David Oliver has been an NHS doctor for 30 years specializing in geriatrics and internal medicine. He is a former national clinical director for older people, ex-president of the British Geriatrics Society and Vice President of the Royal College of Physicians, a visiting fellow at the King’s Fund and writes a weekly column in the British Medical Journal
Acute care for older people provides a viewing arena for the wider stresses in our health and care system and a route to understanding what must change.
As an NHS hospital doctor, with various roles in policy and professional leadership, I’ve had a ringside seat. The new decade needs far better direction than the last.
Decisions made nationally which affect funding, staffing and capacity across a whole range of other services meet and collide locally in acute eldercare. The gaps affect staff, patients and families in ways they see daily but are less tangible, personally impactful and visible to remote decision-makers.
Our public narrative is certainly too hospital-centric and we should shift our focus more towards communities and prevention. But if we can’t address the care of our oldest, sickest citizens in crisis, we’re unlikely to be solving much else.
Adults with frailty, dementia or multiple long-term conditions, are the most likely group to present to acute care systems. GP referral accounts for only around 1 in 5 admissions. Care home residents are at especially high risk. Worried carers or care-workers are often the trigger point and urgent care the default. We lack sufficient capacity and speedy access to in home-based crisis-response, short term community support or rapid access to primary care. People over 75 now account for two thirds of inpatient bed days.
Older people are more likely to require ward admission once in Emergency Departments, with potentially harmful trolley waits in increasingly overcrowded departments, built and staffed for smaller numbers. Total attendances in all ages have grown around 20% since 2009/10 and waiting time performance has worsened. It is sick (usually older) adults needing beds, not minor walk-in, self-presenting patients who get stuck, despite all the public campaigns exhorting them to use alternative services.
Most NHS hospitals start each day rammed full, with a relentless scramble to free beds and fast. That means real staff under immense pressure to take risks and cut corners and prioritise discharge above other considerations. It means real people sent home and real families worrying about them. Despite simplistic policy rhetoric that nobody wants to be in hospital and patients often feel rushed out before they are ready or adequate community support is in place. High rates of emergency re-admission and poor experiences of hospital discharge are well described in reports by Health Watch and the National Audit Office.
“Our public narrative is certainly too hospital centric and we should shift our focus more towards communities and prevention. But if we can’t address the care of our oldest, sickest citizens in crisis, we’re unlikely to be solving much else.”
The main reason for long “front door” waits is the impact of stranded patients and exit block on patient flow through the hospital. The number of official delayed transfers of care bed days hit record highs in 2017 but an NAO report confirmed what practitioners all know. The real number of people stuck and waiting for routes into community health and social care services is far higher than that officially reported.
The NHS has lost around one third of its beds since the 1970s, despite rising demand. We now have among the fewest hospital beds per 1000 among OECD nations, and the comparative percentage spend on inpatient care is low. Stranded patients mean large numbers of beds removed from efficient use, furthering that pressure to discharge people.
Prolonged hospitalization beyond initial acute treatment is bad news for frail or confused older people and exposes them to further risk and their carers to further stress.
All of this leaves clinical staff in typically short-staffed areas, facing moral distress over rushed or missed care, the relentless pace and complexity of work and the daily pressure to take decisions fraught with managed risk and often powerless to provide access to routes back out of hospital that patients beg them for, or community support families crave. There is also a constant background of unhappiness and complaints from patients’ families and expectations that cannot be consistently met. It’s a recipe for demoralization, burnout and worsening retention and we are seeing the impact. The record number of unfilled nursing and medical vacancies is especially high in acute adult care and in coastal and rural communities with an ageing population structure.
Outside hospital, we now have at least 400,000 fewer people in receipt of home care than in 2009/10, with 17% cuts in social care budgets during that time and crises in the social care workforce and care home sector. In the same period, GP numbers have flatlined as workload has risen. District nursing numbers have halved. A failure to plan and invest means we only have around half the required capacity in the very intermediate care services which would help people to leave hospital sooner or avoid admission. Waiting times for intermediate care are rising. NHS Continuing Care funding has been squeezed and contested for people who are dying or have highly complex needs.
The “State of Caring” report highlights the woeful lack of support for unpaid carers who provide most support to older people including the many who don’t meet eligibility criteria of personal care. Their experience trying to navigate our complex, fragmented and disjointed systems and get sense and meaningful timely support is frustrating and fraught.
With the right political will, leadership and investment, actions that would relieve the pressure on acute care are also those which would help improve care in the community and be win/win for services, patients, their families and frontline staff.