interviews

Caring for the elderly is hospitals' core business

Dr Finbarr Martin, president of the British Geriatrics Society, argues against a prevailing view that emphasises shifting elderly people out of hospitals – especially since too many primary care organisations just don’t have the skills to deal with frail older people with multiple health problems.

The NHS has been fed a certain line on the ageing population for some time now, based on assumptions and prejudices that are affecting policy throughout the health service.

It is time for some clarity on these issues and to objectively consider potential paths forward for trusts who remain repeatedly surprised by an increasingly common trend.

NHE spoke to Dr Finbarr Martin, president of the British Geriatrics Society, Professor of Medical Gerontology at King’s College London and consultant physician at Guy’s and St Thomas’ NHS Foundation Trust.

Dr Martin outlined the current challenges facing the NHS, from both structure at the macro level – “Have we got the right major building blocks?” – and from within those systems.

In terms of our changing demographics, he said: “We have to acknowledge that the health service has developed to meet the needs of a population that’s not quite there anymore.”

Left in limbo

Dr Martin described how primary care had changed to provide long-term condition management in a systematic way, but warned that this may not be as successful in meeting the needs of older people.

Many older people now have a wide range of issues that can affect their day-to-day living.

Dr Martin said: “It’s perfectly possible for an individual to have a journey from being completely independent to being in need of daily social care provision, and unable to go out unaided, without that ever actually initiating a general practice referral.”

This general deterioration is not necessarily perceived as having a medical, diagnostic component, he said, and does not generate the same proactive response that long-term condition management for other chronic illness does.

“The problem is the sorts of long-term condition management that older people need don’t fit into the single disease models that have been generated.”

Therefore the demand-led approach to care can miss out this group of the population, leaving older frail people “in limbo”.

He added: “I think there’s a serious question to be asked as to whether the relatively small numbers of very frail older people actually get very much from primary care at all at the moment.

“Many of the patients I see, for example people at home who are often admitted to hospital, are actually often never seen by their GP because they can’t get to the practice.”

This group needs a new model of care, Dr Martin suggested, that is neither the traditional general practice, nor straight to hospital as default.

“We need a more proactive, community-based approach to frail older people, which is beyond the current organisational habits of primary care and in my view is beyond the skill set of the average primary care provider.”

Mixed messages

Dr Martin went on to describe the current system as “crisis-driven”, despite the absolute predictability of frail older people developing complications and needing increased contact with the health service.

“The main issue with hospitals at the moment is that they’re getting very mixed messages,” he said.

“People are being told that it is in some way obvious that hospitals are not very good places for a lot of frail older people and therefore wouldn’t it be better if they weren’t there.

“The reality is that the majority users of hospitals are older people. By and large adverse events that occur to a group of the population are relatively easy to identify.

“So the hospital sector is getting these odd messages: on the one hand that most frail older people shouldn’t be there, and yet actually, most people who need hospitals are frail older people.”

Talk of ‘freeing up beds’ and shifting care to the community reinforces the mindset that the elderly are someone else’s problem, rather than core business for NHS hospitals.

Dr Martin stated: “What people like the King’s Fund have been saying about the importance of reducing admissions of older people to hospitals can result in a misconception that if only community services got things right then hospitals would not need to adapt and focus on the need of these patients. That’s plain wrong.

“The reality is hospitals have got to gear-up for frail older people because that’s core business.

“It’s not some sort of ‘illegitimate’ business that somehow crept through the cracks – it’s core business.”

He called for the NHS to organise hospitals to be ‘age-friendly’ and warned: “If we don’t do that, the health service will continue to be in crisis and it will keep looking for some everhigher wall at the front door to stop these people coming in.”

Predictable problems

Dr Martin expressed surprise at some health professionals’ refusal to accept the reality of our demographic situation and the impact this has on the NHS.

“People are continually shocked by the reality of the increase in hospital use for older people. Well, they shouldn’t be.”

The expected pattern for the ageing population, he explained, will be to live longer, develop several chronic diseases and have episodic deteriorations. Whilst we cannot expect to pinpoint exactly when and to whom this will happen, we can be sure that it will happen, Dr Martin said.

He clarified: “Most people have most of their health service use in the last few years of life, regardless of when they die. Most people die now when they are old so they’re having their health service use in a context in which they usually have several chronic diseases and some physiological frailty.”

This means that in addition to a primary illness which necessitates a hospital visit, there can be other issues concerning mental confusion and physical instability.

“If we know that, then we have to stop being surprised by it and gear up our hospitals to deal with that at every level.”

Fundamental mindset problem

Dr Martin cited past research conducted by the DH in collaboration with Comic Relief, which found that most of the people looking after frail older people in hospitals believed that they shouldn’t be there.

“The mindset of the service is that ‘this isn’t something for which I legitimately ought to have the knowledge or skills’,” he said. This desire to either transfer responsibility for the patient to someone else, or have the patient discharged as soon as possible, represents a “fundamental mindset problem”, Dr Martin said.

An example is with cases of delirium, which occurs in around 20% of adults with an acute illness. Yet despite its frequent occurrence, it is not regarded as a major health hazard.

He described reducing frantic bed management and eliminating discontinuity as important steps to make the development of delirium less likely, “yet we’ve geared up our hospitals to have no choice other than to behave like that”.

To improve this situation and ensure the NHS can effectively deliver healthcare to an ageing population, Dr Martin called for greater integration between geriatricians and their colleagues in general medicine.

“There are lots of initiatives around the country that are beginning to address these issues, but they’ve got to be really generalised and taken on board.”

He reiterated: “Older people are here to stay as far as hospital use is concerned. It is not unpredictable. Our systems respond at the moment as if it’s a surprise and we have to systematically alter the knowledge and the skills and the composition of our clinical teams to make them more appropriate.”

The atypical case

For medical students, training is “disproportionately focused on curable disease occurring in isolation from other problems, in otherwise relatively well people”.

This includes a classic presentation of any illness, and the atypical symptoms which may also occur. Despite the label, these ‘atypical’ symptoms are generally seen more commonly in older people, and as the ageing population grows, this is skewing the reality of what a ‘typical’ case entails.

Dr Martin added: “All the professions are taking a while to realise that these things are not exceptions, they’re actually the rule. I think our teaching and training needs to focus more on it.”

He said: “There are things we can do better during hospital stays and there are things we can do better in the community that will have the effect of reducing the need for hospital beds. But older people are still going to be the predominant group using hospitals.”

Specialist support

The issue has been increasingly appearing in the media, with many dire warnings of the size of the challenge the NHS is facing. But Dr Martin stated that it could be tackled, and that organisations such as the British Geriatrics Society can offer help and support to achieve this.

“I don’t think it’s unmanageable at all: the numbers are not enormous actually. We do have to address it very systematically, though, because otherwise the health service is going to have a real struggle if it doesn’t get this right. But I don’t think it’s an impossible task.

“We’re trying to get this message out there that there is a specialist group of doctors, they are organised, they do have an opinion and we’re here to help.”

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