1. Implications for the labour market, employment, education and lifelong learning; the impact on family members of caring responsibilities
In our response here, we have focussed on family or “informal” carers, who are integral to effectively meeting the health needs of older people with frailty living in the community.
The crucial role of carers in maintaining older people’s independence and wellbeing was recognised in the Dilnot Review on care and support and the Carer’s Strategy . WHO Europe in its strategy for health ageing in Europe identified “public support for informal caregiving” as a key strategic priority . Despite this, the integral role of carers in supporting older adults with frailty is often overlooked in service planning and day-to-day provision.
Considering hospitals as a case example, discharge planning that involves people and their carers reduces the chance of readmission. However, poor experiences for older people and their families of discharge from hospital have been cited in numerous reports.
Health and social care services, across primary and secondary care, need to incorporate carers into all aspects of service design and delivery so that they are involved from the outset in identifying goals and concerns, so that their expectations are managed, and that they have adequate notice of and involvement in any and all changes to care. The incorporation of “I” statements into routine health and social care data collection would be an important first step. The assumption of shared decision making, involving both patients and (with their consent and within the boundaries of the Mental Capacity Act) carers as a standard mode of practice within health and social care is also important.
2. Housing. The impact of changing housing tenure, with a decline in home ownership; the potential of the 'last time' home buyer in stimulating the housing market; the availability of adaptable general needs and purpose built accommodation; examining the scope for mutual forms of home ownership for supporting innovation.
The right supply of housing in terms of location, affordability, size, tenure and facilities is a crucial factor in enabling people to remain in their own homes as they age . It is essential that new housing stock reflects the needs of the local ageing population, with sufficient flexible health and personal care accessible, and extra-care, sheltered and age-friendly housing available . Existing housing stock can also be adapted with aids and technology to assist in daily living and maximise independence and safety. Adaptations and care packages can aid older people’s recovery after a hospital stay and can help them to remain in their own homes at the end of life . Providing adaptations to support remaining at home for just one year can save £28,000 on long-term care costs.
It is important to ensure that homes are climate proof. Countries which invest in winter preparedness have succeeded in all but abolishing excess winter deaths in older people . Localities must develop and implement cold weather plans in line with DH guidance . These should include elements such as action to combat fuel poverty, housing preparedness including insulation, resource planning (for surges in health care demand), emergency and major incident responses and systems for supporting the most vulnerable and housebound. The implications of recent intemperate UK weather, including flooding, for the planning and provision of care for older adults with frailty and dependency has not been studied but BGS members have provided anecdotal accounts of the difficulty in evacuating nursing homes and accommodating residents according to their needs at short notice. This is an important policy consideration if these events are expected to become more frequent.
A key consideration with regard to changing housing tenure is the impact this will have on the planning for funding of long-term care. Currently – and under changes proposed by Dilnot – property-based assets represent a cornerstone of the funding-model for long-term care. A key policy challenge, should the distribution of housing tenure change substantively in the future, is identifying how this will influence the security of funding models for long-term care and sustainability of this sector.
3. How institutions and services in the public and private sectors can adapt to an older society; stimulating growth through innovation, product and service design to support demographic change, including assistive and other technologies.
The health sector is a long way from being fit for purpose when it comes to providing effective care for older people. These will be considered here under people and processes:
Medical training continues to place strong emphasis on learning about pathology, grouped by body systems, at the expense of an understanding of the common presentations of later life and teaching the skills and attitudes required to effectively manage older people with frailty. These skills include: the ability to prioritise and manage multiple concurrent problems across medical, psychological, functional, environmental and social domains; the ability to work as part of a multidisciplinary team across health/social and primary/secondary care boundaries; the ability to support individualised patient centred care in the context of often advanced cognitive impairment and physical dependency. The British Geriatrics Society has produced a core curriculum for undergraduates in medicine , which is evidence-based and supported by the General Medical Council. However, the evidence is that this is not delivered in many medical schools around the country .
Following graduation, it is possible for doctors to complete their training (which may take up to 10 years) without again working as part of a team providing specialised care to frail older people. The skills which would be developed at an undergraduate level, were every medical school to teach the BGS recommended core curriculum, require reinforcement and augmentation at post-graduate level. We have recommended to the Medical Royal Colleges that all physicianly doctors should undergo at least one rotation supervised by a consultant geriatrician following graduation – this could arguably extended to all doctors in all specialties – with the possible exception of future paediatricians.
