Ageing as a game-changer for acute and general medicine and wider systems in which we practice

Transcription

1 Ageing as a game-changer for acute and general medicine and wider systems in which we practice Acute and General Medicine Conference October David Oliver RCP London Clinical Vice President

2 To Cover I: Population Ageing II: Why it s not all bad news III: The downside IV: Implications for acute hospitals V: Why hospitals aren t islands VI: How hospital medicine should change

3 I: POPULATION AGEING

4 Rectangularisation to Elongation of Survival Curve 100% 90% 80% Distribution of death England NHS Founded, 48% died before 65. In 2015 its c 12% 70% % 50% 40% % 20% 10% 0% ONS

5 By 2030 men aged 65 will live on average to 88 and women to 91 Currently 83 and 86 Workforce Implications Brexit

6 UK Population Pyramid& Projection

7 Crucial role of carers 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 are over 65 many in poor health 0.5 M over 80 1 in 4 say own physical or mental health affected by caring role < 5% get statutory support At least daily care the norm and 50 hours a week not uncommon House of Lords Ready for Ageing report 2013 Age UK 2017 Carers are key to maintaining people at home, supporting them in hospital, supporting their discharge We need to work with them and support them

8 II: WHY IT S NOT ALL BAD NEWS

9 Ageist/catastrophising language Grey tsunami Ticking time bomb Burden The Elderly Polarised representations Skydiving grannies vs Vulnerable Victims Similar language creeps into medicine Acopia Social Admission Bed Blocker Failed OT assessment

10 Ageing a success story for public policy, public health and medicine

11 Disability-free life expectancy

12 OECD Self-reported health status

13 Independence in activities of daily living

14 Combatting the misery narrative Over 65s make net contribution to the economy via employment, volunteering, caring, grandparenting, spend (Sternberg report) In Europe & North America, over 80s have higher self reported happiness/satisifaction than most age groups Isolation and loneliness are big health determinants but only 10-16% Lonely all or most of time (Age UK)

15 III: THE DOWNSIDE

16 Multimorbidity (Scottish School Primary Care Study. Lancet. Barnett et al

17 So single disease models/incentives often unfit: polypharmacy follows Guthrie et al, Kendrick et al

18 Comparison of Cognitive Function and Ageing Studies 1991 and Kingston et al Lancet areas of UK, 2,500 in each Between two cohorts Men Living an additional 2.4 years with substantial care needs Women an additional 3 years Substantial care needs defined by dependency on care for common ADLs Fewer living in care homes Compression of Morbidity not seen

19 Dementia Prevalence (n.b 1 in 4 beds in Hospital)

20 Distribution of electronic frailty index England >65s (n =227,000) Clegg et al 2016

21 Electronic Frailty Index (England) n = c 227,648 (Clegg et al Age Ageing 2016) Outcome Mild frailty (HR, 95% CI) Moderate frailty (HR, 95% CI) Severe frailty (HR, 95% CI) 1 yr care home admission 2.00 (1.68 to 2.39) 2.70 (2.41 to 3.04) 5.94 (4.61 to 7.64) 3 yr care home admission 1.52 (1.37 to 1.69) 2.70 (2.41 to 3.04) 3.42 (2.84 to 4.12) 5 yr care home admission 1.56 (1.43 to 1.70) 2.34 (2.10 to 2.61) 3.00 (2.42 to 3.70) 1 yr hospitalisation 1.85 (1.81 to 1.88) 2.96 (2.90 to 3.02) 4.62 (4.50 to 4.74) 3 yr hospitalisation 1.71 (1.69 to 1.73) 2.54 (2.51 to 2.58) 3.64 (3.57 to 3.70) 5 yr hospitalisation 1.63 (1.61 to 1.64) 2.43 (2.40 to 2.46) 3.59 (3.54 to 3.65) 1 yr mortality 1.91 (1.78 to 2.04) 3.39 (3.15 to 3.65) 5.23 (4.73 to 5.79) 3 yr mortality 1.74 (1.68 to 1.81) 3.02 (2.90 to 3.14) 4.56 (4.29 to 4.84) 5 yr mortality 1.66 (1.62 to 1.71) 2.73 (2.64 to 2.81) 3.88 (3.68 to 4.09)

22 How frailty presents

23 How frailty presents (Clegg et al Lancet Clinical Reviews 2012) Progressive dwindling (Meyer and Bowman JRSM) Non-specific E.g. slow walking, muscle weakness 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

24 IV: IMPLICATIONS FOR ACUTE HOSPITALS

25 Age-cost curve for acute care [NHS constitution handbook]

26 ED case mix. Quality Watch 2014

27 Functional decline in over 75s admitted acutely

28 Modern Hospital Case mix

29 Big part of GiM business in 2017 Tailor offer to age but avoid age discrimination/ageism Frailty-related presentations Dementia Delirium Mental capacity Functional Impairment/Dependency Common harms of hospitalisation End of life care & dilemmas Multimorbidity Polypharmacy Prioritisation of goals/treatment Cessation of treatment Rehabilitation Discharge Planning Managed risk Interface with community services

30 V: WHY HOSPITALS AREN T ISLANDS

31 Hospitals not Islands:wider system Oliver D et al King s Fund 2014

32 Current (England) Policy Context Local gov/public health funding cuts & no policy courage Social care funding & provision cuts 400,000 care home residents complex needs Very low, falling and full hospital bed base Financial deficits &workforce gaps in hospitals Insufficient capacity intermediate care Rapid rise in Delayed Transfers Continuing care battles Many more stranded patients on wards GP/comm nursing workforce workload crisis Blame on acute hospitals and their clinicians

33 Older people, integration & care co-ordination 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 Need move to person-centred coordinated care National Voices 2013

34 Emerging (international) policy consensus (also driving STPs) (e.g. Richard Smith BMJ Opinion 2017) Geared to acute Hospital-centric Dr-dependent Episodic Disjointed Reactive System/disease Patient passive Self-care rare Carers undervalued Low-tech Geared to LTCs Community-centric Team-based Continuous Co-ordinated Preventive Person-centred Patient partner Self-care supported Supported as partners High-tech

35 But amidst all the magical thinking People still suffer acute illness and injury And still need hospital care Or at least acute care So have to make hospital and acute care system Age-proof and fit for purpose

36 VI: HOW HOSPITAL MEDICINE SHOULD CHANGE

37 NHS Acute Frailty Network (England)

38 H.I. Scotland OPAC Standards for In- Hospital Care

39 Thankyou @mancunianmedic