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Whether it was a month lacking in more sensational news, a moment of social conscience on the part of the media, or a random choice of “social issues”, March and April saw unprecedented focus on health and social care services for older people.

As an organisation we have not always seen ourselves in a campaigning role. During these weeks when older people’s services was given such prominence in both the media and on the Government’s agenda, the BGS was not at the top (in some cases, not even at the bottom) of the media’s list of contacts to approach for comment, and so during the airing of issues at the core of our business, we had to work hard, and with only variable success, to make our voice heard. It is difficult to forecast when the media’s spotlight will turn on older people’s care. It is also virtually impossible to predict which specific issue relating to older people is going to grab the media’s attention with a view to the BGS having a ready made position statement. If we were to adhere rigidly to our culture of consensus whereby every position statement is screened and approved by a hierarchy of committees, the media’s attention will have long moved on by the time the BGS is ready to comment.

Our core messages are the need for comprehensive specialist assessment and for better training for people working with our patient group. This distinguishes us from other agencies concerned with older people, but they are difficult concepts to convey to the media which is more likely to focus specifically on, for example, living wills, do not resuscitate policies and ageism.

We would very much welcome comments, letters emails etc. on these two themes:

1) What is your view of the NSF to date and the aims expressed in the Next Steps document (see below)?

2) Do you feel we should be more proactive with public relations, campaigning, attempting to explain and influence via the media?

The trouble with old people
In the March issue of this newsletter, we interviewed Tony Robinson in preparation for the screening of his programme, “Me and my mum”, one of a series of four prime time documentaries, “The Trouble with Old People” aired by Channel 4. The series explored issues around home care, long term care, dementia, the role of carers, social isolation, societal attitudes to ageing and political prioritisation of older people’s needs. In the same week, Esther Rantzen’s ‘How to have a good death’, began with a personal account of the death of her husband – leading to a more general exploration of palliative care. The principal recipients of palliative care are older people, but unlike younger terminally ill patients, older people receive less palliative attention, particularly those with non cancer diagnoses.

Living well in later life
On 27 March the joint report of the Healthcare Commission, Audit Commission and CSCI, “Living Well in Later Life” was published. This made front page news in The Independent and the Daily Mail and was a lead story on BBC News. Download the full report. Its rationale was to assess progress against the milestones for the 2001 National Service Framework for Older People. The report highlights successes. For instance; three fifths, as opposed to one fifth of patients with stroke are now receiving specialist services; explicit age discrimination in policies and eligibility criteria for access to services has been largely removed and there is no longer a general presumption that older people should not be offered treatment; 32% ( c.f. 27% in 2001) of frail older people with complex needs are now supported in their own homes, with a reduction in the proportion admitted to long term care. The realisation of more general NHS targets for blood pressure control, smoking cessation etc. will also inevitably benefit older people.

Despite this good news, “Living well in later life”, is no “box-ticking” whitewash and makes no attempt to gloss over continuing shortfalls in service provision. It highlights the facts; that the Single Assessment Process is far from an operational reality in many localities, partly due to deficiencies in IT solutions; The RCP sentinel audit on falls services has shown that whilst some 74% of trusts have an integrated multi-agency falls service, these services rarely have the capacity to deal with most unmet need; there are still major inadequacies in emergency response to falls and in provision of services for bone health; and there is a lack of priority given to the needs of older people when planning and commissioning services e.g. chiropody and continence services are still given low priority for funding. In a survey of six PCT localities, although 70% - 80% of people were satisfied with the treatment they had received there was still widespread evidence of a lack of dignity and respect in the way older people were treated in hospitals or long term care. For instance many patients ‘experience poorly managed discharge, moves from ward to ward to free up social beds, or having meals taken away from them due to poor nursing support’. The report further emphasises that mental health services for older people is a particular problem with ‘a noticeable difference in access to services as they pass 65, and in provision of out of hours services for those with mental health needs’. It also acknowledges that there are insufficient staff with the right training to deal with the increasing prevalence of dementia in healthcare settings.

The report recommends ‘that managers from all organisations make sure that older people are treated with dignity and respect’, ‘that their basic human rights are upheld’, ‘NHS Trusts and local authorities must ensure that the NSF standards are met’, ‘partner organisations involved in providing health and local government services need to work together to develop a joint strategy for promotion of health and wellbeing’ and ‘to ensure a systematic approach’. The point is made that despite good examples of joined up commissioning of services, many health and social care organisations are working to different frameworks and priorities. ‘Unless these overarching issues are tackled as a priority, older people’s experience of public services is unlikely to improve significantly’.

