Community Services for Older People in England
John Young, Professor of Elderly Care Medicine, University of Leeds, UK
In the UK, the service model for geriatric medicine was developed, and has largely been sustained, as a hospital based specialty. The last twenty years has witnessed a demographic transition with increasing demand for geriatric medicine care but with reducing resources due to constant efficiency pressures and the need to realise “cost improvements”, that is, bed closures. The resulting mismatch between rising demand and reducing capacity has necessitated considerable reduction in patient length of hospital stay nationally. Thus patients are essentially now discharged from hospital elderly care medicine units when they have recovered from their acute illness and are physiologically stable, but often still functionally dependent. In this sense a “care gap” has emerged. The strategic response to this, initiated in 2001, has been a policy of “care closer to home”, predominantly through the widespread introduction of intermediate care services. These services operate in the “virtual space” between secondary and primary care. At the outset, three policy aims for intermediate care were described:
To help people avoid going into hospital unnecessarily
To help people be as independent as possible after a stay in hospital and
To prevent or delay the need for admission to long-term care
The research evidence base for the various service models that comprise intermediate care (for example: crisis response teams; community hospitals; hospital-at-home services; day hospitals) remains incompletely developed. The inconsistencies in the evidence base, in combination with varying local provision, led to concerns over its governance in the UK NHS. Moreover, the structural location of intermediate care, lying between primary and secondary care, meant that the services fell between regulating bodies: essentially there was a lack of quality assurance. It was for these reasons that a national audit of intermediate care was established. This annual audit will be in its fifth cycle in 2017. The audit has been funded by local organisation subscription, though the 2017 iteration is being funded directly by NHS England. The audit is led by the British Geriatrics Society, but with multi-professional, multi-agency oversight, and organised by the NHS Benchmarking Network (http://www.nhsbenchmarking.nhs.uk/index.php). The objectives of the audit are (i) to develop quality standards for key metrics based on published Department of Health (England) best practice guidance, (ii) to incorporate patient outcome and patient reported experience measures (PREMs), (iii) to assess performance against the quality standards and outcomes, (iv) to summarise national data and provide local benchmarked results on key performance indicators and (v) to inform policy and service development. To date, audit encompasses about half the NHS in England. The main findings be summarised as:.
There is considerable local variation in provision of intermediate care, but an important finding has been that the national capacity is estimated to be about half of that required.
There is evidence that the functional dependence outcomes from intermediate care are good with about 70% of service users improving their function
There is evidence that crisis response teams are able to respond rapidly and prevent admission to hospital for 90% of referrals
There is evidence that intermediate care services could be better integrated with other health and social care services.
The reported patient experience is very positive, but patient and family involvement in goals and care decisions are areas for improvement.
Frailty and Primary Care
John Young, Professor of Elderly Care Medicine, University of Leeds, UK
One of the widely acknowledged health triumphs is the remarkable and rapid increase in the life expectancy that occurred during the 20th Century. The average life expectancy at birth at the beginning of the 20th Century was less than 50 years. Currently we enjoy an average life expectancy at birth in England of 79.4 years for men and 83.1 years for women. This is a massive change over an ultra-brief biological time frame. And this established trend in longevity is projected to continue during the 21st Century. A cause for celebration, indeed! But the critical issue is the extent to which these “additional” years are spent in good health and how health and care systems can be organised to facilitate this.
In the UK, a report from the Health and Social Care Information Centre indicates that the remaining life expectancy at an age of 65 years is 18 years for a man and 21 years for a woman (roughly 5 years more compared to 1980/82) but that the “Disability Free Life Expectancy” (DFLE) is only 10 years for men and 11 years for a woman. Thus about one half of later life will be spent with some degree of dependency – disappointing for the individual and potentially expensive for our health and social care system. Tantalisingly, the report also presents data on the significant variations in DFLE between local authority areas across the country – a sure indication that modification in DFLE might be possible.
Underlying these late-life adverse health experiences are, of course, the intertwined issues of multi-morbidity and frailty. These mischievous twins tend to travel together (though about 20% of people with frailty have no conventional LTC) but systems of care for people with multi-morbidity and frailty are poorly developed in the UK health service. We are largely organised to respond to people with frailty at their moment of crisis, that is, presenting with the frailty syndromes of falls, delirium, and immobility.
If we are to redesign services that better embrace people with frailty, we therefore firstly need to change our perception of frailty from its traditional characterisation of an enfeebled, emaciated person as portrayed by Shakespeare: “Last scene of all………… sans teeth, … sans taste …….. sans everything.” If we can free our minds from this image, we are now ready to take the new frailty challenge – simply stated - to reconceptualise frailty as of a(nother) long-term condition: that is as a progressive disorder with potentially modifiable components. Then we can profitably think about the very earliest, and the medium term, stages of frailty. Moreover, we can consider applying the well understood care models developed for other LTCs such as risk factor modification, supportive self- management programmes and care
With this evidence base in mind, a “Practical Guide to Healthy Ageing” has been co-produced by NHS England and Age UK (http://www.england.nhs.uk/wp-content/uploads/2015/01/pract-guid-hlthy-age.pdf). It is underpinned by an extensive evidence base (78 cohort studies) of factors that are strongly associated with loss of independence in later life. It is designed to target people with mild frailty and was carefully constructed with the help of focus groups to ensure the content was meaningful and acceptable. Over 300.000 copies of the guide have been requested since it was released in 2015.
Key to a more proactive approach to the management of frailty, just like any other LTC, is reliable detection in routine care, especially in primary care if a more proactive approach is to be realised. The Bradford electronic Frailty Index (eFI) is a robustly developed and validated tool that has been designed for this purpose. The eFI is a worked example of the cumulative deficit model of frailty developed by Prof Rockwood and colleagues in Halifax, Canada. In our case, the underlying deficits are identified by drawing on coding information contained in the primary care electronic health care record. Over 2,200 codes are used. Thus the tool requires no new data or additional work for the practice staff. Patients are identified as fit, mild, moderate or severely frail. It has been uploaded into the IT systems of all primary care practices in England and, from July 2017, will form part of the GP (funding) contract. GPs and their practice staff are being asked to check the frailty status of their patients and take actions such as medicines reviews, falls prevention and care planning, initially for people with severe frailty. With the patients consent, this frailty status can be included in the “Summary Care Record” (SCR) which is an electronic interoperable file that is passed between the electronic systems of different providers. This should allow, for example, secondary care providers such as orthopaedic and oncology departments to know something about the frailty status of their patients. The eFI values and actions taken by GPs is being collated by NHS England so that a better understanding of frailty from a national perspective and prompt further changes to the GP contract.
Call for Abstracts open: 25th October 2016
Registration Opens: 18th November 2016
Call for Abstracts Closes: 24th February 2017
Notification of Abstracts: 20th March 2017
Close of Early Registration: 31st March 2017
Conference: 10th May 2017
Australian and New Zealand Society for Geriatric Medicine (ANZSGM)
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