Adding Life to Years

annex C RECOMMENDATIONS

Summary of Recommendations

Demography and Trends

• NHS Boards should plan to increase provision of elective services used mainly by older patients, including surgery and related rehabilitation.
• NHS Boards should plan to provide high-quality acute care for growing numbers of older people.
• NHS Boards should, in partnership with Local Authorities, explore strategic developments, encompassing health and social care. These should aim to offer more older people with acute illness the possibility of being enabled to live at home where this is clinically appropriate.

The Journey of Care

Staying Well

• Older people should be encouraged to be physically and mentally active.
• Older people should have access to information about healthy life-styles, and health promotion campaigns should actively target and involve them.
• NHS Trusts, Local Authorities, voluntary and private providers with responsibility for long-term care of elderly patients are reminded of the recommendations of the National Nutritional Audit of the Elderly in Long-term Care and of the need to implement these recommendations.
• Older smokers should be encouraged to try to stop; and high-risk groups such as those with heart disease should be targeted for extra help in giving up smoking.
• Health professionals should be aware of the possibility of problem drinking in older people and be ready to help.
• Clinical examination should include assessment of oral health and appropriate referral when required.
• NHS Boards should ensure that older people who wish to do so have access to, and are registered with, an NHS dentist and are made aware that help may be available to assist with payment for treatment.
• Older people in hospital should be assessed to ensure that they can administer their own medications on discharge if that is clinically appropriate.
• Co-ordination of prescribing and drug provision for discharge from hospital should be improved.
• All older people who have repeat prescriptions should have a regular medication review.
• Medication for older people should be dispensed in accessible form, and with legible labelling and advice.
• Effective disease prevention measures should be advised to all older people, as appropriate.
• Disability-reducing surgery - e.g. for cataract and joint replacement - should be available on the basis of clinical need and appropriateness.
• Older patients have most to gain from good multidisciplinary rehabilitation in hospital and at home, and service organisation should reflect this.
• Multi-professional education should foster learning and innovation in service delivery.

Health Screening of Older People

• Screening of the over 75s should be reviewed, with a greater focus on identifying important problems such as falls, mental impairment, increasing dependency, oral disease, poor nutrition, poor foot care, tobacco and alcohol use.
• Standardised data from screening should be available to support planning better services for older people, enabling participation and independent living.
• Consideration should be given to linking screening with a check on uptake of benefit entitlements.

Supporting Older People at Home

• Carers should be seen and valued as partners with the statutory agencies in the provision of care, and should themselves receive appropriate assistance.

Improving Older People's Access to Healthcare

• Older people at high risk in the community, including those in care homes, should be regularly monitored by an appropriate member of the healthcare team and relevant services and specialist care provided as necessary. NHS Boards should encourage and support such developments.

Avoidance of Unnecessary Hospital Admission

• NHS Boards should ensure that older people in long-term care in the community have access to the appropriate care when required.
• LHCCs should lead the process of health needs assessment and primary care service planning in their areas; and recognise the potential of this process in improving local services for older people.
• Older people and their GPs should have access to multidisciplinary, multi-agency support teams to avoid unnecessary hospital admission, to facilitate safe discharge from acute care, and to promote rehabilitation of older people in their own homes.

Accident and Emergency Care and Short-Stay Acute Admission

• Older patients attending A&E Departments or admitted to short-stay acute assessment wards should be assessed to identify those with previous or recently increased dependency.
• Assessment should be multidisciplinary, covering likely risks and determining care needs (e.g. discharge, supported discharge or admission).
• A range of appropriate services should be available to facilitate safe discharge home, minimise unsafe discharge, and avoid unnecessary re-admission.

Acute Hospital Care

• Older people being discharged from acute care should have appropriate access to pre-discharge assessment, multidisciplinary discharge planning, necessary community services, and follow-up to ensure their safety and well-being.
• Acute hospitals should take steps to improve the management of older people requiring multiple acute admissions, to improve continuity of disease management and to minimise repetition and duplication of investigations.
• NHS Boards should recognise that multiple admissions in older people are a problem and take strategic decisions to address this.
• NHS Boards should consider the appropriate recruitment, retention, training and development of specialist staff as part of their overall workforce planning to meet the needs of older people in acute hospital care.

The Confused Older Patient

• All NHS staff should be aware that older patients may be confused, and should be sensitive to their needs.
• Clinical staff should be aware of the causes and management of confusion.

Post-Acute In-Patient Rehabilitation

• Patients who cannot be discharged directly from acute care should have the opportunity of further assessment and rehabilitation in specialist post-acute wards with multidisciplinary staffing, or - in remote and rural areas - in appropriately staffed local hospitals.
• Patients who cannot return home following acute care and post-acute rehabilitation should, until appropriate placement (e.g. in a care home) is achieved, have access to regular medical review and appropriate multidisciplinary care and rehabilitation while still in hospital care.