Within nursing, there is a considerable body of anecdotal evidence from our membership that it is hard to recruit and retain nurses to work in units specialising in Health Care of Older People. Whilst the recent emphasis on basic training in the core skills required to manage older people with frailty for all nurses is welcome, it must also be recognised that managing more complex older people, with multiple conditions, is a highly skilled area, with a specialist knowledge base akin to intensive care, long-terms conditions management or neuro-rehabilitation. Future efforts around training of nurses should seek to give recognition to this more advanced level of expertise in the area of care of older people in order to help recruit and retain excellent nurses within these services.
Older people with frailty raise specific challenges. One is the need to collate complex information about multiple problems across multiple domains; another is for that information to be communicated consistently and effectively between health and social care providers.
Key transitions where information sharing must be done well are when entering and leaving the social care caseload, when being admitted to and discharged from hospital, and when entering or leaving a care home.
The British Geriatrics Society has set out guidelines about how older people should be assessed and the results of these assessments collated and communicated at the point of transition into hospital and at the point of transition into care home . It has also highlighted, in both these documents, the importance of careful pathway navigation and care management at these key transition points. In some respects, the recent discussions of a single responsible practitioner for older people at national governmental level reflect these priorities. It must be understood, however, that care co-ordination in these instances takes time and skill and needs to be adequately resourced. The general practitioner may not always be the natural case co-ordinator – people who are already working with a community matron, or resident within a nursing home and known to the care team there, may be better managed by those professionals.
Many of the health care approaches which have been shown to work for the management of frail older people can be effectively gathered together under the heading of comprehensive geriatric assessment (CGA) . This has been well described as multimodal (taking account of physical and mental health, functional status, social and environmental contexts), multidisciplinary, goal-oriented and iterative. It has been shown to reduce the incidence of illness, death, readmission, cognitive decline and functional deterioration. It has been recognised to do so for over 20 years but has only recently entered mainstream medical discourse. This is an example of classical “know-do” gap. Ensuring that all health and social care economies recognise the substantial evidence base for CGA and commission care according to its tenets would be an important step forward.
Considering technology, the evidence for telehealth services for people with long-term conditions is mixed, with the best evidence pointing to possible effectiveness of telecare services for older people with specific conditions such as cardiac failure, diabetes or chronic lung disease , and can be important in the delivery of care to remote and rural populations. It has been a component valued by staff and service users in some local examples of care co-ordination or virtual wards , or in housing-based interventions to help keep older people at home though it is hard to disentangle its effect from other service components. However, there is no strong evidence that it reduces hospital admissions or costs . The WSD trial found ambiguous evidence in relation to hospital admission and no real benefits in terms of cost-effectiveness or quality of life And in the UK, there is still doubt on both sides about how to improve joint working between the industry and health services.
4. Public health, health and social care; examining the scope to prevent and postpone the onset of care needs, including opportunities for increasing the proportion of the population engaged in behaviours and activities that support healthy ageing throughout life, and the potential positive health impact of successful policies in other fields such as education, employment and housing.
There is now a significant body of evidence that physical activity is beneficial at all stages of life and that regular physical exertion throughout the lifespan is important in terms of reducing the risk of cardiovascular disease, physical dependency, falls and fractures . This does not mean that all people at all ages should be undertaking similar exercise programmes – nor does it mean that all people in later life should be undertaking similar exercise programmes. A person who wants to improve core stability to reduce falls risk might choose to practice Tai Chi; somebody who wants to minimise fracture risk might choose Nordic walking or Zumba, whilst somebody who is looking to reduce the risk of a heart attack might choose swimming. As people approach later life, there is therefore an increased need for individualised exercise programmes which take account not only of personal preferences but also underlying health conditions and health risk profiles. It is not clear that this sort of expertise is widely available to older people at present.
There is a clear evidence base, from the research literature around frailty, that it is now possible to identify patients with early frailty (sometimes referred to as “pre-frailty”) before the physical manifestations of the syndrome become apparent . This is done by considering measures such as walking speed, grip strength and weight loss. There is also an emerging, although less than complete, evidence base that particular medical and lifestyle interventions in those who are identified as having early subclinical frailty may be able to delay or reverse progression into more advanced frailty associated with increased physical dependency. The interventions which may make a difference (in addition to physical exercise programmes) are minimisation of unnecessary drug therapy, vitamin D supplementation and dietary changes. Further research is needed to establish whether screening for subclinical frailty (pre-frailty) is resource- and cost-effective and to decide what health or lifestyle interventions have the most substantial impact . This should be a priority for central funding.
