Commissioning services for an ageing population throws up its own set of challenges and opportunities.
Our ageing population is one of the great success stories of modern medicine and public health. The number of people in the UK aged over 85 has doubled in the past three decades and continues to rise. Many of us remain healthy and happy well into old age, and tomorrow’s older people are likely to be even healthier and more independent than today’s. However, as we age we are more likely to develop multiple, complex conditions, disability and frailty. The ageing population therefore presents significant challenges to our health and care system.
Older people are the group most likely to suffer problems with co-ordination of care and transitions between services. Capacity in rehabilitation and re-ablement services is insufficient to meet demand, and numerous recent reports have exposed failings in safety and quality for older people in hospitals. Simply put, our current fragmented services are not meeting their needs. Transforming services for older people requires a major shift towards care that is co-ordinated around the full range of an individual’s needs and care that truly prioritises prevention and support for maintaining independence. We need to move away from reactive care that picks up the pieces after crises occur, to care that prevents those crises occurring in the first place and that focuses as much on wellness as on responding to illness.
To achieve this, commissioners and health and care leaders need to review the whole range of services for older people – from services to help people remain healthy and active, through to end-of-life care. Figure 1 sets out nine components that make up care for older people.
In any local area, there will be opportunities to improve the quality and continuity of care for older people within any one of these components – whether through initiatives to encourage physical activity, or greater use of comprehensive geriatric assessment for frail older people admitted to hospital, or increasing the proportion of care home residents getting regular medical reviews and access to specialist services.
But the biggest gains will come from looking across all components of care to make sure that the right services are provided by the right people at the right time. That is why the figure includes a tenth, overarching component – the importance of providing integrated services that focus on older people’s full range of needs.
Across the country, there are impressive examples of localities transforming services for older people by taking this joined-up approach. For example, in conjunction with Newcastle Council, Newcastle West clinical commissioning group (CCG) has developed an ageing well strategy that comprises ‘preparing for active old age’ (50 onwards), ‘active old age’, ‘vulnerable old age’ and ‘dependent old age’. The strategy includes: health checks aimed at identifying risk factors such as obesity, physical inactivity and poor diet; engaging older people as volunteers and health champions; a focus on case-finding to identify older people who are vulnerable to deterioration or dependency so that they can receive proactive support; and a focus on supported self-management.
In other areas, new services are helping to reduce moves to long-term care. Birmingham Cross-City CCG has worked with Birmingham Community Healthcare NHS Trust to provide two community health unit wards on acute sites within the Heart of England Foundation Trust. Each provides a period of intensive multidisciplinary assessment, and support with decision-making, for vulnerable and frail older adults facing significant changes to their care and accommodation. Being outside an acute care environment enables these individuals to regain their independence while identifying the areas where they require support. Joint health and social care funding is used to support patients in the units. After initial assessment and identification of need for long-term services, people are moved out of the wards and into a local authority-funded phase of care and onto long-term services as soon as possible. Joint funding enables a more seamless transition and avoids delays to care transfers. The community units have enabled more people to return to their own homes, and reduced delayed transfers and excess bed days in the acute trust.
Our recent report – Making our health and care systems fit for an ageing population – has brought these and other examples of local innovation together, reviewing the evidence of what works, as well as examples of good local innovation, and pointers to relevant guidance. It is a practical resource for local service leaders interested in reviewing and improving their services for older people. Using this catalogue of best practice, commissioners and local service leaders could assess their own services and develop plans to improve them. One approach to do this would be to:
– Walk the journey of care for older people in your area from prevention through to long-term care and the end of life.
– Agree an overarching vision for improvement and some key standards that all agencies can sign up to.
– Map out which elements of good practice are already provided, whether they are sufficient to meet the needs of all older people who would benefit from them, and where the gaps are.
– Pay particular attention to assessing where there are workforce gaps or need for changes in skill mix and roles.
– Identify early priorities for change (such as minimising multiple repeated assessments or improving capacity in intermediate care) and quick wins.
– Ensure that the work is informed by meaningful input from older people and their carers about what matters most to them in service redesign, and that progress and performance is measured against this, using systematically collected feedback from older people and their carers on their experience of care.
– Agree some outcome measures that define the performance of individual services but, more importantly, whole systems of care for older people.
Our health and care systems have a long way to go to adapt to the twin challenges of an ageing population and tighter funding. There is plenty we can do to improve services for older people, and we urgently need to see these experiences spread more widely. And marginal change is not enough; transformation is needed at scale and at pace. Failure to act now will continue to leave older people becoming avoidably ill or dependent, or struggling to navigate complex and frustrating systems.
But the good news is that if we can get health and care systems and services right for our older population – those with the highest complexity, activity, spend, variability, and use of multiple services – we should help get it right for other people too. If this seems unattainable in the current financial climate, we should be encouraged by the fact that for every good practice example we have showcased from frontline services in our report, we could have picked many more. Service leaders and policy-makers are arguably more focused on this goal now than they have been at any time since the NHS was founded. Taking a comprehensive approach to reviewing and improving our care for older people offers an important opportunity to develop truly person-centred care.
Catherine Foot is Assistant Director of Policy at The King’s Fund.
