There is clear evidence older people benefit from preventive healthcare. For the fulfilled old age that people want, services must spot depression early and support good diet and mobility
No one in the NHS can now doubt they are being asked to shift their focus to promoting good health and prevention of illness. Reducing the number of years people live in poor health is one of the government's biggets aims. Too many older people spend their last years in poor health - yet most of the illnesses and disabilities that blight their lives could be either prevented or postponed. For its plans to increase healthy life expectancy to work in practice, this aim must also be at the core of the NHS.
Two recent developments have underlined this strategy. First, the Department of Health has announced a prevention package for older people, more details of which will be released in the autumn. Second, the outcome of the next stage review requires every primary care trust to commission comprehensive well-being and prevention services in partnership with local authorities - these services will need to be personalised to meet the specific needs of local populations.
But what does prevention mean and what does it look like in practice? The primary purpose of preventive services, as with all health services, is to improve the quality of people's lives. In a clinically focused NHS, however, there is a risk that prevention will be interpreted either as a purely medical activity or that it will only be seen as marginal to the business of the NHS.
While prevention does include early detection and treatment of disease through interventions such as screening and regular health check-ups, such a narrow definition excludes the wider spectrum of preventive services. The services older people themselves value the most focus on sustaining good health, independence and well-being for as long as possible.
Initiatives from healthy eating to hospital aftercare all fall under the prevention umbrella. It also covers services that straddle the boundaries of the NHS and social care, such as rehabilitation and falls prevention, and in its widest sense includes the whole web of services and support available in the community to delay the need for care at all.
The first report from the UK inquiry into mental health and well-being in later life asked older people what they thought were the most important problems to tackle. Their priorities were good physical health, continuing to make a positive contribution, tackling isolation and loneliness and relieving poverty. Sitting across these was the need to tackle age discrimination encountered throughout society. The NHS has a major contribution to make on all of these priorities, sometimes alone but more often in working with others. But faced with such large-scale challenges it can be daunting to decide where to make a start and what will make a difference.
In the new NHS there is a need to make sure the views and experiences of older people, as the main adult users of the service, are heard and acted on. Age Concern's suggestions for what should be the priorities for prevention stem from what we know is important to the lives of older people.
Depression is the most common mental health problem in later life, affecting one in four older people, but the overwhelming majority do not get any support - often because depression is seen as an inevitable part of getting older.
Depression leads to increased use of health services and is the main cause of suicide in older people. Yet there is much scope to prevent depression by helping people to stay healthy (for example through exercise and healthy eating), making sure that regular vision and hearing checks are available to pick up problems early and by tackling the loneliness and isolation which so many older people experience. This type of prevention needs partnership working both at strategic and grassroots levels.
For example GP practices can link up with Age Concern befriending schemes to identify older people who are feeling lonely and signpost the service. For those who do develop illnesses or disabilities, it is often the impact this has on their day-to-day lives which can lead to depression and which it is therefore essential to alleviate, for example with aids, adaptations and practical support.
Targeting help at known trigger points for depression, such as bereavement or moving into a care home, is essential to the overall prevention approach.
Foot care is another important prevention measure. Healthy feet are vital for older people to remain physically active and independent in later life. Poor foot health can frequently lead to complications that can result in dangerous falls, severe restrictions on mobility and social isolation. Almost one in three older people are unable to cut their own toenails, yet NHS foot care services have been scaled back severely over many years after the NHS made the mistake of making foot services focus on the purely clinical and curative, putting it out of touch with what the population wants and needs.
The DH has promised a review of foot care services, including nail cutting, in its prevention package for older people. Addressing this need will be an important test for older people in determining whether the NHS has changed to look out rather than up. All commissioners need to include foot health services in their well-being plans. Commissioning these services from a range of providers, across NHS, private and voluntary sectors, will hit another button of reform.
The rising tide of obesity is also an issue for older people. They need to be included in plans to solve the problem. At the same time, malnutrition is a significant problem for large numbers of older people and often goes undetected. One in 10 older people living in the community and 30 per cent of those admitted to hospital are malnourished. Yet older people visit health services more often than other age groups - on average they visit their GP practices about seven times a year, presenting lots of opportunities (which are usually missed) to identify the problem and intervene.
The link between poverty and ill-health is also well established and there is growing evidence that claiming benefits can improve health and well-being. As some GP practices have found, it makes sense to be linked to a benefits advice service - particularly as many older people on a low income are in regular contact with their doctor. Up to£5bn of benefits went unclaimed by older people last year while an extra£58m in benefits was claimed in 2006 as a result of people receiving benefits advice in healthcare settings.
Age Concern's report Just What the Doctor Ordered revealed one in 10 GP practices in England already offer this link and those that do report they add value and can reduce demand for health services. Advice services also find that links with healthcare professionals enable them to provide a more rounded service. Benefits advice needs to be designed into the NHS in GP practices and the new GP-led health centres.
Finally, the issue that has long plagued prevention is whether or not its cost-effectiveness can be proven. This broad range of "prevention" services is not all trying to achieve the same ends over the same timescale. Sometimes prevention is intended to deliver results in months, while other effects will only emerge over decades, making it more difficult to measure the expenditure against the positive effects of the programme.
While the driver behind many preventive initiatives has been short term cost savings, the focus should be on quality of life.
Alongside the strategic visions for the NHS there must be practical action that is meaningful to all local people. Far from being too old to benefit, there is clear evidence that older people's aspirations fit with a preventive approach and that there is often no section of society that stands to benefit more. It really is never too late.