Frail older care in hospital 'fragmented', experts warn

The Royal College of Physicians Future Hospital project fellow Mark Temple said older patients with complex conditions were “not well managed” by the “fragmented NHS systems of care”.

“The frail older patient presenting with an acute illness is now ‘core business’ for almost all NHS healthcare practitioners,” he added.

The Department of Health said conversations have been ongoing for decades between NHS leaders and clinicians over the “importance of joining up the health and care system to deal with our ageing population”.

The spokeswoman added: “The Better Care Fund plans show, in detail, how local areas will focus on preventing people from becoming ill in the first place to reduce emergency admissions and deliver an estimated half a billion pounds in savings. On top of this, we’re making sure older people get care that’s tailored to their needs by introducing a named GP for over 75s and proactive care plans for our most vulnerable patients.”

NHS England welcomed “this contribution to the debate on the future of hospital care for frail older people”.

“It is critical that we get care right, not just because an aging population is a challenge the NHS must face but the frail older people of today are the public who’ve paid for the NHS throughout their lives. Their contribution, hard work and belief have sustained the NHS. They should always feel it continues to offer the best for them,” the spokeswoman added.

The Royal College of Physicians supported the findings and called for increased collaborative working by geriatricians and their teams with primary care services to identify frail older patients in the community early in order to manage the illness at home, identifying those patients who present to hospital as an emergency but who do not require admission and organising services so that frail older patients who require admission receive a comprehensive geriatric assessment early in their admission pathway.

Janet Davies, executive director of nursing and service delivery at the Royal College of Nursing, said the “important” report asks “challenging questions” and presents “further evidence that much more needs to be done to ensure older people always receive the highest quality of care”.

She added: “The integration of health and social care cannot be relied upon as a quick fix to the problems facing the health service. The fundamental issue is the woeful lack of investment in the services required to properly meet the needs of our ageing population.”

Zoe Wyrko, director of workforce planning at the British Geriatrics Society, said she hoped “the key principles” of the report would be taken on board by national policymakers and organisations responsible for commissioning and providing care for older people with frailty.

NHS Confederation chief executive Rob Webster said the commission was a “helpful call” to ensure hospitals played a fundamental part in the provision of care for older people.

“I particularly welcome the recognition that local leaders - our members - can get on with making many of the changes… to improve care,” he added.

“There is a widespread consensus on the need for care to be more integrated, more community based and person centred. The role of hospitals in achieving this cannot be ignored.”

Caroline Abrahams, director of charity Age UK, said hospital admissions should not always be seen as a “failure”. She added: “Nobody should be discharged anxious, depressed and weak, with no progress on the issue for which they were admitted and no plan for ongoing care.”

“We are led to believe the only solution to this is to prevent older people coming in to hospital, but that is not the answer.”

A spokeswoman from the Department of Health said local better care fund plans showed “in detail” how each area would contribute to saving £500m.

“On top of this, we’re making sure older people get care that’s tailored to their needs by introducing a named GP for over-75s and proactive care plans for our most vulnerable patients,” she added.

Catherine Foot, assistant director of policy at the King’s Fund, said that while NHS leaders “continue to espouse the critical importance” of patient and family involvement across the health system, “the reality of many people’s experiences remains far from this ideal”.

She added: “There is clear evidence that proactive input from specialist geriatricians working with multidisciplinary teams can improve outcomes for frail older people in hospital.

“But most hospitals will not be able to provide specialist units for all the older people in their care. Specialist “in reach” teams can be used to give people specialist assessment and offer expert advice and follow up.

Such “teams at St Thomas’ and Charing Cross hospitals for example have been shown to improve clinical effectiveness and efficiency”.

Additional comments:

Don Redding, director of policy National Voices, said the charity coalition particularly welcomes the “emphasis on better relational care, involvement in decisions as the core of good patient experience, and focusing on the person not just the illness”.

“It is not helpful to polarise this debate by pitting ‘integrated care’, which is often seen as ‘community-based’, against acute care.”

“Coordinated care is coordinated care, whatever array of services a person may need at a given time. Person centred coordinated care should include people’s use of hospital services, and transitions across settings,” he added.

“People should have a care plan that they have drawn up, and which anticipates emergencies. The care plan should go with them into the hospital, and be reviewed and used throughout their care journey, including their move home or to residential care.

Karen Middleton, chief executive of the Chartered Society of Physiotherapy, said: “The Commission is right to highlight the need to tackle delayed discharge, particularly in the week when it was revealed it had reached its highest level.” 

“But while the report suggests that community services may only delay a subsequent hospital admission, it is important to remember that the NHS should not only add years to the life, but also life to the years,” she said.

 “That is what can be achieved through keeping people out of hospitals and it is essential now that the necessary decisions to deliver that are taken.”