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Making systems fit for an ageing population Implications for palliative care? Thames Valley Workshop. Madejski October 8 th 2015 Prof David Oliver Consultant Physician, Royal Berks President, British Geriatrics Society ECIST Speciality Advisor Senior Visiting Fellow, Kings Fund Professor, City University, London Slide 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 Slide 3 NHS Benchmarking 2014. Continuing care & delays Slide 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 Slide 5 Check out the I statements from patients view Slide 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) Slide 7 Oliver D, Foot C, Humphries R et al Kings Fund 2014 SAM Palliative Care & Care Planning Cross All Domains Slide 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_TWE M 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 Theres a second what went wrong on youtube with solutions Slide 9 II: Population Ageing A success story, not a catastrophe Slide 10 A success for society, preventative and curative medicine Slide 11 From rectanguralisation to elongation of survival curve. ONS 1947 NHS Founded, 48% died before 65. In 2015 its c 14% Slide 12 By 2030 51% more over 65, 101% more over 85 Slide 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 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 dont 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) Slide 18 Multimorbidity in Scotland (Scottish School of Primary Care Barnett et al Lancet May 2012) Slide 19 Scottish School of Primary Care Guthrie BMJ 2012 e.g. Only 18% with COPD just have COPD Slide 20 Problematic Polypharmacy. (10% over 75s on 10 + meds). (See also Greenhalgh BMJ 2014 Evidence-based medicine a movement in decline?) Slide 21 Melzer D Age UK 2015 Slide 22 Slide 23 Melzer D et al Age UK 2015 Slide 24 Mobility Slide 25 Clegg et al Lancet 2013 Frailty Clinical Review Slide 26 Slide 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 Slide 28 From Prof John Young. National Director for Integration and Frail Older People England. Where should geriatricians & specialist teams best focus efforts? Slide 29 Slide 30 IV: Some implications for care planning, palliative care Youve seen some of the primary care data and others will speak more re general practice Slide 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 cant always be predicted from community Two recent tales to illustrate Slide 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 Slide 33 Median age of intermediate care patient = 82 (NHS Benchmarking) Slide 34 Care Home Case Mix 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) Slide 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 Slide 36 Slide 37 Slide 38 Slide 39 Slide 40 Slide 41 Slide 42 Ombudsman Slide 43 NHS Atlas of Variation 2015 Slide 44 V: Some very specific solutions Slide 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 Slide 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 cant 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 Slide 47 Working together?.. Slide 48 Enjoy today and the challenge beyond. Thank you D.oliver@kingsfund.org.uk David.Oliver@royalberkshire.nhs.uk President@bgs.org.uk @mancunianmedic D.oliver@kingsfund.org.uk David.Oliver@royalberkshire.nhs.uk President@bgs.org.uk