Wanless Report
On 30 March the Wanless Report, “Securing Good Care for Older People” was published. The report examines various funding models for provision of future social care for older people, in much the same way as the Royal Commission on Long Term Care for the elderly (1998) looked at the financial implications of long term care funding. The Royal Commission Report was never fully implemented in England, ostensibly due to treasury fears about the accuracy of the economic models and potential cost to the exchequer. It has been implemented in Scotland, leading to operational lessons, suggesting that the costs are greater than projected, but not impossible to meet. Since that report, we have also seen the framework for evaluation of free registered nursing contributions and in the wake of the case of Coughlan V North Devon and Exeter Health Authority, altered criteria for continuing care funding.

Wanless stated that to continue service provision at current levels would require total public and private expenditure to increase from £10 billion in 2002 (1.1% of GDP) to £24 billion by 2026 (1.5% of GDP). To achieve a ‘more ambitious goal’ for social care would mean an increase of 2% GDP by 2026. The review found ‘serious shortcomings in social care provision and funding arrangements’, the current means tested funding system should be scrapped and replaced with a partnership model. Under this system everyone in need would be entitled to free care up to a specified limit, any care after which individuals’ contributions will be met pound for pound by the state to a specified limit. This reconfiguration of services would be cost effective and will provide more community based services including better access for those with moderate care needs, better support for carers and improved services for people with dementia. Currently, in comparison to many other developed nations, the proportion of people receiving home care services is relatively low. To achieve these aims there would need to be ‘a substantial growth in the supply of services and a wider review of the benefit system’. If the more ambitious level of services were to be attained under a partnership funding model, up to 450,000 more older people in England would receive social care services such as home care, day care and respite at any time and to a greater degree. The offset additional public spending would be an annual £1.7 billion. Sir Derek concluded that ‘to provide good social care for older people in twenty years time and to meet people’s expectations, we will need to devote a larger share of national income to social care … at the moment we have a safety network for poorer people but social care should be about more than that …we need to ensure that older people are able to remain as healthy and independent as possible … the current system is failing to do this and is too focused on a number of older people with the most significant social care needs’. The Wanless Report was given a cautious welcome by the Government who said that they would examine its implications but stopped short of saying that they would implement its recommendations, either partially or in full. Déjà vu, anyone?

Primary Care
In the same week there was a public meeting of the Associated Parliamentary Health Group on Older People’s Services attended by leaders from key organisations and members of the House of Commons and House of Lords, all with an interest in older people’s issues. David Colin Thome, National Director of Older Primary Care, also discussed the implications of the Primary Care White Paper, “Our health, our care, our say” http://tinyurl.com/elx2d. The emphasis is on putting people in control of their own lives with more self management of chronic illnesses, high quality services close to people’s homes and an aim of a 5% shift from secondary to primary care. The key actions emphasised by Dr Colin Thome:

1) Primary care provision to be increased in working class communities – there is currently unequal provision of services and the GMS contract needs to be used to drive this redistribution of resource.

2) GP’s need to consider the balance between providing a range of services close to where people live, respecting continuity and personal relationships, rather than ‘primary care factories’. This is especially relevant for older people who, in every survey, look favourably on traditional models of primary care.

3) The Quality and Outcomes Framework (QOF) (see article by Jonathan Bayly on p28) needs to be employed to have some measures on performance on older people’s issues, including satisfaction surveys.

4) More investment in capital premises and intermediate care facilities.

5) Practice based commissioning might influence services for older people as GP’s are likely to pick community care on a case by case basis rather than commissioning from a large organisation.

6) Long term conditions and case management. Dr Colin Thome admitted that the evidence base for “community matron” intervention is inconsistent even before the Evercare pilot study. Whilst the intervention has been shown to reduce length of stay and an increase in satisfaction and quality of life, there was no clear evidence that it reduces admission to hospital.

Despite this lack of clear evidence from trials there is still likely to be an expansion of the scheme with the appointment of 3,000 new community matrons for patients with multiple chronic conditions. The bulk of these high intensity users are likely to be older people with chronic disease.

7) Assessment protocols need to be available where they can be accessed. The single assessment process needs to be real and useable rather than a virtual and distant aim.

At the same meeting Baroness Greengross spoke about ageism in services and negative attitudes to older people, ‘too much emphasis on acute and long term care and not enough on prevention’. She also highlighted the need for all staff dealing with older people to have the appropriate core skills and knowledge.

New Ambition for Old Age
Also at this meeting, Ian Philp presented the outline of his ‘next steps’ plan for the next five years of the Older People’s NSF. He felt that that the NSF had produced good early progress until ‘Achieving a Balance’ came in, making partnership working more difficult. He also admitted that unlike other NSF’s it had come with no additional money apart from £500 million specifically for enabling older people to remain at home and this had hampered its progress. The NSF has been the starter for a ten year quality improvement programme for older people’s services and this is only the mid term report. There is also clearly a move away from incentives based around “targets”, which often achieve their principal aim whilst distorting other priorities. The trend is more towards a use of a variety of ‘levers and incentives’. Revolutionising attitudes and systems is an iterative process requiring a variety of approaches and there is an increasing recognition of this.

