Making systems fit for an ageing population Implications for palliative care?

1. Making systems fit for an ageing population Implications for palliative care? Thames Valley Workshop. Madejski October 8th 2015 Prof David Oliver Consultant Physician, Royal Berks President, British Geriatrics Society ECIST Speciality Advisor Senior Visiting Fellow, King’s Fund Professor, City University, London

2. Before I start • A personal view from my “day job” • In the ED and AMU • On the “deeper wards” • In planning discharge • Working with Palliative Care • & Other services e.g. Mental Health/COCOC • At interface with community services • Care Homes • Intermediate Care • Social Care • Continuing Care Assessment and Funding

3. NHS Benchmarking 2014. Continuing care & delays

4. I: A scheme for thinking about integrated services for older people Always putting the person and their families in the centre of our thinking in how we deliver and design services

5. Check out the “I statements” from patients view

6. Older people and the integration and care co-ordination agenda Older people Especially with complex needs/frailty Most likely to use multiple services See multiple professionals And suffer at hand offs between agencies And from disjointed, poorly co-ordinated care Loads of evidence that they do (I can share references)

7. Palliative Care & Care Planning Cross All Domains Oliver D, Foot C, Humphries R et al King’s Fund 2014 SAM

8. Mrs Andrews’ Story( Which I wrote for HSJ Commission on Frail Older People HSJ Nov 2014/March 2015) Please watch actively https://www.youtube.com/watch?v=Fj_9HG_TWEM And reflect at each stage, what could/should have happened differently This shows essentially caring people trying to do the right thing But the system letting her down There’s a second “what went wrong” on youtube with solutions

9. II: Population Ageing A success story, not a catastrophe

10. A success for society, preventative and curative medicine

11. From “rectanguralisation” to “elongation” of survival curve. 1947 NHS Founded, 48% died before 65. In 2015 its c 14% ONS

12. By 2030 51% more over 65, 101% more over 85

13. Ageing, Carers & care-workers • Already around 6 million people in the UK are carers for an older relative • By 2022, the supply of carers will be outstripped by demand • 1.5 m carers are over 65 often or poor health themselves • House of Lords “Ready for Ageing” report 2013 • <5% receive statutory support • Age UK 2014 • Always “Older People and their carers” • Demographic transition & dependency ratio has major implications for workforce to support our older citizens (e.g. currently in general practice & community nursing) • And retirement age of health and social care staff

14. Following the money.NHS Constitution Technical Handbook

15. III: What ageing means for population health. Reality. However much we invest in prevention & wellbeing, people will get ill. & Even if more older people stay well for longer, there will be more older people to compensate.

16. “Grey Tsunami” “Time Bomb” “Burden” Older people invisible Or “elite” (sky-diving grannies) Portrayal as dependent, vulnerable, isolated, ill Labelled “bed blocker” “social admission” etc Ageist values Age discrimination (e.g. CPA report 2009) Even in health professionals Values/priorities Language, labelling and perceptions

17. In fact, most older people in decent nick and contributing still (UK cohort studies/census) 70% M & 60% of F > 75 self report health as “good” or “very good” 2/3 over 75 say they don’t live with life-limiting LTC Most over 75 remain in own homes with no statutory social support 70-80 year olds self report highest levels of satisfaction with life Taking into account unpaid caring, granparenting, volunteering, spending, paid employment, over 65s make net contribution to economy (Sternberg Report) Wider determinants count (e.g.Isolation/Housing)

18. Multimorbidity in Scotland (Scottish School of Primary Care Barnett et al Lancet May 2012)

19. Scottish School of Primary Care Guthrie BMJ 2012 e.g. Only 18% with COPD just have COPD

20. Problematic Polypharmacy. (10% over 75s on 10 + meds). (See also Greenhalgh BMJ 2014 “Evidence-based medicine a movement in decline?)

21. Melzer D Age UK 2015

22. Melzer D Age UK 2015

23. Melzer D et al Age UK 2015

24. Mobility

25. Clegg et al Lancet 2013 Frailty Clinical Review

27. Frailty Syndromes (how people with frailty present to services).Clegg, Lancet. BGS “Fit for Frailty” “Non-specific” E.g. fatigue, weight loss, recurrent infection Falls/Collapse Immobility/worsening mobility Delirium (“acute confusion”) Incontinence (new or worsening) Fluctuating disability Increased susceptibility to medication side effects e.g. Hypotension, Delirium

28. From Prof John Young. National Director for Integration and Frail Older People – England. Where should geriatricians & specialist teams best focus efforts?

30. IV: Some implications for care planning, palliative care You’ve seen some of the primary care data and others will speak more re general practice

31. Older people & families often can and do get good end of life care • Despite some poor care, some it unacceptable and bad experiences • In all settings • home, care home, hospice, community hosp • Including acute hospitals • where they often choose to stay • despite alternative offers • can’t always be predicted from community • Two recent tales to illustrate

32. Hospital • Median age of new acute admission 71 • 25% of all bed days are in over 80s • Delayed transfers rising • Re-admissions rising • Bed numbers falling • Admissions rising • Hospitals v close to capacity year round • c. 1 in 3 patients in acute hospital bed are in last year of life • Clark D et al Palliative Med 2014

33. Median age of intermediate care patient = 82 (NHS Benchmarking)

34. 16% die within 6 months and 25% within 12 Median survival 16 months 67% immobile or need help with mobility 78% dementia or other mental impairment c. 20% Stroke 10% end stage cardiac/respiratory disease 8-12% documented depression 30-65% incontinent of urine/faeces or both Average resident falls 2-6 times a year Median medications per resident 9 (Barber N CHUMS study) (high prescribing, admin, follow-up error) Care Home Case Mix

35. Acute admissions from care homes (Quality Watch 2015) – many are at or near the end of life and add distress but little value to care. Many preventable through good planning and support

42. Ombudsman

43. NHS Atlas of Variation 2015

44. V: Some very specific solutions

45. Some very specific solutions I • Use specific diagnoses, including & contact with any health setting • This should include frailty and dementia • To initiate care planning/advance care planning • (see GSF, RCGP guidance, Coalition for Collaborative Care, BGS “Fit for Frailty”) • This includes advance decisions, potential appointment of attorneys • Adequate capacity and responsiveness in community palliative care • Tailored support to care homes including GSF accreditation

46. Some very specific solutions II • Look at impact of better planning and palliative care on admission prevention, LOS, readmission, delays • Involve carers/bereaved in design, feedback, teaching • Learn from feedback and complaints • As palliative care can’t see everyone, ensure more people have awareness, or training • Make access to palliative care quick and 7/7 • Really put people & wishes at centre • In hospital, mustnt shy away from difficult conversation or DNACPR • Better understanding of mental capacity & related legislation • And end of life decisions over CPR, Artificial Nutrition/Hydration • Culturally sensitive • Age Attuned and Non Discriminatory

47. Working together?..

48. Enjoy today and the challenge beyond. Thank youD.oliver@kingsfund.org.ukDavid.Oliver@royalberkshire.nhs.ukPresident@bgs.org.uk@mancunianmedic