It is important to realise that health promotion should not stop at the point that a patient starts to become physically dependent and should continue throughout the lifespan even up to and including the point of receiving long-term institutional care. The emphases, however, change. Health promotion in more advanced frailty states should focus around minimisation of inappropriate drug therapy , effective identification and management of incontinence , treatment of vitamin D deficiency and early commencement of medications which have been shown to prevent fractures , early identification of falls risk and intervening to reduce this and effective implementation of vaccination strategies where they have been shown to convey benefit (which is particularly the case for influenza) .
5. Next steps for integration of health and other services, including better alignment with the benefits system, for example attendance allowance.
The continued organisation of care provided (if not commissioned) by discrete primary and secondary healthcare sectors, and health and social care sectors raises specific challenges for integration. These are “vertical” integration (primary/secondary care) and “horizontal” integration (health/social care).
Intermediate care facilities, bridging the gap between primary and secondary care and representing a venue where co-ordinated and integrated assessment of older patients with frailty can take place, have an important role to play in an integrated health and social care economy. The recent National Audit of Intermediate Care stated clearly both the role that these facilities have to play in ensuring that the health service as a whole is more responsive to patient needs and demonstrated that they remain underdeveloped and under-resourced in many parts of the country. A more strategic response to commissioning and delivery of intermediate care would help address these issues.
Considering benefits, local authorities in conjunction with health partners should ensure that older people and their carers are offered the choice to take up personal care budgets and direct care payments, ensuring that there are sufficient safeguards to provide any vital care and support needs not covered. Most personal budget holders report a positive impact on many aspects of their lives including being supported with dignity and respect, staying independent, being in control of support, relationships with paid carers and with family members, and improved physical health, personal safety and access to care. The impact of “cash for care” in older people with complex needs is less clear than for younger people with disabilities or mental health problems with benefits potentially offset by anxiety and uncertainty among older people trying to navigate systems or co-ordinate their own care. However, it may be that the type of support needs to be tailored better to the needs of older people.
A key challenge to effective integration is dysfunctional and poorly integrated IT systems. Removing statutory information governance barriers that stand in the way of effective information sharing should be a legislative priority.
6. Examining the extent of stigma associated with ageing and the barriers this creates to full participation in economic activity and in society and what measures need to be take to reduce the stigma.
A key aspect of good long-term conditions management is ensuring that the services and support provided reflect the person’s own circumstances and preferences . The “House of Care” model offers one approach for achieving this, where people with long-term conditions engage in collaborative care planning through pre-arranged appointments, co-producing a single holistic care plan with their care co-ordinator. This is particularly important for older people with multiple long-term conditions, since interventions and care planning approaches which focus on single chronic conditions can lead to chaotic care overall for these patients. This fits with the tenets of shared-decision making and “I” statements as discussed under section 1 above.
7. Considering the impact of family breakup and geographical mobility on social isolation in old age; examining options for promoting greater social connectedness and wellbeing – particularly intergenerational schemes.
Loneliness, social isolation and social exclusion are important risk factors for ill health and mortality in older people . Positive and supportive relationships with close family members contribute to the wellbeing of older people, but those aged 75 and over are least likely to have these networks. Given the complex factors involved in isolation and loneliness, it is perhaps unsurprising that evidence for interventions is relatively limited, although group activities tend to have better evidence than one-to-one interventions. Effective interventions to combat isolation and exclusion in older people often combine public services action with volunteering and action with families and communities, and voluntary work by older people is associated with improved wellbeing and quality of life . The UK-wide Campaign to End Loneliness has a toolkit for Health and Wellbeing Boards (www.campaigntoendloneliness.org) and the Local Government Association (LGA) has produced a wealth of material demonstrating what can be achieved at a community level in promoting active ageing.
Dr Adam Gordon
Honorary Deputy Secretary
Prof David Oliver
Mr Colin Nee
Chief Executive Officer,
on Behalf of the British Geriatrics Society.
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