KCL Older Persons Fellowship Conference 2017

Future models of care in an ageing society: implications for workforce development

Finbarr C MARTINEmeritus Geriatrician at GSTT and

Professor of Medical Gerontology, KCL

President-electEuropean Union Geriatric Medicine Society

Summary

• Reasons to be cheerful

• Reasons to be not so cheerful

• Older people, frailty and multimorbidity

• Older people and healthcare use in UK

• What does age attuning healthcare mean?

• Some wider perspectives eg WHO and Europe

• Training a suitable workforce

3

Older people are older ( rectangularisation to elongation of age distribution)

Source: mortality.org, originally ONS

Distribution of death England 1841 - 2006

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97 101 105 109

1841

1941

19811991

2001

2006

Around 18% of all deaths were before 65 in 2006 –same proportion as in 1991This is now falling quickly

AND old live longer so

many more old old

The impact of older ageing

Most older people now live long enough

– To have several long-term conditions (NCDs)

(+ polypharmacy)

+ sensory impairments

+ dementia

+ sarcopenia and inflammaging

+ homeostatic dysregulation

Resulting in frailty and “geriatric syndromes

But older people are also highly variable

Ageing is a lifelong project

Genetics and chance

Lifelong circumstances and opportunities

Injuries, events and illnesses

Specific diseasesFrailty

Spectrum of capacity, health and function

Trends in Functional Disability (FD) in older age in relation to

Socio-Economic Status (SES) (Family Resource Survey n=96,733)

Differential

increase in

FDs in

people of

lower SES

Morciano, Hancock, Pudney. Social Science & Medicine 2015

Majority of over-65s have 2 or more conditions, most over-75s have 3+

Multimorbidity(Scottish School of Primary Care Barnett et al Lancet May 2012)

Healthcare trends

-

100,000

200,000

300,000

400,000

500,000

600,000

700,000

2001/022002/032003/042004/052005/062006/072007/082008/092009/102010/112011/12

Num

ber

of adm

issio

ns

Emergency hospital admissions by age band

85+

80-84

75-79

70-74

65-69

Over the last decade, 40% of the increase in emergency admissions is from over 65s

The rate of emergency readmissions has also grown faster for older people

Who are the high hospital users?

• Hospital Episode Statistics in England

• Codes to identify frailty from routine data

Unspecified protein-energy malnutrition

Dementia+ acute illness

Incontinence+ acute illness

Difficulty in walking

Very low level of personal hygiene

Senility

Falls causing the admission

‘Z-codes’ – functional limitations

Percentage of total admissions 57%

Percentage of total bed days 87%

Percentage of emergency readmissions within 90 days 84%

Percentage of deaths within 90 days of admission 84%

The contribution of patients with “frailty” to hospital activity

BUT ….there has been a panic about older people in hospital

Evidence shows a health service unprepared for the number or the nature of the typical modern patient.

First Francis Enquiry 2010

• “Many of the cases in which patients and their families have reported concerns have involved elderly patients. The multiple needs of such patients in terms of diagnosis, management, communication and nursing care are in many ways distinct from those of younger patients. ..”

• .. “Older patients will often .....require a skilled and multi disciplinary team approach. ..Specialist advice will often be needed. ......”

• ...the Trust had a service for the care of the elderly but there has been little evidence of its contribution in many of the cases of concern reported to the Inquiry”

Is it a complication .....or a modern surgical patient?

Wilson Br J Anaesth 2010;105:297; Makary 2010Partridge Age & Ageing 2012;41:142

Outcomes associated with frailty and multimorbidity

...supported by even more reports

Highlights the

outdated style of

care in our

general

hospitals

Research on Dignity in Care

• DH/Comic Relief £5 million programme of

research into elder abuse in our hospitals and

care homes

• They found that where care was poor, it was

associated with this attitude:

“these older people in our wards should not be

here. They should never been admitted or be in

another ward”

Age attune our health services:

adapting services and clinical

practice to accommodate the

modern (older) patient

OR

So let’s PANIC !!

This has been the result of a failure of vision and planning(and confused mixed messages about

the promise of community alternatives)........but is already stimulating the changes we need for age attuned health services

Scope of changes needed

•Whole service needs reorientation in expectations and attitudes•Service models need redesign•Specialists need to spread their wings•Others need to skill up•Integration across and along•etc

Berwick inquiry into the NHS

“Culture trumps regulation”

Barbara’s Story – 5 episodesStaff education

A story of a person with dementia coming to hospitalSeen by all types and grades of staff Won the ‘best internal communications’ award at the International Visual Communications Awards in 2013

find it on youtube

Examples of age attuned approaches in NHS

• POPs- surgical service for older people

• Frailty recognition and responses – Frailsafe and acute frailty network models

• Delirium – bundle for recognition and action

• Incorporate end of life considerations

• eg GSF and AMBER

Single disease approaches don’t

work for frail older people and

possibly from may people in

developing countries

Puts real discussion with patients at centre of decision making

2015 Endorsed by World Health Assembly 2016 with mandate for actions

Functional Ability = health related attributes that

enable people to be and to do what they have reason to value.

