Key points

There is increasing concern about quality of care received by older people in our health services.

Real progress over recent decades in overcoming ignorance and ageism is at risk if these services cannot become age-attuned.

Today’s older people are older, more numerous, and present complex challenges of multimorbidity and frailty.

Traditional divisions of staff and skills between primary and secondary care, and between clinical specialties, are an obstacle to meeting the challenge.

Promising innovative new models of care are emerging and will need refinement through research and experience.

Skills and attitudes needed to recognize and manage the geriatric syndromes must be mainstreamed through education, training, and dissemination of good practice.

Specialists in old-age medicine and mental health cannot do it all, but must champion this transformation.

1 Introduction

An ageing society represents a real success but brings new challenges to health and social care provision. In recent years, there has been a deluge of press reports, inquiries, and political attention to the plight of older people in the health and social care services. Increasing concern about quality of care for older people is welcome. Unfortunately it is often couched in negative terms of a ‘tsunami’ of demand and moral panic on loss of caring capacity of staff.

In truth, there has never been a golden age of health services for older people. The models of care which cope reasonably well with acute episodic illness in previously well adults do not do well with the multimorbidity and frailty of old age which this chapter will briefly describe. Getting services right is a continuous process of adaption—to new circumstances, new cohorts of older people, and the ever-changing possibilities of medicine and health care. Making sense of current services and their attendant challenges is as much an exercise in political history as it is in medical history. And going forward successfully will depend as much on appreciating the social and cultural perspective as on new innovations in treatment.

Specialists in old-age health care, including geriatricians and old-age psychiatrists, need to be in the vanguard of getting health services fit for our modern population’s needs: in short we need an age-attuned NHS. This will include new models of specialist services but also embedding the necessary attitudes, skills, and know-how throughout the service.

2 Towards a strategic approach to older people

The 1980s saw a reduction in the scope and a shrinkage in the size of specialist older peoples’ medical services with the welcome development of acute wards on general hospital sites but the almost total closure of NHS long-stay facilities and a significant reduction of designated rehabilitation wards. Facility to admit older people directly gave geriatricians an increasing role in their acute medical care. But pressures of beds and reductions of doctors’ working time forced amalgamation into all-age adult medical admission wards, with geriatricians playing a larger role generally but at the expense of their time commitment to more specialized old-age services.

On the positive side, geriatricians’ presence on the acute hospital site and better access for older people to higher-tech medicine resulted in many developing subspecialty skills and roles: e.g. in stroke, cardiorespiratory conditions, and orthogeriatrics.

Hospital bed numbers reduced with dramatic reductions in lengths of hospital stay outstripping the gradual increase in numbers of emergency and planned admissions. The NHS Plan 2000 (1) made continuing reduction of acute beds official policy, investing great hope in the capacity of community services to accommodate increasing complexity and volume of need. The large reduction in total medical and geriatric beds was accompanied by growth of alternative community-based services used mainly by older people, and featuring various degrees of health and social care collaboration.

Collectively these are known as intermediate care (IC) as they address the care phase between medical recovery and functional stability, with the general strategic aim of reducing hospital use while attempting to promote independence and avoid unnecessary dependence on institutional or domiciliary social care. The word intermediate also highlights that these service models were distinct both from hospitals and primary care. Geriatricians have rarely been in a clear-cut leadership role. Examples are described throughout in relation to alternatives to hospital admission and to post-acute care.

The National Service Framework (NSF) for older people in 2001 (2) set out for the first time a government view of the scope of services for older people with some clarification of the role of specialists. The NSF was organized around geriatric syndromes such as falls rather than organ-based conditions. This supported the emergence of more evidence-based service models.

3 The changing nature of health in old age

Health and social care use are concentrated at the beginning and towards the end of life. When the NHS was founded, over a third of the population died before age 65. Half a century later, it had fallen to approximately 18%and the chance of surviving from birth to age 85 has more than doubled for men over the last three decades from 14%in 1980–1982 to 38%in 2009–2011. Most of us will die in relative old age, but that age is getting older, as survival within older age is increasing rapidly. Life expectancy at age 65 in England and Wales for men in 2009–2011 rose by 5.1 years since 1980–1982 when it was 13.0 years. Women have seen a smaller increase of 3.8 years since 1980–1982 when it was 17.0 years (3). ‘Thus ‘older people’ are older and more numerous than they were, but they are also different, and the nature of this difference is central to appreciating the way that services need to change.

The number of people living with one or more long-term medical conditions (LTCs) is increasing: 40%of those 65+ report two or more self-reported LTCs. But this does not justify a gloomy outlook (4). Rates of LTCs do correlate generally with poorer well-being, but neither the English Longitudinal Study of Ageing (5) nor the Census (4) show post-65 rates of poor health or disability to be increasing. Indeed, the Health Survey for England (6) shows that mental well-being peaks at ages 65–74. But rates do increase—most people age 75+ report three or more LTCs—and LTCs have increasing impact. LTCs account for 55%of GP appointments, 77%of in-patient bed days, and approximately 70%of Englands total health budget (7).

