, it is clear that NHS and care sector staff need to work in partnership, to help find solutions across the health, social care and housing system.
There are more than three and a half times the number of beds in care homes than the whole of the NHS – mainly run by private organisations. We ignore them at our peril.
Over the past two years we have both been commissioners on the HSJ Commission on Hospital Care for Frail Older People chaired by Dame Julie Moore.
In parallel,Julienne Meyer has been a commissioner on the Demos Commission for Residential Care (CORC), chaired by Paul Burstow.
What to do, based on the findings of CORC
- Need a sustainable funding settlement for housing, health and social care.
- Separate the “what” (the care and support people need) from the “where” this care is delivered (housing), giving freer choice of housing to meet individual preferences.
- Introduce a new responsibility for the Office for Budget Responsibility to conduct a five yearly, 20 year projection of demand for housing with care services.
- Invest more in the care workforce to ensure this vital workforce is properly remunerated and trained.
- Ensure all new homes are built to Lifetime Homes standards and 10 per cent are fully wheelchair accessible so that people have a real choice around where they live.
With the launch of the final report of the HSJ commission, it is timely to explore the overlaps and common themes across the two reports, which while focusing on different care settings, seek to address similar issues.
Housing has an impact on NHS reform plans
CORC says NHS England chief executive Simon Stevens “neglected” the role of housing in his plans for the NHS.
‘A lack of suitable housing for disabled and older people means only the richest get proper choice’
They argue that a rapid review of housing, health and care demand and funding must be a priority for any new government.
Almost 450,000 people live in care homes in England with an additional 239,000 over 85s predicted to need round the clock care by 2030.
In addition, five million disabled people are currently in need of accessible homes.
CORC warns that a lack of suitable housing for disabled and older people means that only the richest will get a proper choice about where they live and the care they receive, with little more than a “tattered safety net” for the rest.
It is calling for a rapid review of health, care and housing demand and spending by the next government to ensure that the whole system is fit for purpose and sustainable for the future.
Build homes not hospitals
If the final report of the HSJ commission talks about pennywise pound foolish decision making in relation to out of hospital care.
CORC highlights the need for strategic thinking in relation to excess NHS land. By incentivising the use of this land to build care homes, we could offset the need to build more hospitals.
CORC commissioners recommend that the relaxed change of use measures introduced in 2013 to help local authorities convert offices to housing should be extended to enable NHS, Ministry of Defence and university land banks, and appropriate office buildings, to be converted into housing with care more easily.
Care from skilled and specialist staff was a theme of both commissions.
Care homes provide a significant amount of care to some of the most vulnerable and sickest members of our society.
Yet only 4,400 of the 19,884 care homes in the UK are registered to provide nursing care. Most care homes in the UK do not have registered nurses working in them.
‘We can’t afford a fragmented approach to nursing when demand is set to increase’
A more joined up approach to training, recruitment and staffing between the NHS and residential care sector could ensure appropriate staffing levels in care homes enabling more patients to receive care where they live as opposed to in the hospital.
Better partnership working between NHS providers and care homes could reduce avoidable admissions, accelerate discharge, and improve rehabilitation, re-ablement and respite care.
We can’t afford a fragmented approach to nursing when demand for nurses in hospitals, adult social care and residential care is set to increase.
We need to change public and professional views on this. One of the CORC recommendations calls for a vocational nursing role that allows nurses to be trained while working in care settings.
When the Care Act comes into force in April it will represent the biggest change in English adult social care law in more than 60 years.
Social care and housing are rising on the political agenda. With the election a matter of months away, it is time that we urgently show policy makers the true extent of the problems that they can take a joined up approach.
While our population continues to age, we can’t stand still and risk making these very real problems even worse.
Julienne Meyer CBE is professor of nursing: care for older people at City University and John Myatt is strategic development director at Serco and an HSJ commissioner