Age-attuning the future hospital
The need for partnership
David Oliver FRCP
President, BGS
Consultant Physician Royal Berks
Visiting Fellow, King’s Fund
Clinical Adviser NHS ECIST
Professor, City University
RCP London. Acute and General Medicine for the
Physician
28th October 2015
Very last talk 3 day conference.
…at train/beer o’clock on a Friday
My Plan
I: Show you one slide to get you thinking about
10 components of services for older people
II: Show you a 4 minute animated patient story
to get you thinking and remind us all who we are
really here for
III: Tell you why acute hospitals aren’t islands
IV: Tell you how ageing has changed the nature
of acute hospital work for good
V: Suggest how we might need to change
For those who want to know more
Most key references are in the King’s Fund Paper
Which also has a free slideset on website
I will signpost some more as we go
Or just email/tweet me
I: The slide describing the range
of services around the patient &
the acute hospital
SAM
Oliver D, Foot
C, Humphries R
et al King’s
Fund 2014
II: The animated patient story
Mrs Andrews’ Story
( I wrote this for HSJ Commission on Frail Older People)
Please watch actively
https://www.youtube.com/watch?v=Fj_9HG_TWE
M
And reflect at each stage, what could/should
have happened differently across the 10
components
This shows essentially caring people trying to do
the right thing
But the system letting her down
There is a second “what should have happened”
free on youtube with the first
III: Why acute hospitals aren’t
islands
Somerset Levels 2013
Quotes
“When we say the hospital is full, we really mean
the community is full”
John Young (National Intermediate Care Audit 2013)
“After some time pulling people out of the river
we need to spend some time walking up stream
to see who is pushing them in”
Desmond Tutu
“Regulating and judging individual trusts in isolation from
the wider health economy is unfair & unhelpful”
Chris Hopson. NHS Providers HSJ
King’s Fund Older People & Emergency
Bed Use in over 65s (see also NHS Atlas of
variation
Variation = scope for improvement
We mustn’t duck our own part in the story
Minimise internal delays
Senior decision makers at
front door 7/7
With rapid supported
discharge teams
Relentless focus on post acute
rehab and discharge planning
as core business
Chair based alternatives
Collaboration with other
agencies in pathway redesign
Effective communication with
community clinical/social care
colleagues
Genuine patient/carer focus
Wider eco-system for acute care I
GP and Community Nursing workforce crisis
– HEE 2015. QNI 2014
Inexorably rising ED attendance and admission rates
– King’s Fund Quarterly Monitoring 2015
For over 75s with primary care sensitive conditions, only
25% referred in by GP or OOH & falling
– Cowling T JRSM 2014
1/3 of hospital beds lost over 25 years
– Appleby J BMJ 2013
UK (England esp) fewer beds/1000 than nearly all OECD
– Economist intelligence Unit 2015
4 hour target effects?
Tariff effects?
3/4 Acutes in England forecasting deficit 2014/15 total
£900 M
HSJ October 2015
Wider eco-system for acute care II
440, 000 people in care homes in UK v complex care needs
Far more likely to be admitted to hospital
– BGS 2013
6 fold v in rate of placement from hospital to care home
– NAO, NHS Atlas
Social care cut savagely since 2010 leaving many with no
statutory support & hard to recruit staff
– Oliver D BMJ 2015
Only c half the intermediate care beds and places we need
& access getting slower
– NHS Benchmarking Intermediate Care Audit 2014
Big waits for continuing care assessment
– NHS Benchmarking Acute Hospital Audit 2015
Delayed transfers record high
– Kings Fund QMR 2015
Readmissions in over 65s c 15% at 28 days, 7% within 7
days
– Oliver D BMJ 2015
IV: How ageing has changed the
nature of acute hospital medical care
for good
By 2030 men aged 65 will live on average to 88 and women to 91
By 2030 51% more over 65, 101% more over
85
Crucial role of carers
Already around 6 million people in the UK are carers for
an older relative
By 2022, the supply of carers will be outstripped by
demand
1.5 M are over 65 – many in poor health
Few get statutory support
House of Lords “Ready for Ageing” report 2013
Carers are key to maintaining people at home, supporting
them in hospital, supporting their discharge
We need to work with them and support them
Following the money.
NHS Constitution Technical Handbook
Over 65s in hospital (England)
(DH analysis of HES data from Kings Fund Care of
Frail Older People. Cornwell 2012)
68% bed days in over 65s. Median age
new acute patient = 72.
Multimorbidity in Scotland
(Scottish School of Primary Care Barnett et al Lancet May 2012)
Single disease services & evidence often
unfit for purpose
Scottish School of Primary Care Study Guthrie BMJ 2012
e.g. Only 18% with
COPD just have
COPD
Dementia
Frailty as “poor functional reserve”
Clegg A et al Lancet Frailty Clinical Review 2013
Frailty Syndromes (how people with
frailty present to hospital services).
Clegg, Lancet. BGS “Fit for Frailty” 2014
“Non-specific”
• E.g. fatigue, weight loss, recurrent infection
Falls/Collapse
Immobility/worsening mobility
Delirium (“acute confusion”)
Incontinence (new or worsening)
Fluctuating disability
Increased susceptibility to medication side effects
• e.g. Hypotension, Delirium
Functional decline in acutely admitted
older patients. Mudge et al 2011
High intensity users of hospital services
have overlap of physical and social
vulnerabilities
“Our hospitals are struggling to cope with the
challenges of an ageing population and rising
emergency admissions””
“A third fewer general and
acute hospital beds than 25
years ago but last decade has
seen 37% increase in
emergency admissions with
biggest increase in over 75s”
“2/3 of patients admitted to
hospital are over 65 and
many have dementia, frailty
or complex needs….buildings,
services and staff are not
equipped to deal with them”
Older people and the integration and
care co-ordination agenda
Older people
Especially with complex needs/frailty
Most likely to use multiple services
See multiple professionals
And suffer at hand offs between agencies
And from disjointed, poorly co-ordinated care
Need move to “person-centred co-ordinated care”
– National Voices 2013
V: Implications for all of us
Reflecting on Mrs Andrews Story
Implications for clinicians in local
services
Workforce with right training, skills and values to
deal with the (older) patients now using services
Matching balance of speciality expertise/beds
with need
Focus on frailty, dementia, multimorbidity as high
priority
Multidisciplinary workforce (e.g. AHPs, nurse
specialists)
Effective collaboration, communication, planning
across whole pathway
No hospital or team is an island
Thankyou. And questions/comments?
[email protected]
[email protected]
[email protected]
@mancunianmedic