But the most profound difference characterizing health care in older ages is the presence of frailty. This can be defined in several ways, with prevalence varying accordingly from 6%upwards (8). It results from the effects of ageing, lifestyle, events, and disease combining to render bodily and mental functions impaired, with the resultant diminished reserve making the individual vulnerable to decompensation with additional ‘minor’ illnesses or challenges. This lost resilience may manifest as the geriatric syndromes of falls, immobility, confusion, and a general failure to thrive or to recover from new illness (9). It is strongly associated with poor outcomes, increased mortality, and use of health and social care (10,11).

3.1 The implications for evidence-based medicine

LTCs emerging in later life include osteoporosis, with the risk of fractures; urinary incontinence, which affects a quarter of women over 65; and dementia. But conditions of frailer older people are significantly less well managed in primary care than the familiar middle-age conditions of hypertension, diabetes, and respiratory disease (12), even when national clinical guidance exists, such as for secondary falls and fractures prevention (13–15). Furthermore, while the presence of several LTCs is the reality, clinical guidance is generally arranged around single conditions, and the research providing the evidence for this guidance has often excluded co-morbidity or frailty (16, 17).

Clinical decision making is more difficult in the presence of co-morbidities and frailty. Attribution of risk from individual components of a complex mix of conditions is difficult. Estimating potential benefit in terms of ameliorating symptoms, disability, or mortality risk is also difficult; indeed the relative importance of these differs between individuals and at different stages of life. Nowhere is this more pressing than for the most complex patients who are residents of care homes. We need new evidence reflecting these complexities. Addressing these issues is a challenge both to primary care and specialist geriatric services.

3.2 Health policies and levers

Centralized targets have galvanized sluggish processes without much impact on quality. Financial incentives have improved care quality of some LTC management in primary care and in several hospital services. Clinically led networks and other professional drivers have had greater impact. It remains to be seen whether clinically led commissioning will improve or impede the integration of services which is so important for frail older people.

Considerable funding and managerial effort has gone into short-term initiatives to reduce the rate of acute hospital admissions of older people, usually based on weak or nonexistent evidence. Most have clear strategic aims but ill-defined clinical content and are delivered by undertrained staff. They have failed to grasp the complexities outlined above and little has been achieved (18). In contrast, evidence is growing for new service models built on the technology of comprehensive geriatric assessment (CGA) (19).

4 Current and emerging models of care

Since older people are the majority of health services users, health-care providers with specialist expertise need to be more numerous. The geriatrician-led multidisciplinary team (MDT) should provide much of the direct clinical care in hospitals for the more complex and frail medically ill older patients. But they also need to support embedding appropriate clinical approaches in the wider hospital and community health services. This implies transforming services, education, and training of the general health workforce and supporting the clinical care of older patients provided by other secondary care specialists, physicians, and surgeons. The following sections describe these roles within clinical contexts.

4.1 Acute and episodic illness

Involvement of members of the geriatric MDT at the ‘front door’ of the acute hospital is becoming more common, notably occupational therapists, physiotherapists, and geriatricians. There is increasing evidence that re-attendance of older patients to the emergency department (ED) is predictable by relatively simple assessment at the index visit. This has been linked to various service initiatives aimed at reducing this risk.

4.1.1 Interface geriatrics

This term has emerged to denote the need both for the right clinical skills and the right connectivity between the hospital and the community. Services described so far provide a range of clinical and social-care responses, and significant impact is claimed by evaluations which do not yet constitute Class I evidence (20). A recent randomized controlled trial (RCT) showed that it is feasible to apply CGA with frail older people in the ED and this was associated with reduced admissions and readmissions (21). This is promising, but complex interventions of this nature are likely highly context dependent in effectiveness and cost, and there may be no generalizable elements except general clinical principles.

Case finding in urgent-care settings usually includes links to less specialized community-based IC teams with a focus on hospital admission avoidance. The Cochrane Review of such services (22) summarized with a meta-analysis the findings from ten RCTs, only three of which included older patients with mix of conditions, one from England. Overall no differences in mortality or other outcomes such as functional ability, quality of life, or cognitive ability were found. Patients reported increased satisfaction with admission avoidance (‘hospital at home’). The settings, services, and patients were so variable that no practically useful conclusions can be drawn. Nevertheless such services now exist in almost all local health services in England and many elsewhere in UK. There are therefore plenty of questions to be addressed by future clinical and health services research:

Can a brief CGA be embedded into routine ED assessments of older people to identify those for whom a more time-consuming specialized approach is worthwhile?

What clinical features predict a better recovery of function by receiving home-based rather than hospital-based care? This will need reliable methods to operationalize relevant psychosocial aspects such as self-efficacy.

Can telehealth be developed to enable remote diagnostic assessment of patients presenting acutely but with nonspecific ‘geriatric syndromes’ sufficiently reliably to safely limit hospital attendances?

Is it cost-effective to provide home-based care for acutely ill patients as an alternative to hospital admission?

What skills and training enable teams to function safely and cost-effectively?

ED attendance also offers an opportunity for case finding linked to secondary prevention. The evidence of benefit is best established for falls (23), but this trial and others also demonstrated gains in functional independence through a CGA approach to attendees who had fallen. Evidence-based clinical guidance (13

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