The next steps document “A New Ambition for Old Age” was then released on 19 April. Its key themes are:

1) Dignity in care: Dignity is given the highest priority. It is to be addressed using a variety of approaches in seven key areas: a) Nutrition and physical environment – with adequate assistance for feeding, upgrading the physical environment and designing new facilities to take older people into account b) Skills, competencies and leadership in the workforce, including named practice leaders in nursing (labelled by the press as “dignity nurses”) c) Assuring quality - using inspection, regulation and action for breaches of dignity. d) Ensuring dignity for those with mental health problems and equitable access to services e) Ensuring dignity at the end of life – using NHS end of life care programmes for people in their own homes, hospital or care homes, f) Equalities and human rights - with a clear link to the Commission for equality and human rights g) Championing change – by informing and raising awareness among care providers, staff and older people’s champions, of unacceptable care and involving older people as citizens to improve care.

2) Making systems “age proof” and fit for purpose: The core users of health and social care are older people, yet services are often not designed around their needs, nor are services for older people prioritised. Not only do many staff caring for older people require a transformation in skills, knowledge and attitudes, there needs to be greater investment and more emphasis still on: services for falls and bone health (especially around emergency responses to falls; stroke; mental health in old age – with fairer access to services for those over 65 with mental health needs and better dementia care; better co-ordination of care for those with complex needs; better urgent care for older people presenting with syndromes such as immobility, falls or delirium; improved care records – with a simplification of the Single Assessment Process and plans to make its use real rather than virtual.

3) More enjoyable active and healthy ageing: Although there has been an emphasis in these reports on the care of those who are ill or dependent, health promotion is equally important. This target would aim to promote independent wellbeing and choice. Core elements would include availability of disease prevention programmes, removal of barriers to full participation in treatment e.g. by dealing with chiropody, hearing, vision and equipment, inclusion of excluded groups (those in poverty, isolation, ethnic minorities, or those with mental health problems), widespread provision of exercise. Overall the report concluded that we needed to ‘raise aspirations so that politicians respond’ and ‘make services a political priority so that politicians refocus’.

Quo Vadis
As a society and as practitioners dealing with older people, it would be hard to argue with any of these aspirations and we can welcome them while expressing justifiable scepticism as to the likelihood that they will be achieved. Perhaps better still, we can adopt a “let’s see how we can help make it happen” stance.

“Our health, our care, our say” has not been costed. The government have not said that they will take Sir Derek Wanless’ recommendations on board. Whilst the transformational approach using a variety of methods rather than a narrow focus on targets is undoubtedly the way to go, the original NSF did not come with new ring fenced resources (despite the repeated claim that £500 million put into maintaining more older people at home was a part of the initial NSF). In this new document, the only specific figure is £3m for additional DXA scanning with a further £17m for DXA scanning equipment. This is unlikely to result in all patients for whom DXA is required by NICE, receiving the test. Nor is it likely to improve access in specialised services to prevent the falls which lead to fractures. As Jonathan Bayly outlines in this article, there is no QOF target for falls. It may still be difficult to persuade commissioners of services to buy all the arguments for investing more. Genuine integrated falls and bone health or stroke services for instance, or better provision of mental health services for older people, or training and education for staff, will all produce comprehensive geriatric assessment for patients. This will in turn, yield dividends for the system in terms of access, capacity, bed management, quality and outcomes in the medium term. More importantly it will produce gains for individual patients and their families. Likewise, improving the quality of care in homes would be a good thing but as these institutions operate with narrow margins and have difficulty in recruiting and retaining staff, this can only be addressed by greater involvement of specialist doctors and nurses in a community and continuing care role. In the current financial climate in the NHS, however well the arguments are made, this does not always translate to real changes in practice or system reorganisation. Staff are more likely to be performance managed over financial balance or NHS Plan targets than quality and governance in the care of older patients. The first round of NSF milestones has effected real gains in terms of getting partner organisations to discuss services for older people and in increasing stroke units and intermediate care places. However, many milestones were not realised in full because of a lack of investment and because meeting NSF targets came well down the pecking order of other priorities that organisations had to achieve.

As a speciality whose practitioners have consistently fought and campaigned pn better care for older people, and who have developed an evidence base for practice and a system of training, we should be at the forefront of leading this change.

David Oliver
Honorary Deputy Secretary