As a short life working group addressing current issues, the Expert Group on the Healthcare of Older People focused its efforts on identifying the challenges of today, and - where possible - responses to those challenges that could be delivered soon or fairly soon. In general terms, much of this work was directed at ensuring that NHSScotland is providing services that reflect a positive response to the demographic change of the last few decades.
Meeting Future Demographic Change
However, in the course of discussion it became clear that NHSScotland must - beyond the work of the Expert Group - take a more strategic approach to planning for demographic change than had occurred in the past.
Although in international demographic terms Scotland's population is fairly mature, future projections show increasing numbers of older people, and in particular substantially increasing numbers of the very old. The population pyramid for 2031 (see fig- 1) clearly demonstrates this effect.
The Group recognises that greater longevity is a positive societal gain, and that the survival of large numbers into old age should be seen in a positive light. But it would be regrettable if the Group's proposals, which essentially seek to enable NHSScotland to "catch up with demography", were not followed up by serious consideration of the service planning implications of significant further ageing of the population.
The recognition of care of older people as the central task of NHSScotland is a promising start, and the more detailed recommendations of the report will, to some extent, reshape services towards fitness for their tasks. But planning for continuing increases in the numbers of older people in Scotland should also take account of the following:
Tomorrow's older people - today's middle-aged and young - are very likely to have higher expectations of service availability and quality than are encountered in older people today, whose attitudes and expectations may still reflect to some extent the relative austerity of the 1940s and 1950s. All public services will have to cope with this and NHSScotland - as Scotland's biggest public service - should anticipate pressures for much more convenient access, such as the availability of primary care and hospital clinics in the evenings and at weekends; and higher standards of amenity extending much more widely through the service.
Many recent and fairly recent technological advances - such as lens implants, minimal access surgery, improvements in joint replacement and interventions for coronary heart disease - have brought more benefits to older people than to any other section of the population. No doubt further advances in coming decades will bring further benefits, and these are likely to be accompanied by greater convenience and increasing cost-effectiveness. It is important that these developments and their introduction into service use are managed as part of an explicit strategy to improve the care of older people within a still ageing population.
Although much of medical care is directed at older people, medical research does not sufficiently reflect this. It is recognised that there are special difficulties in conducting research on older patients - such as the problems arising from co-morbidity (having more than one illness at once) - but it is important that new medicines are evaluated in the age groups most likely to be using them.
NHSScotland's recognition of its central task - the care of older people - should now extend to its biomedical research agenda, its approach to service development and evaluation, and indeed inform its whole Research and Development Strategy.
In order to deliver sustainable improvements in both volume and quality of services for older people over the coming decades, NHSScotland must address fundamental service planning and personnel issues.
Projections of the use of both elective and emergency services show continuing substantial changes: both will deal with many more older and very old patients. There is much serious work to be done, in detail and service by service, in order to match provision to clearly demonstrated future demand.
In particular, and as a matter of urgency, the effective staffing of acute services requires to be addressed. The needs of older patients, and especially the needs of the frailest, should be matched by real expertise in their care. In nursing, specialist skills in the care of older people are recognised but must be made far more widely available in acute services. In medical staffing the nature of the acute care caseload should also be addressed by the wider involvement of care of the elderly specialists in early management of acutely admitted older patients. And in recognition of the importance of early rehabilitation in the acute care of older people, specialist occupational therapy and physiotherapy inputs should also be strengthened.
All clinical professions and disciplines must also take account of such projections and the resulting change in service shape and practice. The care of older people is no longer a minority interest, a subspecialty, or a footnote in professional education. Different health professions will respond to this challenge in different ways, but all must respond with major shifts in emphasis in basic training, in-service training and in their research and development agenda.
Again detailed studies are required to ensure that hospitals and indeed all healthcare premises reflect the needs of their main user group. Obviously this covers such matters as convenient access; but at a more strategic level there is a need to consider hospital building programmes in closer relation to the journey of care.
Ideally, the only patients in acute beds will be those whose needs can be met only in such beds. Older people whose acute care has been completed and who cannot be discharged timeously to their own homes need post-acute care in differently and appropriately staffed and equipped facilities which have not featured widely in NHSScotland's current building programme. A strategic approach to the problem of delayed discharge should certainly include balancing acute and post-acute elements of hospital services around the different elements of the journey of care of older patients.
The success of NHSScotland's approach to strategic planning for an ageing population is more likely if the views of today's and tomorrow's older people are sought at an early stage. As noted above, expectations are rising as part of generational change, and planning for the services of the future should take account of that. Public consultation and systematic opinion polling played a powerful role in the preparation of this report, and the Group recommends that follow-up action, including strategic planning, adopts a similarly open and consultative approach.
Recommendation:
changing demography;
emerging healthcare technology;
increasing research and development of services for older people;
increasing expectations amongst patients and carers;
addressing workforce training, recruitment, retention and development.