NCEPOD Report – an age old problem Nov 2010 Reflections and how we can do better Finbarr Martin Geriatrician, Guys and St Thomas’ Hospitals and 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 miss oPrimary diagnosis oRelevant co-morbidities  Lose opportunities to optimise chances Routine pre-op clinic assessments not suitable for many patients oInadequate use of risk prediction oFocus on information not preparation oNot 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