Demography and trends
Scotland's population has already aged significantly and will age still further. Mass survival into older age, along with the baby boom of the 50s and 60s, will lead to a rise from 787,000 to 1.2 million over-65s from 2001 to 2031, and a rise from 84,000 to 150,000 in over 85s over the same period.
The 15% of the population now over age 65 accounts for around 40% of health and social care spending. Over 75s make greatest use of services. Elective surgery - such as hip replacement - mainly benefits older people and has increased in recent decades. Further increases should be planned for.
Acute admissions are rising most rapidly in older age groups, and again further increases should be anticipated. However, improved primary care and community services should allow a proportion of potential in-patients to be cared for at home.
Many of the problems currently encountered in service provision reflect a long-term failure to match that provision to the needs of an ageing population. Information on current and projected demography, taken together with data on current and predicted service use, means that care of older people is the major task of NHSScotland as it enters the 21st century. This challenge must now be addressed positively.
The Journey of Care:
At Home
Ninety-five per cent of over 65s live at home, the majority in good health. Health promotion measures such as moderate exercise, a good diet and avoidance of smoking and excessive drinking can preserve and enhance health in later life, and should be encouraged. A number of simple interventions - such as vaccination against flu, aspirin for stroke prevention and calcium and vitamin D to improve bone strength - are effective in reducing risk of illness and injury. Health screening of over 75s could be improved, to detect loss of function and provide better population data.
Around 20% of over 65s need help to stay at home. A number of recent initiatives should improve joint working between health and social work services to make care for older people at home more accessible, more effective and more responsive to individual need; and to support the efforts of carers.
Recent developments have also broadened the scope of primary care health services for older people, with many examples of innovative multidisciplinary care for older people at home and in community hospitals. These include schemes to support patients with acute or sub-acute illness at home where this is clinically appropriate; better rehabilitation services; and better management of chronic disease.
Hospital Care
Almost all hospital services look after older patients, and many acute services do little else. This should be fully recognised in the way they are organised, with the needs of this major client group at the centre of service provision and planning.
Care of older people attending Accident and Emergency Departments or admitted briefly to Assessment Units should include assessment of dependency and the provision of services to facilitate safe discharge home, minimise unsafe discharge, and avoid unnecessary readmission.
Older, frailer patients admitted for acute care are most at risk if their needs are not recognised. Sensitive and effective management of acute confusional states - common in older patients in the acute setting - is an essential component of good care. Early multidisciplinary assessment and rehabilitation will minimise dependency, and good collaborative discharge management, with follow-up to ensure patient safety and check on service delivery, will improve outcomes, reduce length of stay and minimise readmission.
For patients unable to return home even when such support is available, further in-patient multidisciplinary rehabilitation away from the acute ward may provide a last chance of returning home. Patients who, despite adequate rehabilitation, cannot go home and require other care in future, are at greater risk of prolonged hospital stay.
If such care is not available when and where it is needed, delayed discharge - unacceptable to patients and their carers, and an inefficient use of hospital resources - ensues. NHS Boards and Local Authorities should address delayed discharge as a top priority within joint management and joint resourcing of services; they should increase the transparency of resource use in the care of older people; and both agencies, together with private sector care providers, should address population needs and capacity planning issues.
Nearing the end of life
Increasing longevity means that mortality is now compressed largely into the eighth and ninth decades. Good care for older people therefore means ensuring for them good quality of care as life approaches its end. Most die in hospital or care home settings, but improving community services will allow more who wish to do so to remain at home longer, or to the end.
For people with more prolonged dependency, lasting months or years, strengthened community services may serve to defer the move from home to a care home or NHS continuing care. Recent legislation - the Regulation of Care (Scotland) Act 2001 - seeks to ensure high standards of care at home, in day care and in care homes.
Overview of major health problems
Most of the care of older people in NHSScotland is provided in mainstream services, and the improvement of their care and rehabilitation in these settings is the central theme of this report. Much work has already been done, via a number earlier reports, to improve the way NHSScotland provides care for the 'big three' - cancer; coronary heart disease/stroke; and mental health problems - from which many older people suffer.
This report does not attempt to duplicate such work for older patients. Rather it seeks to ensure that improvements in care are fully shared by older service users, and it positively asserts their rights to care matched to individual circumstances - with age alone as no bar to appropriate and beneficial treatment.
