Making hospitals fit for the frail older people who actually use them

On June 9, I finished my ward round of 24 inpatients – median age 80-plus, legged it to the station and got into London just in time to set up my workshop on models of care for frail older people at the Nuffield Trust Future Hospitals conference.

At the event, I presented some challenging ‘home truths’ alongside an animation and some practical solutions.

The “home truths”

Sometimes, people who feel they are challenging orthodoxies end up becoming the new orthodoxy, the new establishment. Group thinking takes over, factoids are repeated.

Zeitgeisty buzzwords proliferate and so it is with the constant narrative that investing in “asset based approaches”, “community resilience” and “wrap around community alternatives” to “too many hospital beds” will save the day – when in fact even a levelling off of demand for acute services would be a result.

I told the Health Service Journal (HSJ) last year that hopes for drastic reductions in urgent activity in older patients were “la la land” and was attacked by some. Being proven right has given me no great pleasure.

Hands up who thinks a broken hip, an acute stroke or severe sepsis should be dealt with “in the community”?

1. With rapid population ageing especially in the over 80s. However much we invest in prevention and healthier lifestyles there will be more people with multiple age-related long-term conditions including dementia; multiple medications; more people with frailty syndrome (and related presentations such as falls, acute confusion, incontinence, and mobility problems) which worsen dramatically in the face of acute illness, leading to long-term disability without adequate post-acute rehabilitation, more dependence on support from carers and more people using multiple health and care services suffering from fragmentation. It’s a fact, Jack.

2. These people are increasingly the “core customers” of our services including bed-based acute ones. Even in places which have invested heavily in senior front door decision makers, case management or schemes badged as “admission prevention”, many of the older people who make it into hospital really are sick and do need to be there. It’s just that they then stay too long. Hands up who thinks a broken hip, an acute stroke or severe sepsis should be dealt with “in the community”?

3. We don’t have enough credible responsive alternatives outside hospital, as shown in the national intermediate care audit. You can only define “inappropriate bed occupancy” with reference to what else is available. Often the capacity just isn’t there and of course the evidence for admission prevention at pace and scale in frail older people is patchy at best.

4. The notion that we are over-bedded is dubious. We have lost one third of our acute beds in England over the past 20 years and have fewer per capita beds than any OECD country bar Sweden. Our hospitals run very close to full capacity which is bad for efficiency and patient flow.

Let’s get care right for the people who actually come to the front door instead of wishing them away. Systems, attitude and values – age, dementia and frailty attuned.

And the solutions?

Space means I can’t set them all out here. But: we already have ample evidence of “what good looks like” in pre-acute, acute and post-acute care for older people. And service leaders delivering it. We are just frustratingly bad at dissemination, adoption and implementation with no-one in the NHS apparatus really embracing this function – and an over-reliance on external consultancy when the NHS already owns most of the solutions.

If you want to know more, I and colleagues at The Kings Fund have tried to set the evidence out in our recent paper “making health and care systems fit for an ageing population”. They are also in the Silver Book on urgent and emergency care for older people and NHS England document “safe compassionate care”.

Let’s end the serial pilotitis afflicting our service, drop the obsession with “innovation” (i.e. each locality reinventing the wheel) and get better at learning about what others have already done to tackle these wicked problems.

Professor David Oliver is a Consultant Physician; Visiting Fellow at The Kings Fund and President-Elect, British Geriatrics Society. Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors’ own.