Every year, Age UK publishes a briefing on the health and care of older people in England. Internally, it is thought of as a stock take or “state of play” for NHS and social care services, helping us and others to better understand how well those sectors are doing in meeting older people’s needs.
We were due to publish this year’s version within weeks of the coronavirus pandemic shutting down most of the country. The NHS shifted to full-blown crisis mode while social care, and in particular care homes, found themselves at the centre of an unfolding disaster. The state of play had shifted.
However, there is a great deal that we can draw from understanding where things were before the crisis hit and what impact this might have on the next phase of the pandemic.
As ever, a headline figure from the report is the level of unmet need in social care. 1.5 million older people who need help to do at least one important daily activity – dressing, washing, using the toilet, for example – do not receive adequate support to do so.
Two thirds of older people live with at least 1 health condition – around a fifth living with at least 2. Of these people, around a third reported that they feel under-supported in managing their condition.
Around 1 in 4 older people live with depression and/or anxiety, yet many do not access the support they need to address them. Despite efforts to increase the numbers, only 6.2% of referrals to talking therapies are made up by older people despite having the same level of need as other age groups. A target was set over ten years ago that 12% would be the expected figure if it reflected need.
Avoiding hospital, staying well
Many of these issues often combine to leave people in need of avoidable hospital care. The numbers of people admitted to hospital in an emergency for a health problem that could have been managed in the community has steadily risen over the last ten years, peaking in 2016/17. Older people are the group most likely to experience these admissions, coming in for things such as urinary tract infections, unmanaged chronic obstructive pulmonary disease and pneumonia.
Effective primary care and support to manage health conditions can keep such problems at bay, avoiding a stay in hospital that puts people at risk of deconditioning, healthcare-acquired infections and delirium. Despite this, spending in primary care is dwarfed by spending in hospitals and has experienced much slower growth.
Between 2013/14 and 2018/19, spending on Foundations Trusts alone, representing one portion of the secondary care sector, grew from £37 to £46 billion. In contrast, primary care, estimated to account for 90% of public interactions with the NHS, went from £8.2 to £8.5 billion (all in 2018/19 prices). The NHS Long Term Plan (2019) committed to address some of this imbalance, but there is significant work to be done in making sure care shifts much closer to people’s homes.
Clap for carers
NHS and care workers have mounted a heroic effort to confront COVID-19 and in many areas have already started to adapt local services to meet both the immediate crisis and these historic challenges. The next phases of the pandemic will mean both restoring services that have reduced or stopped during the last few months but also harnessing this innovation and making lasting change to the care of older people.
What does this look like in practice?
Not out of the woods
First and foremost, it means a sustained and aggressive focus on preventing the spread of coronavirus. As much as we can have confidence that rates of transmission are now stable in most of the country, lockdowns remain in places as large as Greater Manchester and Leicester has only just ended their restrictions. It is widely accepted that managing transmission rates will be harder in autumn and winter, during which the NHS will be dealing with its usual winter pressures. There is no place for complacency as more of the country opens up.
This itself brings opportunities for reducing contact with healthcare settings such as hospitals. Not for urgent acute need which must be there for all of us, but for those avoidable admissions outlined above, for conditions that should be managed in the community. COVID-19 brings a sharp focus to the idea that admissions to hospital are not always in the interests of older people.
Duty of care
This does not mean expanding the kinds of practices that proliferated at the start of the crisis in which older people were encouraged, for lack of a better word, to refuse conveyance to hospital or decisions were taken on their behalf to the same effect.
What it does mean is having a more comprehensive offer in the community, both from GPs and community services, that can anticipate care needs and build a package of support around people to reduce the risk of deterioration. These principles were at the centre of the Ageing Well programme, some of which was deferred into next year.
If the case was already clear before the crisis that these approaches are needed and that older people are the primary target for them, it is now inescapable. Older people have made up almost 90% of all deaths from COVID-19. Admission to hospital, or unsafe discharge to a care home, has always carried its own risk and in many respects, COVID-19 presented a tragically heightened version of this risk.
Doing all we can to make sure older people are able to stay well, active and engaged in their communities is the best way to reduce the need for care in hospital.
Restoration of services
There is also a major task in restoring those services that older people have missed during the pandemic. The most immediate and obvious area is rehabilitation, services that help people to manage their long-term conditions and recover from ill health.
Many services like this were not able to operate during the last few months and it is likely that many older people will be in significantly poorer health as a result. The effect is also likely to be compounded by the widespread drop in physical activity and social contact that will have had a severe effect on older people’s physical and mental health.
This aspect of the lockdown was most likely under-appreciated by the advisors guiding the Government. Some advice suggested that lockdown would be relatively straightforward for older people because, to paraphrase, they didn’t go out much anyway. However, for many older people, the impact of little physical activity will mean lower resilience, weaker muscle strength, increased falls risk and worse cardio-vascular health. This will mean premature development of frailty for some and significantly worsening frailty for others.
Lack of social contact will be equally damaging with some losing cognitive function as a result of not talking or interacting with others and the spectre of anxiety and depression either developing or returning with the absence of coping mechanisms like local social groups or even just trips to the shops.
Even before we talk about addressing the mammoth waiting list for procedures that will need to be worked through – many of them older people waiting for cataract surgery and joint replacements – health and care services will have to tackle this potential wave of deconditioning and newly developed frailty.
Focus on older people
These are some of the steps that NHS and social care services will need to take to get a grip on in the coming weeks and months, particularly as it is widely believed a second wave of coronavirus is coming in the winter:
- Urgently identify and reach out to older people at risk of deterioration; fully assess their needs and guarantee services that both aid recovery from existing problems and work towards maintaining physical and social activity.
- Restore community and rehabilitation services and create an enhanced offer that can be delivered as close as possible to people’s homes, including care homes.
- Prioritise the most urgent and those waiting the longest for access to delayed or cancelled elective treatments. This process must be based on need and must not discriminate on the basis of age.
- Guarantee local services that can respond quickly in a crisis so that people at risk of admission to hospital can be fully supported at home.
- Embed and/or spread integrated practices that have emerged during the pandemic that bring together primary, community and social care services.
Many areas across the country have got to grips with the COVID-19 crisis by already addressing many of these challenges and health and care services must act quickly to retain and enhance the good practice that has emerged.
We are encouraged that the NHS has already started this process. However, this must be consistent and not rely simply on the commitment of local champions to make sure it’s happening.
There will inevitably be questions to answer about the response to COVID-19 and what could have been done differently to reduce the tragic impact on the tens of thousands of older people that have died and the many more that will be living with the impact of the disease.
What must happen now is a clear and urgent focus on not allowing this toll to rise further, not just from preventing spread of the disease but from finally taking the care of older people seriously.
Simple ways to stay active at home
Prolonged time at home can make it harder to stay motivated. These exercises, curated with the help of a fitness lead from Nuffield Health, can help you stay active.