The Challenging Demographics for the General Physician

Dr Phil Rushton

Poole Hospital NHS Trust

Literal Approach

• The Demographics• The Challenges• The General Physician?

Old News

Old News

Old News

In the next 20 years • Over-85’s will double

• Over-100’s will quadruple

What’s the problem?

• Currently -Over 65’s account for 60%

Social Care Budget -Twice as NHS-costly

-Hospital spend: Three times as much

Local Picture: Dorset

The Future?

Dorset Christchurch Highcliffe

% aged 0-15 yrs 17.0 15.8 5.6

% aged 15-59 yrs 52.8 48.2 25.3

% aged 60-74 yrs 17.6 20.4 29.8

% aged 75+ yrs 1.7 15.7 39.4

% households ‘pensioner’ 33.4 40.6 70.9

No. ‘economically active’ 178,519 18,859 709

Highcliffe

• Average size practice• c10,000 patients• 6 partners, 3 salaried

HighcliffeHighcliffe Prevalence (%)

National Prevalence (%)

Cancer 4.4 1.7

CHD 7.3 3.4

HF 1.4 0.7

Dementia 1.6 0.5

Stroke 4.1 1.7

HT 23.2 13.6

DM 6.7 5.8

Highcliffe• Particular stresses

Home visitsNHDrug Budget

• And yet:Admission rates lowPrescribing rates low Staff retention good

Meeting the Challenge in Hospital

“Hospitals and medical specialities emerged in an era when many people died in childhood or midlife of single diseases. In 2012, the main activity of general hospitals is the care of (generally older) people with (multiple) long-term conditions.”

The challenge..

• Frailty • Safe Discharges• Readmissions

Comprehensive Geriatric

Assessment

Frailty: Complexity + Poor Reserve

• A state of reduced homeostasis & resistance to stress that leads to increased vulnerability & risk to adverse outcomes such as disease progression, falls, disability & premature death

• Non-specific decompensation: “Acopia”

CGAPain Delirium and Dementia

Depression Nutrition and Hydration

Skin Integrity Sensory Loss

Falls and Mobility ADL’s

Continence Vital Signs

Safeguarding Issues End of Life Care Issues

Safe Discharges: CGA +

• Community services: – IC, GP, DN, LTC, CM

• Care providers: – family, care agency, RH / NH, SW, 3rd Sector

Readmissions

• The new geriatric giant?

Models of Acute Care: Resources

• RCP Acute Care Toolkit 3: Acute medical Care for Frail Older People

• Quality Care for Older People with Urgent and Emergency Care Needs: ‘Silver Book’

• Both support application of CGA within an integrated system.

Local Model: Poole

Problems

• Generic MAU not leading to CGA• LOS > national average• Necessity: Ward closures triggered by

£10m overspend

Aims

• CGA:– Senior clinical review and initiation of

treatment– Early MDT assessment

• Facilitate discharge• Reduce non DME outliers (to close beds

safely)• Manage emergency activity

Ethos of unit• Senior triage of admission calls

– Present alternatives• Early senior assessment

– Medical, Nursing, Therapy• Prioritised diagnostics support• Early Discharge planning • Daily MDTM• Support from SS to keep POC open • Support from IC (Care, Clinical)

Length of stay data

Average LOS DME - April 2010-June 2011

02468

1012141618

April 1

0

May

10

June 1

0

July

10

Aug 1

0

Sep 1

0

Oct

10

Nov

10

Dec

10

Jan 1

1

Feb 1

1

Mar 11

April 1

1

May

11

June 1

1

Jul 1

1

Aug 1

1

Sep 1

1

Oct

11

Month

LO

S (

Day

s)

Occupied bed days

Elderly Admissions, Beddays & Outliers

0

1000

2000

3000

4000

5000

6000

7000

Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11

Elderly Beddays Elderly outlier beddays Elderly Admissions (excluding daycase)

Re admissions

Elderly Readmission Rate

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11

7 day readmission rate 30 day readmission rate

Linear (7 day readmission rate) Linear (30 day readmission rate)

Limitations / threats

• Changing relationship with providers• Gaps in service

– Lack of Step-Down beds– Non-commissioned services– Local EMI NH provision

• Ongoing CIP• White Paper…

Summary

• Ageing population• Integrated Systems to deliver CGA,

facilitate safe discharge• Some successes, some Threats

Thanks