The Vulnerable Older People's Plan - Important points from the coalface
Dr Adam Gordon is a Consultant Geriatrician and Honorary Associate Professor in Medicine of Older People at Nottingham University Hospitals NHS Trust. He is Deputy Honorary Secretary of the British Geriatrics Society and also edits this blog.
The list of imperatives to improve care for older people is convincing. It’s now difficult to accept a future version of our National Health Service that doesn’t have a coordinated plan for frail older people at its middle. In this respect it’s good to see that the government is taking the issue seriously with a national consultation on it’s Vulnerable Older People’s plan (VOPP). On September 11th, I went to a meeting in London to present the British Geriatrics Society’s position.
The emphasis on living healthily for longer is to be commended. 65 year olds can today, on average, expect to live for another 20 years. My 1-year old daughter, notwithstanding her Scottish genes, has a one in three chance of living to 100. So health promotion beyond 65 seems sensible. A challenge to this agenda is the recognition that it should not end with the onset of disease or disability. There is good evidence that we can prevent falls and fractures, and pressure ulcers. We can reverse incontinence and malnutrition. We can detect and intervene early to avoid the adverse effects of elder abuse. These interventions work in even the most frail and dependent of people. Health and social care teams know this and already deliver very effective care in these areas but there has, thus far, been a failure to incentivize a coherent response to health promotion in later life at a national level. Careful thought about this should be part of the VOPP.
The concept of both named accountable clinician and care coordinators makes sense. We know that the most effective model of healthcare delivery for frail older people is comprehensive geriatric assessment (CGA) and that a core feature of that model is a single professional who is able to draw together the assorted inputs of a multi-professional team. It seems logical that the coordinator should, in the first instance, be a GP. Nobody is better placed. It is, however, important that the need to collate information not just on medical interventions but also from allied health and social care colleagues is made an explicit part of the role. GPs and care coordinators will also need power of delegation. If a community matron, or a long-term conditions nurse practitioner, is involved they might be the most appropriate named accountable clinician. If a person is in long-term care, their care home manager might be the most appropriate care coordinator. This last point, although intuitive and supported by the emerging evidence from research, would require a renegotiation of the terms in which the NHS engages with long-term care – particularly with regard to opening up some of our services to direct access by care home managers.
The concept of joined-up care raises the issue, at a practical level, of shared information between health and social care. The reality from the clinical coalface across much of the country, is that health and social care staff are desperate to share data more closely but that administrative barriers prohibit us from doing so. Clear leadership is needed as part of the VOPP to remove these hurdles.
Under the heading of improving access, we have to recognise the component of the frail older population that can’t come, shouldn’t come or won’t come to clinic – either in primary or secondary care. Can’t come because they’re too immobile. Shouldn’t come because to do so causes distress or exacerbates cognitive impairment, or because more useful information can be gleaned by seeing them in their home environment. The won’t comes have been dealt with relatively well by primary care in the past - but in secondary care we’ve allowed them a couple of “do not attends” and then bid them farewell. The problem is that they end up coming in anyway, once their health has deteriorated to the point of requiring admission. In these regards, initiatives that take secondary care clinicians out of hospital and closer to the patient, even into their own homes, should be encouraged. We have to recognise that this is not a very time-efficient way of providing care and that it clearly should not apply to all patients. There is, however, a group for whom it is essential. The VOPP needs to consider how services can be structured along these lines.
Finally, out-of-hours care. There is such a thing as an avoidable admission. Several of the mechanisms underpinning avoidance of inappropriate admissions are there within the VOPP. But we have to recognise that, by virtue of their multiple, often serious, long-term conditions, frail older people will from time-to-time need hospitals. We have to make sure that appropriate access to secondary care, both in and out of hours, in enshrined in the VOPP. We need to avoid the debate becoming polarized to the extent that all secondary care admissions are viewed as bad. Geriatric medicine evolved in the 1930s out of the failure of our world class health services to engage effectively with frail older people. We can’t return to this. This should not be about rolling back secondary care provision, which is already overstretched, it should be about extending provision outside of hospital so that older people can get the right care, in the right place, at the right time, wherever that may be.
It’s not too late to provide your thoughts on the VOPP – the consultation exercise is online at http://betterhealthandcare.readandcomment.com