Delayed Discharge

• NHS Boards and Local Authorities should address delayed discharge as a top priority within joint management and joint resourcing of services, including community rehabilitation services.
• NHS Boards and Local Authorities should - as part of joint working - increase the transparency of resource use in the care of older people.
• NHS Boards, Local Authorities and the private and voluntary sectors should assess population needs and plan capacity to meet likely demands.
• NHS Boards, Local Authorities and the private and voluntary sectors should explore innovative means of addressing the problems associated with longer-term collaboration in service provision.
• ISD should continue to monitor and report standard comparative information to allow continuing scrutiny of problems and progress in the management of delayed discharge across Scotland.

Overview of major health problems

Better Care for Older People with Chronic Disease

• Primary care and acute services should take steps to improve the management of older people with chronic disease and at risk of multiple admissions in order to improve the continuity and quality of their care.

Cancer in Older People

• Older people with cancer should have full access to the service developments that follow from the implementation of Cancer in Scotland, Action for Change.
• Older patients should have access to appropriate investigation and treatment of cancer on the basis of their individual clinical needs.
• CSBS standards should adequately assess care provided to all age groups including older people.
• Older patients with cancer should have access to rehabilitation to enable them to cope with the impact of disease and treatment.

Coronary Heart Disease

• Older people with coronary heart disease should have full access to service developments that follow from the implementation of the CHD/Stroke Task Force Report.
• There should be increased professional awareness of heart disease in the elderly: its presentation, the range of potentially useful treatment options and the need for individual assessment on the basis of need and potential benefit.
• There should be increased awareness of the potential of preventive intervention in later life.
• Rehabilitation and support for older people with CHD should be improved by better coordination between hospital and primary care, including outreach specialist services.
• Monitoring, by means of transparent audit, of the access by older patients to appropriate investigation and treatment for CHD should be undertaken.
• Further research should be carried out to clarify best treatment, access to care, and attitudes to treatment for CHD specifically in older age groups.
• CSBS standards should adequately assess care provided to all age groups including older people.

Stroke Care and Rehabilitation

• Stroke patients admitted to hospital should be managed in a stroke unit by a coordinated multidisciplinary team.
• Rehabilitation should be coordinated between hospital and primary care to ensure continuity.
• NHS Boards should ensure that stroke care reflects current national SIGN guidelines.

Mental Health Problems in Older People

• NHS Boards should work to raise awareness of older people's mental health issues, and to promote recognition and treatment of problems at an early stage.
• NHS Boards and Local Authorities should assess population needs for dementia and other mental health services and plan appropriate capacity at all levels.
• NHS Boards should ensure there are services to provide rapid assessment of cognitive impairment, with appropriate access to modern drug treatment and follow up.

Falls and Fracture Prevention

• All older people should be asked annually if they have fallen in the past year.
• In those who have fallen once only, balance and gait should be assessed by the Get Up and Go Test.
• All who report recurrent falls, appear unsteady or who have difficulty with the Get Up and Go Test, and all presenting to medical attention with a fall should undergo multidisciplinary evaluation.
• NHS Boards should ensure that falls assessment services are available and that these provide interventions of proven effectiveness, tailored to community or care home settings.
• Osteoporosis management should be an important part of any falls assessment.

Ageism in NHSScotland

Specific Issues

• NHSScotland should be aware of concerns about ageism and take action to identify and remedy them.
• NHSScotland should demonstrate sensitivity, fairness and equity in its treatment of older people. This should be done continously and transparently.
• The Scottish Executive should ensure that the PAF adequately measures the success or otherwise of NHS Boards in meeting the concerns of older people about ageism.
• NHS Boards should consult older people and their carers about their experience of services and routinely involve them in the development and monitoring of these services.
• NHS Boards should encourage feedback, both positive and negative, about the care of older patients, and address any issues raised.
• NHS Boards should involve older people in service planning and review at an organisational as well as at an individual level.
• NHS Boards should ensure compliance with existing and well-respected national ethical guidelines about decision-making around cardiopulmonary resuscitation.
• The Scottish Executive should continue to promote the opportunities offered by the Adults with Incapacity (Scotland) Act 2000 to allow people to specify, in advance of the onset of incapacity, their wishes in respect of treatment.
• All training and professional development in NHSScotland should recognise and address the needs of older people as a mainstream activity.
• NHS staff should have specific training in awareness about sensory and cognitive impairment.
• Patient areas in all NHSScotland premises should be freely accessible to people with disabilities.
• NHSScotland should develop information systems suitable for people with disabilities.

Strategic Issues

• NHSScotland should plan strategically for the healthcare needs of older people, including meeting the challenges of:

  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.

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