Four principles to improve the care of older patients

Is older people’s care in crisis?

The short answer to the question is “yes” – resulting from a failure to understand, prevent and respond to frailty. But the foundations are in place to provide cost-effective, humane care for older people.

Older people have the legal right to receive care based on individual need, and not be denied treatment because of their age. The Care Quality Commission has put dignity in care for older people at the centre of its systems that inspect and regulate services.

In England, for the first time, healthy active life expectancy is increasing more than overall life expectancy. This is due to a combination of people being more health aware and informed by the media, and an increase in uptake of disease prevention activities by older people. This has all been enabled by financial incentives in primary care and removing age barriers to disease prevention schemes.

So why are there so many reports of lack of dignity in care for older people? And why are our hospitals full of older people who don’t need to be there?

As we get older, our strength, balance and cognitive function  decline so, after even minor threats, we can suddenly lose our ability to get around or do basic things such as dressing and bathing. We are likely to suffer falls and episodes of confusion. Such presentations of frailty will be known to staff in adult health and care services.

Problems with older people’s health, lack of support or an inadequate environment are often unrecognised and a response delayed until there is a crisis. About two thirds of the most serious threats to an older person’s health, independence and wellbeing are unknown to their GPs, including conditions such as dementia and osteoporosis. Many older people also suffer poor housing, poverty and loneliness.

Get in early

With adult social care retreating under budgetary constraints to provide care only for those with the most serious needs, little is available to older people losing their independence with low to moderate levels of need. But it is possible to act.

I lead a project promoting early intervention and response to older people’s health and care needs in 30 countries, of all income levels and states of development. In every setting we found similar categories of need and priorities among older people, and some capacity in the formal or informal sectors to respond to those needs.

Often, information and advice is sufficient to meet these needs but, for a small minority, there are problems that need targeted intervention. We found no evidence of demand that would overwhelm services.

The message is clear: the first step in responding to frailty is to get in early and identify threats to health and wellbeing in old age, so preventing unnecessary loss of independence.

As successful as we may be in preventing frailty, people in their 70s, 80s and 90s will still be vulnerable to sudden loss of mobility, falls and confusion.  Our biggest system failure is that many of these end up in an acute bed or stay there for too long. The dangers of  such unnecessary care – healthcare acquired infections, falls, confusion, withdrawal of support systems at home and loss of confidence to manage independently – are well known.

Some interventions have not proved successful in addressing this problem. Randomised controlled trials of care coordination for older people by community nurses have shown no evidence of cutting emergency bed days; trials of hospital discharge planning systems have not shown benefits from reduced length of stay; and use of step down units has been shown to increase costs and produce worse outcomes.

There is, however, overwhelming evidence from trials and comparisons with international best practice about the need to integrate acute and intermediate care services and access to old age specialist teams. From this we can derive four redesign principles:

• choose to admit only those frail older people who have evidence of underlying life-threatening illness or need for surgery – they should be admitted, as an emergency, to an acute bed;
• provide early access to an old age acute care specialist, ideally within the first 24 hours, to set up the right management plan;
• discharge to assess as soon as the acute episode is complete, in order to plan post-acute care in the person’s own home;
• provide comprehensive assessment and reablement during post-acute care to determine and reduce long term care needs.

Implementing these redesign principles will require changes in commissioning models, the development of provider partnerships, shared information systems, closure of hospital beds to fund community resources, a workforce that can work across service boundaries and respond quickly to a crisis in the community, and effective communication with the public.

This year’s NHS operating framework rightly identified care of older people as a key challenge. It also provides commissioners and providers with the flexibility to redesign NHS care for frail older people. In so doing we could cut the human and financial costs of frailty and lay the foundations for a clinically and financially sustainable NHS.