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Growing Old in the NHS
The CQC intends to rate practices against six population groups – older people, long term conditions, mothers, babies and children, working age, people living in vulnerable circumstances, including people with a learning disability and people experiencing poor mental health , including dementia. This article, the first in a series of six, will address the ‘elderly’ population group, the crises faced in providing care for this rapidly growing group of patients, and how we are trying to improve services for the elderly.
Professor David Oliver, Consultant Geriatrician, explains that, “Population ageing is a ‘game changer’ for health and social care services. While many people remain well, engaged and active well into later life, report high levels of happiness and continue to make a major contribution to local communities – as carers or volunteers, for instance – increasing age also brings an increasing chance of long-term medical conditions, frailty, dementia, disability, dependence or social isolation.” He also said that; “Too often, long-term conditions strategies have tended to focus on single conditions, whereas most people over 75 have a number of conditions and want to be treated as an individual who needs coordinated, person-centred care rather than as a collection of diseases. Too often, these strategies ignore common conditions associated with ageing and, in particular, fail to mention the unique challenge of frailty. Older people who are frail often require a different level and type of support to those who are younger and fitter.”
Older people are struggling
There has been a push for doctors to take greater responsibility for the most vulnerable patients in society to relieve pressure on hospitals. An analysis by NHS England showed many of the winter pressures on A&E came from frail, elderly patients. Contrary to common perception, it found that summer was the busiest time for A&E units in terms of numbers, but winter was when the difficulties arose because of the rise in the numbers of elderly patients needing care. A third of emergency admissions are among the over 75s, many of which could be avoided if they received earlier and better care in the community. Thousands of older people in England are struggling in their own home with little or no help, research suggests, and many of these patients do not have regular contact with their GP practice.
- Older people and care in numbers:
- There are 8.6 million people in England aged 65 or above
- Of these, about four million are living at home with limited day-to-day activities, although some of these have needs classed as low-level
- Of these, more than two million have difficulty with one or more daily tasks, such as washing, dressing, cooking or eating
- Of these, about one in four (560,000) have needs classed as severe
- Of these,160,000 say the help they receive is inadequate, and another 70,000 receive no help, paid or unpaid
- 850,000 older people receive paid help funded by themselves or their local authority
- Another 1.5 million rely on unpaid care from friends and family
- 30,000 older people care for others in situations considered a risk to their health and wellbeing
Source: Independent Age and Strategic Society Centre based on 2011 to 2013 data
Working in partnership
The health and wellbeing of older people depends on them accessing GP services in a timely way. Effective joint working between GP and other healthcare providers, the involvement of patients and their relatives or carers and the engagement of practice staff are factors that can affect the outcome and lead to quality improvements.
Working in partnership with the patient is essential to providing a good-quality service, particularly to the elderly. Good relationships between GPs and patients are built up through regular contact and respectful, interpersonal communication which builds trust and confidence. Positive relationships between GPs and patients are often from GPs 'getting to know' their patients, and this is associated with positive outcomes. These include patients feeling reassured and listened to, understanding their medical issues and being encouraged to take medication or cooperate with treatment; GPs following patients' wishes for treatment and care; and reductions in hospital admissions.
When the 2014-15 contract changes came into force they stipulated that patients aged 75 and over would have a named GP to co-ordinate their care. Many heralded this as the return of ‘the family doctor’. The contract changes were designed to introduce more personalised care, more choice for patients, remove unnecessary targets and improve the transparency of the quality of GP services. GPs now oversee personalised care plans, integrating all services for patients with complex health and care needs. This is in order to reduce unplanned hospital admissions, which should benefit the patients concerned and the NHS. All patients aged 75 and over now have a named GP, responsible for co-ordinating their care, as will those with complex health needs. They will develop and regularly review personalised care plans for these patients.
GPs should offer patients same-day telephone consultations, co-ordinate care for elderly patients discharged from A&E, and monitor and report on the quality of out-of-hours care. They should also provide paramedics, A&E doctors and care homes with a dedicated telephone line so they can advise on treatment, and regularly review emergency admissions from care homes to avoid unnecessary call-outs in future.
Integrated Care Pathway
NHS England have produced a practical guide for commissioners, providers and nursing, medical and allied health professional leaders to offer safe, compassionate care for frail older people using an integrated care pathway. The guide explains how NHS England’s mission of ensuring high-quality care for all relates to its definition for quality, how it will measure success, and what care should look and feel like for patients.
Outcome measures are of key importance, but process and balancing measures will be scrutinised by the CQC. It is recommended that measures to evaluate the implementation of any frail older people’s pathways are based on the following categories:
- Patient experience: where patients themselves have provided feedback on the quality or effectiveness of the service they have received.
- Harm reduction: where outcome measures indicate whether harm to frail older patients has occurred.
- Quality of life: whether or not frail older patients are able to maintain reasonable quality of life after contact with health services.
- Systems supporting older people: where measures relate to the systems that treat frail older patients, and whether these support improvements in care.
- Financial: where indicators show any savings released as a result of changes to the pathway.
“Care needs to be just as important as treatment. Older people should be properly valued and listened to, and treated with compassion, dignity and respect at all times. They need to be cared for by skilled staff who are engaged, understand the particular needs of older people and have time to care”. Hard Truths, the Journey to Putting Patients First – Government response to the Francis Report, November 2013.
“From warm meals, to daily exercise, to healthcare; one can't help but wonder how our society would be different if tended to the elderly as we do to our imprisoned.” ― Steve Maraboli, Unapologetically You: Reflections on Life and the Human Experience.