Tuesday, 4 October 2016

Ageing: a crisis for healthcare. Or an opportunity for integrated care?

It’s obvious, isn’t it? The wealthy nations face a crisis due to their ageing populations. The problem’s particularly acute for healthcare.

It’s so obvious that even I have said it in the past. But it isn’t entirely true. The error needs correcting, if only because ageing isn’t a curse but a measure of unprecedented success. At the beginning of the last century, life expectancy in the US was just over 48 years. Today, it is nearly 79. In Britain over the same period, it has grown from 45 to 81. How’s that a disaster?

After all, it’s not as though the picture is the same everywhere. In Syria, life expectancy is 64.5 years. In Sierra Leone it's just 50 years, little better than the US over a century ago.

Where there have been gains, the extra years include an increasing proportion in good health. That’s according to a study by the British healthcare think tank, the King’s Fund. It suggests the trend is likely to continue, with our ageing population adding further years of healthy life.

More years of healthy life? Why’s that a problem?
Not so much a healthcare crisis as a cause for celebration, surely. 

That being said, the trend does raise new challenges for healthcare. They need to be addressed. That means a change in approach.

As the King’s Fund points out, what we are seeing is an increase in the specific kind of health problem characteristic of old age. There are more long-term conditions such as diabetes, some lasting for life, and more patients suffering from several disease conditions at the same time.

Why is that such a challenge to the health services? Because historically healthcare has been built around specialisation. Hospitals are organised into departments dealing with neurology or rheumatology or cardiology. But today they’re having to deal with patients who may have suffered a stroke exacerbated by a chronic heart problem, who are also struggling with the pain of rheumatoid arthritis.

How does a specialist of just one of these conditions approach such a patient?

These issues also raise the question I’ve been addressing throughout this series: in what setting should a patient be treated?

The King’s Fund tells us:

…we must strive wherever possible to ‘shift the curve’ from high-cost, reactive and bed-based care to care that is preventive, proactive and based closer to people’s homes, focusing as much on wellness as on responding to illness. When asked what they value in terms of wellbeing and quality of life, older people report that health and care services when they become ill or dependent are only part of the story. Many other things matter: the ability to remain at home in clean, warm, affordable accommodation; to remain socially engaged; to continue with activities that give their life meaning; to contribute to their family or community; to feel safe and to maintain independence, choice, control, personal appearance and dignity; to be free from discrimination; and to feel they are not a ‘burden’ to their own families and that they can continue their own role as caregivers.

Admission to hospital may be vital in certain circumstances but, as well as being the most expensive way to deliver care, it corresponds to only a tiny part of the aspirations older people expressed to the King’s Fund team. They propose reform based on nine points:
  1. helping people maintain their independence, to live at home in good health, for as long as possible;
  2. helping people to live as well as possible with simple or stable long-term conditions if they develop them
  3. helping people deal with complex or multiple health problems, including dementia and frailty
  4. in cases of real crisis, delivering rapid help close to home
  5. when it becomes necessary to provide hospital care, making sure it’s good and delivered humanely
  6. planning discharge from hospital on admission or before, ensuring patients leave with sufficient support and avoid the risk of readmission
  7. providing good rehabilitation and re-ablement services so patients quickly return to the best possible level of health and independence
  8. providing high-quality long-term nursing and residential care for those who need them
  9. ensuring that services supporting patient choice and control, with all the care and support required, are available towards the end of life
The tenth point is that all the others require integrated healthcare, bringing together medical, nursing and social care, in hospitals, family practices and community settings. An integrated approach sees a patient as a whole, not as the vehicle of a single medical condition, or even several. It accentuates quality of life and does everything to maximise choice and independence. Such care would certainly be the best imaginable.  What may seem paradoxical, but isn’t, is that is also likely to be the least expensive. That’s because it minimises healthcare demand and shifts as much as it can to less costly settings, in particular away from the acute hospital.

This approach will have benefits far beyond care for elderly patients. As the King’s Fund argues:

The balance of evidence is clear that integration can improve people’s experience and outcomes of care, and deliver greater efficiencies… It is important to recognise that achieving improvements for older people will also positively affect care for the rest of the population. More effective urgent care and post-acute rehabilitation and re-ablement services are important for people of all ages, while reducing inappropriate care and shortening acute lengths of stay for older people could release resources to meet other needs.

Avoiding the avoidable and coordinating care more effectively will deliver better care. Far from costing more, that may free up resources. So the ageing of the population may not be so much a crisis, as an opportunity.

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