From gut feeling to evidence base: drivers and barriers to the development of health care for older people

Paul V. Knight

Key points

Major advances in medicine, policy, and services for older people have been made over the past 50 years.

The numbers of older people in the UK and elsewhere are increasing and will continue to do so.

This increase has concomitant sociological, medical, and economic challenges that need to be met because they affect the provision of services at all levels.

These challenges are occurring at a time when resources are becoming scarcer and budgets shrinking.

Governments are faced with orchestrating infrastructure and policy in this demanding and complex scenario.

Managers are attempting to do more with less.

Clinicians and other medical professionals are trying to base treatments on sound evidence-based strategies.

There is recognition of the need to include older people and the general public in these processes.

Research may provide us with information that can help resolve these problems.

1 The emergence of geriatric medicine

Prior to the NHS, illness and disability of older adults of average or low wealth was largely met by local authority provision. Only acute illness preceded by reasonable good health would have reached the ‘proper hospitals’ in the voluntary and charitable sectors, including the teaching hospitals. With generally poor housing stock, and little more than family and other informal care to fall back on in the community, institutionalization was a much more common outcome than it is now. The National Health Service Act 1946 was a defining event for older people’s care as it brought these large and poorly staffed institutions into a health care oriented universal service. The specialty of geriatric medicine was made necessary by this political act, though it needed early clinical pioneers to give it life.

Meanwhile the National Assistance Act 1948 empowered local authorities to provide accommodation for older people whose frailty, old age, or poverty rendered unable to manage at home. This arbitrary distinction of health and social care was set down in law, and remains a challenge to the provision of a flexible yet holistic approach.

2 Older people’s medicine into the mainstream

The initial focus of geriatric medicine was people with ongoing disability, mostly in long-stay NHS hospitals inherited from local councils. The buildings often previously served as workhouses. The changes from the 1950s to the 1980s can be summarized as follows:

Application of conventional medicine to this previously underserved population of patients rendered many able to recover sufficiently to leave hospital.

Early but quite basic developments in rehabilitation and devices reduced disability.

Organization of geographical areas under health boards (with various names) brought some order to the distribution of resources and the gradual spread of geriatricians to most areas.

Closure of worn-out buildings and the rationalization of dispersed services into larger district general hospitals brought geriatric medical beds into the mainstream, with better access to facilities and staff, notably junior doctors.

Facility to admit older people directly, rather than from waiting lists or by transfer from other hospital departments (usually less than satisfactory recovery), gave geriatricians a role in their acute medical care.

This, along with expansion of social care provision, brought about markedly better outcomes and reduced hospital lengths of stay.

Closure of NHS long-stay hospitals, plus changes to statutory regulations enabling older people to access various forms of supplementary income, resulted in major expansion of the private and voluntary care home sector. This coincided with a general loss of NHS long-stay beds, particularly in England.

This privatization had the consequence of transferring medical responsibility for thousands of hitherto ‘hospital patients’ into primary and community care, with little transfer of the commitment or skills necessary for their care. Thus the focus of geriatric medicine became acute hospital services, with dwindling capacity for day-hospital activity such as elective multidisciplinary assessment.

The increasing public costs of funding care home places and domiciliary social support associated with inadequate assessment of disabled older people led to the NHS and Community Care Act 1990. This created a framework for better health and social care collaboration.

Geriatricians’ presence on the acute hospital site and better access for older people to higher-tech medicine resulted in many of them developing subspecialty skills and roles (e.g. in stroke, cardiovascular conditions, endoscopy, and orthogeriatric rehabilitation).¹

3 Demographics

When Marjory Warren published the first of her much-quoted articles in the BMJ in 1943 (1), she annotated no references to support her conclusions but drew on her personal observations of the many patients who had alighted in the wards of the West Middlesex County Hospital. One of the main drivers to support her assertion that a modus operandi of care was needed was the fact that the absolute numbers of elderly people in the population was rising and would continue to do so.

The numbers of people over the age of 65 years has continued to increase in the UK and elsewhere. The trend is set to continue according to many national surveys (Box 1.1). This increase in the older population carries with it sociological, medical, and economic burdens that are likely to affect the provision of services at all levels. These challenges are occurring at a time when resources are becoming scarcer and budgets shrinking. Due to the complexity of these challenges, governments alone are unlikely to be able to deal with them. Instead there will likely be a need for collaboration between multiple agencies with integration of services nationally and across different disciplines at multiple levels.

Box 1.1 Ageing statistics

The UK has now reached a point where there are more people over State Pension age than children. By 2020, the Office for National Statistics (ONS) predicts that people over 50 will comprise almost a third (32%) of the workforce and almost half (47%) the adult population’.