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The percentage of the population over 65 years will rise by 50 per cent within the next twenty-five years and that over 80 years by around 80 per cent.

Projections suggest increases of similar magnitude in the prevalence of physical dependency, disability and people surviving with one or more long-term conditions, such as dementia, osteoporosis, heart failure or stroke disease. Even with current demographics, people over 65 account for over 60 per cent of hospital bed days and health and social care spend, and so are effectively core service users.

Whilst open to debate, concerns about the effect of population ageing and dependency ratios on pensions and on health and social services understandably occupy the thoughts of politicians. Government has acknowledged the increasing importance of care of the old to health service delivery and the funding of long term social care.

In a speech in 2008, the Health Secretary, Alan Johnson said in a speech¹:

“Old age is the new middle age. Health and social care services need to adapt to the changing needs of today’s older people . . . to promote health in old age and help older people to maintain independence and quality of life. The biggest challenge now facing the NHS is the health of older people.”
Some of the thinking he outlined around prevention drew on the success of the various Partnerships for Older People Projects (POPPS) projects which had been evaluated around England and which were said to have demonstrated the cost-effectiveness of investing in prevention to reduce service utilisation.²

The Older People’s Team at the Department of Health is developing the “Prevention Package” for Older People, aimed at giving providers, professionals and commissioners guidance and toolkits to commission, deliver and monitor better services in key areas.³

The first round of the toolkit, announced in July, covered falls and bone health, intermediate care, telecare and foot care. The intermediate care toolkit re-emphasised the principle of not discriminating against patients with a diagnosis of dementia in access to services. The second round of the prevention package will cover arthritis, depression and osteoporosis.

“Must do” versus “National Priorities”
We need to be realistic about the current climate in which such services are to be provided. The NHS operating framework (a key read for anyone who wants to understand how services are driven)⁴ contains only a small number of central “must do” elements. It lists a larger number of “national priorities for local delivery”. “High Quality Care for All”⁵ may emphasise quality (outcomes, safety and patient satisfaction), but it also emphasises local commissioning, contractual incentives, regulation and payment by results to drive this. The National Institute of Health and Clinical Excellence (NIHCE), on the other hand, has a stronger role in defining quality. The Quality Assurance framework for “world class commissioning”⁶ does not define which elements of services need to be commissioned.
So the buzz word of the moment is “subsidiarity” i.e. devolving service commissioning and oversight to localities. The phrase which best characterises this approach is, “Central co-ordination, regional assurance, local delivery” – with the centre taking a move towards “arms length”.

If we combine all this with the significant financial pain expected in the public sector after the next spending round, we can see that the era of central initiatives with earmarked funding and binding targets/deadlines is ending.

Those expecting resources such as the prevention package to contain absolute directives may therefore be disappointed. The idea is to give commissioners and providers a “direction of travel”, a summary of current evidence for good practice and gaps in the service and information on which services could be commissioned to address these gaps, metrics to monitor their implementation and good practice models or business cases for other localities.

Falls and bone health toolkit
The falls and bone health toolkit provides an example of this approach. In falls, fractures and osteoporosis, we have problems which affect large numbers of older people, consume significant health resources and which are potentially preventable by better case finding, systematic assessment and intervention, and better funded or co-ordinated services, even when patients do go on to suffer hip fracture (accounting for around 80% of the HRGs spent on fractures). There are relevant guidelines from NIHCE, the National Osteoporosis Guideline Group (OGG) and from the joint BOA/BGS/ BOAST and NHS work on hip fracture management, but national audits against these guidelines have shown significant gaps in services provided and variations in treatments received by individual older people. Until such time as relevant Quality Outcomes Framework (QoF) targets, Payment by Results tariffs or Operating Framework “Must-Dos” appear, the key is better local commissioning of services.

The toolkit has had input from a wide variety of stakeholders and is also being presented at a series of regional workshops, attended by clinicians, commissioners and service users.
Its key aims are set out simply in our pyramid, with the idea that the earliest gains to deliver are the better management of those who have already suffered a hip fracture or who have already suffered a “herald fracture” (around 45% of patients who go on to break their hip have experienced this problem) with the primary care and preventative agenda around prevention of falls or frailty taking longer to achieve.

The important thing with the falls and fractures agenda is that we need to move away from pockets of good service to integrated cross agency services which genuinely provide assessment and intervention for those at risk and have an impact on the incidence of falls and fractures in whole populations. Whilst we can see that this has happened with Ischaemic Heart Disease and is beginning to happen with Stroke and TIA, there are more patients suffering fragility fractures than there are those who experience either MI or Stroke, despite the evidence for primary and secondary prevention and better outcomes. What the commissioning toolkit does, is to provide a mechanism for getting this evidence into practice. In view of the financial squeeze on services, the multiple competing priorities, the lack of central “must dos” and the medium term gains from investing in better falls and bone services, only time will tell how effective this approach is.

David Oliver
Co-Chair, BGS Falls and Bone Health Section

References

1. Speech by the Rt Hon Alan Jonson MP, “Old Age is the New Middle Age”

2. National Evaluation of the POPP programme

3. Prevention package for older people

4. The NHS in England: The operating framework for 2009/10

5. High Quality Care for All

6. World class commissioning

BGS Newsletter, September 2009
Issue 23 ISSN 1748-634000 23