•Consists of the intrinsic capacity of the individual, relevant environmental characteristics and the interactions between the individual and these characteristics.

•Intrinsic capacity is the composite of all the physical and mental capacities of an individual.

•Environments - factors in the extrinsic world that form the context of an individual’s life.

home, communities and the broader society.

range of factors, including the built environment

people and their relationships, attitudes and values

health and social policies, and their services

Range and mean of intrinsic capacity from

Study on adult health and AGEing (SAGE)

Source: Beard et al. the Lancet 2015

Population in the second half of life

Increasing age group

Intrinsic Capacity

High and Stable Declining Significant loss

Intrinsic Capacity

Potential for interventions

WHO Report 2015: Ageing and life-course

“A bright future awaits”

The Report highlights 3 key areas for action

• .... make the places we live in much more friendly to older people. Good examples can be found in WHO’s Global Network of Age-friendly Cities and Communities

• Realigning health systems to the needs of older people ... ...a shift from systems that are designed around curing acute disease, to systems ..for the chronic conditions

• Governments also need to develop long-term care systems .... reduce inappropriate use of acute health services and ensure people live their last years with dignity.

WHO Mandate 2016 to support age aligned health systems

To technical assistance and guidance :

• to develop standardized approached to assess health system alignment to needs of older people.

• to support health systems change, re workforce, IT systems, medical products and technologies

• Toolkit for interventions on intrinsic capacity decline

• develop evidence-based service delivery models that are effective in supporting intrinsic capacity.

Changing the future medical staff

1. The basic medical graduate (every doctor)

2. The specialist in old age medicine – the geriatrician

3. The other specialists who look after older people

Knowledge

Skills

Behaviours (attitudes)

UK General Medical Council –

the professional regulator

Undergraduate training – EU Law (directive 2005/36, Article 24)

• Enables EU medicine graduate to practice

anywhere in EU

• Stipulates the minimum duration (6y) or total

time (5500 hr) for study for the basic medical

training to obtain a license

• Specifies the general scope of the knowledge

AND

• “....behaviour of healthy and sick persons, as well as

relations between the state of health and physical and

social surroundings of the human being.’

•

EU (UEMS) Consensus

Ten domains

1.Patient respect

2.Ageing principles

3.Common medical conditions

4.Geriatric assessment

5.Medication use

6.Multiple morbidities and social factors

7.Ethical and legal issues

8.Roles of other healthcare professionals –

multidisciplinary teams

9.Healthcare in different settings

10.Regional aspects of health and social care

Training of geriatrician specialists

• Requirements specified in chapter 6 of the Charter on Training of Medical Specialists in the European Union (http://www.uems.be/) (2003)

• Training institutions have to be accredited

• Minimum 4 years of total postgraduate training

• It is commonly accepted that contemporary

specialist medical training cannot be

satisfactorily completed within less than five years (UEMS)

Current (2015) situation in the 22 European countries with geriatrics as a primary specialty

Country Years

Cyprus, Liechtenstein, Luxembourg unknown

Bulgaria, Czech Republic, Italy , Lithuania, Romania , Spain

4

Finland , Hungary, Netherlands, Poland, Slovakia

5

Belgium 6

Denmark, Norway, Sweden 7

Iceland, Ireland, Malta 8

UK 9

2016 EUGMS Education & Training Group

European Delphi consensus to update content of postgraduate training in geriatric medicine

BUT...More and better old age specialists are necessary but not sufficient for

our ageing populations

EU based collaborations between specialities

EXAMPLE:

Joint training curriculum between EUGMS and European Emergency Medicine

What about surgeons of the future?

Survey responses

Awareness

2/3 unaware of NCEPOD findings about older people

Training

68% report inadequate training in issues such as frailty

77% unable to identify key features related to mental capacity

90% want geriatric medicine issues included in surgical curricula

Service

85% believe support from geriatric medicine essential

68% think it is inadequate

What about the rest of the workforce?

• same patients• same challenges• same need for mix of generic and specialisms• but need more champions•... Hence the fellowship

Conclusions

Modern demography is a historic triumph

• Most people now live long enough to develop age related challenges to health and functional capacity

• Variation suggests opportunities

• Age-attuned healthcare involves

• Attitude changes in society

• Changing patient expectations and involvement

• New health care models

• All staff & most specialties

• Education and training will be central