NCEPOD Report – an age old problem Nov 2010

Reflections and how we can do better

Finbarr Martin

Geriatrician, Guys and St Thomas’ Hospitalsand

President, British Geriatrics Society

Older Peoples’ Care in England

• People aged 65+ are ~ 17 % of the population• And use 65% of acute hospital bed-days• >50% of the patients having surgery, (>major)• Use nearly half the NHS total budget• Over half social services’ budgets• Over £3 billion for NHS continuing care

So, are the older population a challenge to the NHS?

Older Peoples’ Care in England

• People aged 65+ are ~ 17 % of the population• And use 65% of acute hospital bed-days• >50% of the patients having surgery, (>major)• Use nearly half the NHS total budget• Over half social services’ budgets• Over £3 billion for NHS continuing care

So, are the older population a challenge to the NHS?

OR, are older people core business??

NSF etc but also other relevant policies

• Human Rights Act• Equality Act – law in 2012 for

healthcare• National Dementia Strategy

– Memory clinics in each area for early diagnosis

– Dementia champion (clinician) in every hospital to improve assessment, management and referrals

– Reduced use of psychotropics

The clinical challenges

• Subtle presentation of serious illness− Functional decline is always “suspicious”

• Co-morbidity is common (ASA grades)• Loss of reserve is common

– Physiological– Psychosocial

Variability - age is unreliable indicator

Clinical implications

• Initial assessments of emergency patients by junior staff may misso Primary diagnosiso Relevant co-morbiditiesLose opportunities to optimise chances

• Routine pre-op clinic assessments not suitable for many patientso Inadequate use of risk predictiono Focus on information not preparationo Not linked to pre-operative optimisation

Why don’t guidelines always work?

• The report highlights suboptimal management of common post-operative complications

• gap between the existence of policies and guidelines such as fluid management and pain management and routine clinical practice.

Improving clinical outcomes – what does work?

• Clarity about what needs doing• Leadership – professional and

managerial• A strategic intention

(commissioning)• Motivation to do it • Models of care• Performance and clinical governance

We need to overcome “silos” of care

• Current models are not designed to meet the predictable clinical challenges of old age

• Specialists in old age medicine are PART of the solution

• Pathways of care need to be designed, evaluated and implemented.

• Management and budget setting must adapt • Other specialist eg. general acute medicine

will need to adapt• There will be training implications• There will be workforce planning implications

Blue Book & NHFD launched together – Sept 2007

Six standards – monitored by NHFD

1. All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of presentation

2. All patients with hip fracture who are medically fit should have surgery within 48 hours of admission, during normal working hours

3. All patients with hip fracture should be assessed and cared for with a view to minimising their risk of developing a pressure ulcer

4. All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to orthogeriatric medical support from the time of admission

5. All patients presenting with fragility fracture should be assessed to determine their need for antiresorptive therapy to prevent future osteoporotic fractures

6. All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls

NHFD Reports: 2009 & 2010

Co-morbidity is to be expected, and thus built into service capability

The fracture impact will ADD to previous functional limitation

What needs to de done?

• Better care is often cheaper care in the end, so NHS must get better to survive economically

• Older people with problems are to be expected• Frailty and geriatric syndromes can be identified -

comprehensive geriatric assessment (CGA)• “Complications” can be predicted• Expert teams + up-skilling general services• It must be multidisciplinary• Clinical governance across traditional boundaries

Principles

Surgical Outpatients/PAC

Proactive referral of patients aged 65+

Screen to identify risk

Including “medically unfit for surgery”

Pre-operative CGA

Consultant

Clinical Nurse Specialist

Occupational therapist

Physiotherapy

Social worker

Patient education

Hospital Admission

Post-op consultant geriatrician and specialist nurse interventions

Therapy liaison

Discharge planning

Post Discharge

Intermediate Care

Links with primary care/ social care

Specialist clinic follow up (falls etc)Preadmission Liaison

Surgical team

Anaesthetists

GP and Community services

Patient

Proactive care of Older People having surgery

-“POPS”

Assessment• Recognition of known comorbidity• Identification of unrecognised disease, disability• Assessment of functional reserve• Assess the coping strategies and preferences• Capacity, consent, advanced directives

Optimisation• Standardised management of medical

complications• Early identification of medical complications• Assess and enhance functional reserve• Prepare the patient psychologically

Prediction and preparation of discharge support

What can be done pre-operatively ?

Benefits demonstrated over 5 years multiple hospital appointments late cancellations • Improved quality of care

post operative complications– Better management of postoperative

complications• Improved discharge planning length of stay• High patient and staff satisfaction• Knowledge for the NHS

The way forward

• Translating the evidence base for single organ disease assessment and management into routine clinical practice for older people with multiple co-morbidities.

• Move on from risk assessment tools to interventions to reduce postoperative complications and mortality.

• Integrated care pathways joining skills of surgical teams, anaesthetic teams, organ specialists and geriatricians.

Patients should expect it BGS (and RCP) look forward to working for it