Better care for older people with chronic disease will mean more involvement of patients and carers and better information for them. The Group found many examples of good practice, with local services based in primary care and good access to more specialist advice when required. Such work, however, must be more widely replicated across NHSScotland.
Most patients with cancer are over 65. Early detection - especially of some skin and mouth cancers, and lymphoma - is worthwhile. Careful individual assessment, sympathetic explanation and patient involvement in decision-making are needed if older people are to gain maximum benefits from modern cancer treatments for the common serious cancers (e.g. of lung, breast, prostate and bowel). Although outcomes are generally poorer than in younger patients - because of frailty or co-existing illness - recent advances in care have much to offer. There is never 'nothing we can do'.
Coronary heart disease also affects mainly older patients, and preventive measures can still be effective in later life. Older people gain from modern high-technology interventions, though there is evidence that they may be underused. This should be monitored. Successful developments in management of heart failure at home should be more widely available.
Good care of stroke patients, most of whom are old or very old, improves survival and minimises disability. Good care includes early multidisciplinary assessment, specialist rehabilitation and well-organised discharge and follow up.
Depression and dementia are both common in later life. Depression is under-recognised and generally treatable. Drug treatment for dementia continues to improve, and appropriate patients should have access to it. Eighty percent of dementia patients live at home, and they and their carers need access to a range of services from health and social work agencies. Again good practice exists, and improved joint working will facilitate its spread.
Falls and the fear of falling greatly limit activity; and, although most falls do not result in injury, most injuries in older people are sustained as the result of a fall. Routine checks should identify patients at risk, and multidisciplinary assessment services for patients who fall should be available for older people. Osteoporosis management should be part of falls assessment.
Ageism
There have been concerns about ageism, defined as "systematic and negative age discrimination", in NHSScotland. Polling carried out for this Report showed that, though older people were generally satisfied with their experience of care, around one sixth had a perception that older people received poorer service, and that long waiting times were a common cause of dissatisfaction.
The Group affirmed the right of older people to treatments - including the most advanced and expensive - that will benefit them, while also recognising anxieties about injudicious interventions. Better communication - particularly about such sensitive matters as cardiopulmonary resuscitation and treatment decisions towards the end of life - will help. Both active treatment and the withholding of active treatment should always be considered in the detailed circumstances of the individual patient, with individual patients and their carers fully informed about the options, risks and potential benefits.
The needs of older people from ethnic minorities should be recognised, with appropriate sensitivity to cultural and language issues. All services should recognise the higher prevalence of mobility and sensory difficulties in older age groups and provide suitable access, skills and communication technology.
A review of the published literature carried out on behalf of the Expert Group did not support allegations of widespread ageism. However, as the Group acknowledged, concerns about ageism clearly do exist, and it is important that these concerns are addressed. The effective involvement of older people in the development and monitoring of the services they use offers a powerful means of doing this.
In the longer term, the best response to concerns about ageism in NHSScotland would be to achieve a widespread and visible improvement in the quality of service experienced by older people. This report is aimed at doing precisely that.
Strategic Issues
This short-life working group makes detailed recommendations to effect early improvement in the care of older people throughout NHSScotland, but recognises also that strategic issues must be addressed in anticipation of further demographic change. The volume of elective and acute care needed will increase; and the next generation of older people will also have higher expectations of accessibility, flexibility and quality in the services provided for them.
Further technological advances in medical care will continue to benefit older patients, and should be managed as part of an explicit strategy for their care. Education and training of staff, and workforce planning in NHSScotland, should also respond to the need to balance services in response to changing demography. The Research and Development agenda should also reflect demographic reality, and future NHSScotland building programmes should recognise the need for post-acute as well as acute care of an ageing population.
Strategic planning should include public consultation.
Making it Happen
This report highlights the health and healthcare needs of older people, and emphasises that their care is the central responsibility of NHSScotland, with good mainstream care as a goal of current and future efforts in health service reform. Already good practice exists widely, and its generalisation throughout the service offers a quick route to improve care throughout Scotland.
A number of agencies and mechanisms can assist in ensuring that the desired improvements are achieved. These include the Performance Assessment Framework; NHSScotland; the Joint Future Group implementation work; the Scottish Health Advisory Service; the Information and Statistics Division; and - particularly through its Standards for Older People in Acute Care, with their emphasis on the journey of care - the Clinical Standards Board for Scotland.
The work of the Expert Group will be followed by an SEHD Implementation Group, to be chaired by the CMO, which will monitor the impact on care and report on progress.