“Admission prevention” and “care closer to home” for older people – between the sceptics and enthusiasts
Prof David Oliver is BGS President-Elect, is a Consultant Geriatrician at the Royal Berkshire Hospital, Visiting Professor of Medicine for Older People at City University London and a Kings Fund Visiting Fellow. He recently stood down from his role as National Clinical Director for Older People at the Department of Health.
This is my first blog since becoming President-Elect of the British Geriatrics Society. Alongside my day job as a busy coalface geriatrician, I have spent the best part of four years seconded to the Department of Health as a senior government advisor in the Civil Service. I resigned at the end of 2012 because I couldn't reconcile my new role as a BGS officer with the role as National Clinical Director or (as the press would have it) “tsar”.
No longer bound by the Civil Service Code, I am free again to speak my mind. A particular issue I want to discuss here is the thorny subject of “admission prevention”, “admission avoidance”, “care closer to home”, “care outside hospital” – take your pick.
Colleagues will notice that when these terms are used, they are frequently followed by “for older people”. Sir David Nicholson recently added to the narrative currently popular in the health and social care leadership communities, saying that “hospitals are bad places to care for older people and we need to learn from what happened in the seventies with mental asylums and move towards new models of community care”. I am pleased to say that the BGS responded assertively and publicly to this claim.
Sir David’s voice is, however, not a lone one. There is currently a push around the use of telecare and telehealth with much spinning of the evidence-base or partial citation of research findings (often in company-sponsored features). I spoke at both the National Association of Primary Care and NHS Alliance conferences this year, where there was much (almost boastful) talk from the more entrepeneurial GP leaders of how “we will take thirty per cent of the activity out of our acute providers and do it cheaper and better”.
No event is now complete without commentators engaged in a race to see who can talk most about “self-care”, “shared care” “asset-based approaches” and “personal health budgets”. An associated narrative characterises health care providers as depersonalising, paternalistic and not concerned with patients’ welfare. ”We have to stop talking about doing things to people in hospital and focus on helping people to realise their own goals for wellbeing” etc. Much of this talk is predicated on the idea that typical patients are working-age adults, empowered, informed and suffering “single organ” diseases and wishing to manage their own conditions.
In delivering the “Nicholson Challenge” (4% efficiency savings for at least 4 consecutive years) much faith has been placed in taking capacity out of acute hospitals (where most patients are old and frail). There is much talk about the need to “invert the triangle” and focus more resources on prevention and reducing inequalities, so that older people are less likely to become ill or frail or dependent in the first place.
Dr Michael O’Donnell in A Sceptics Medical Dictionary defined a platitude in terms of the inverse absurdity rule. Try saying the precise opposite and see how preposterous it sounds. “We believe in an authoritarian, paternalistic model of medical care where we know best and where we wait until people become acutely ill, before treating them – with hospital being the default option. We believe the NHS should ignore preventative lifestyles and healthcare across the life-course.” Nobody could disagree in principle with the need to focus on prevention and the better management of long-term conditions.
It’s a bit more nuanced that that though. When it comes to how geriatricians respond to such talk, you can split us into sceptics and enthusiasts.
The sceptics are, for the most part, instinctively troubled by the constant talk of care outside hospital and fewer hospital beds as the solution to all the ills in the system. There are several reasons for this:
- First, our lived experience in frontline services. When we are on-call we see many older patients for whom acute hospital admission is the only viable option, or the best way to meet their needs. For an older person with a hip fracture, or an acute stroke, acute kidney injury or septicaemic shock, are we really suggesting they could, or should, be managed at home?
- Second, we are very wary of age discrimination – now explicitly banned in British Health and Social Care Services but still rampant and repeatedly evidenced. Why should older people be denied the full facilities of the general hospital, whilst such access is apparently fine for working age adults?
- Third, as medics, we are broadly signed-up to the idea of evidence-based practice. The evidence is strongly in favour of acute inpatient management in many instances. Stroke units save lives. Modern models of hip fracture care deliver better outcomes. Comprehensive Geriatric Assessment delivered by a hospital-based team delivers better long-term outcomes for patients. By contrast, the evidence that interventions to prevent hospital admission and reduce bed occupancy are cheaper, more effective or cost-effective than current models is at best highly contestable.
The enthusiasts think differently:
- Hospital is not always the right place for frail older people. Let us consider other experiences from the frontline. We often see patients who have been deteriorating for some time and have eventually defaulted into an acute bed. This often happens at weekends and holidays, or outside of the normal working day. We see patients with needs which could hypothetically have been met by other services – in many cases by support for carers, respite, social care or “step up” rehabilitation – but these services were either not available or went unused. We see patients with advanced co-morbid dementia who are diagnosed for the first time on admission to hospital – seemingly on no-one’s radar. We see patients admitted from nursing homes, often in extremis for want of adequate medical support. We all of us go to see ward referrals in other parts of the hospital who have been mismanaged, allowed to become immobile, or delirious, or dependent because of insufficiently expert management, or assessment drift, or repeated ward moves.
- There are 3.5-fold variations in rates of admission and bed-occupancy in over 65s across England. There is a 6-fold variation in the risk of patients being placed from acute hospital beds immediately into a nursing home. Similar variations exist in rates of emergency readmission to hospital and in length of stay and outcomes for intermediate care services. Clearly some health economies are doing a much better job than others at keeping older people at home, shortening hospital episodes or improving outcomes than others. So perhaps, done a particular way, community-based care can make a difference.
- Even when the evidence-base strongly supports hospital care, there is additional research that reminds us of a continuum starting in the community and ending back there. Taking the well-studied area of hip fractures there are findings (not all from RCTs) about models of care (for instance integration, risk stratification, anticipatory care or post discharge transitional care) which can deliver better outcomes when coupled to gold standard care in hospital.
The truth is that this is an artificially polarised debate. The trick we have to pull off as geriatricians is to accept and reconcile the view of both sceptics and enthusiasts. We should never cease to advocate for older patients’ right to receive appropriate evidence-based specialist hospital treatment. We should be saying forcibly that the solution to hospitals being poor places to care for older people is not to close the doors on the frail and demented but to make hospitals fit to care for them. Meanwhile, we need to engage constructively across the whole pathway of care to ensure that older people are in the right service for their needs, at the right time. Advocating for our patients demands that geriatricians speak up for both high quality acute care and the best possible healthcare between admissions. We need to do what we’ve always done, remind everybody that will listen that the best way to care for frail older people is the best possible care, at the right time, in the right place – whether that’s in hospital, or in the community.