1. Ageing Well Reducing unwarranted variation in health outcomes
Martin Vernon
NCD Older People
11th July 2017

2. Healthy aging – supporting people to live well and independently for as long as possible
Risk assessment, diagnosis and registration of people at risk of, or living with, frailty
Proactive care and support – managing multi-morbidity and the trajectory of frailty as a long-term condition. Including supported self-management for people with mild frailty, and co-ordinated, person-centred care for people with multi-morbidity and/or moderate and severe frailty and support for older carers
End of life care – supporting timely, high quality, coordinated and compassionate end of life care
Delivery enablers – supporting an effective and coordinated approach to care for older people across local health economies including, for example, agreeing a standard metrics for quality and outcomes, and considering skills requirements and organisation of multi-disciplinary teams.
Where we’re heading

3. Projected UK age structure
Foresight, 2016

4. Spend on adult social care
Since 2010 councils have had to deal with a 40 per cent real terms reduction to their core government grant.
Gross current expenditure by Councils with Adult Social Services Responsibilities on adult social care was £17bn in This is a 26% decrease in real terms since % (£13bn) of this gross current expenditure was spent on long-term support, 3% on short-term support and the remaining 20% (£3.4bn) on other social services expenditure.
53% (£7.2bn) was spent on people aged 65 and over, compared to 47% (£6.4bn) on people aged
These figures are small compared with £116bn on NHS overall (NHE £101bn) (15%)

5. Population 2015-2025: Age 65 and over
Number of people will increase by 19·4%: from 10·4M to 12·4M
Number with disability will increase by 25·0%: from 2·25M to 2·81M
Prevalence of disability will remain constant: 21%
Total life expectancy at 65 will increase by 1·7 yrs (to 21·8 yrs)
Disability-free life expectancy at 65 increase by 1 yr (to 16·4 yrs)
Life expectancy with disability will increase more in relative terms
~15% increase DLE from 4·7 years (2015) to 5·4 years (2025)
Forecasted trends in disability and life expectancy in England and Wales up to 2025: a modelling study: Guzman-Castillo et al, Lancet Public Health 2017

6. Ageing health impacts 15 million live with a long term condition (LTC)
58% people with a LTC are over 60 (14% under 40)
A&E attendances by people aged 60+ by two thirds 2007 to 2014
: 18% emergency hospital older people admissions

7. Wellbeing and Inequalities in Later Life
Growing socio-economic inequalities
Mechanisms:
Economic wellbeing
Quality of work
Retirement processes
Engagement in productive activity in later life
Social and cultural engagement
Negative outcomes:
Biological
Physiological
Psychological
Policy responses
Must address social, economic, health inequalities
Communities & Social Wellbeing
Economic Wellbeing & Work
Active and Healthy Ageing
The Golden Generation? MICRA 2017

8. Wellbeing and Inequalities in Later Life
Growing socio-economic inequalities
Mechanisms:
Economic wellbeing
Quality of work
Retirement processes
Engagement in productive activity in later life
Social and cultural engagement
Negative outcomes:
Biological
Physiological
Psychological
Policy responses
Must address social, economic, health inequalities
Communities & Social Wellbeing
Economic Wellbeing & Work
Active and Healthy Ageing
The Golden Generation? MICRA 2017

9. Ageing: key health objectives
KEEP THESE PEOPLE AGEING WELL
KEEP THESE PEOPLE HEALTHY AND PRODUCTIVE
Foresight, 2016

10. 5YFV: Older People
Focus on prevention
Stronger community services
Integration of care
Lead role of GPs
Prevent modifiable aspects of unhealthy ageing & unnecessary hospital admission
Enabling people greater control of their care: shared health & social care budgets
Support unpaid carers with partnerships: NHS, voluntary organisations, communities
Break down barriers to support people with multiple health conditions: older people living with frailty
Support communities to choose effective new care delivery options which integrate out of hospital care, primary care & other community based providers
Improve support to older people in care homes

11. 5YFV: Next Steps Priorities ‘Health and high quality care –now and for future generations’
Urgent and emergency care 24/7: up to 3M ED visits could have been dealt with elsewhere
Admitting sicker patients and discharging them promptly back home
Next 2 years hospitals to free up 2-3K beds through close community services working
Less severe conditions to be offered more convenient alternatives
Urgent Treatment Centres
GP appointments
More nurses, doctors, paramedics handling calls to 111
Most NHS care provided by GP: public priority is to get convenient, timely GP appointment
Recruiting over next 2 years
3250 more GPs
1300 clinical pharmacists
1500 MH therapists: IAPT to 60K more people in next year, 200K more in next 2 years
Cancer: will affect 1 in 3 in lifetime: survival at record high: 7K more surviving that 3 years ago
Increased service diagnostic and treatment capacity will increase this by a further 5K in 2 years
Mental health: extra 280K physical health checks by 2018/19 for people with SMI
Older people: Help frail and older people stay healthy and independent
Better integration between GP, community health, MH and hospital services
More joined up working with home care and care homes
Sustainability and Transformation Partnerships – integration of services and funding into Accountable Care Systems
Workforce development to support front line staff working with HEE
Continue drive to improve safety
Leverage potential of technology & innovation: enable patients to take greater role in self care

12. Increasing Community Presence
Acute bed numbers
Increasing Community Presence
8% reduction in general and acute beds since 2010: NHSB 2017

13. GPFV: Older People Greater focus on prevention
Stronger community services
Better integrated
Lead role of GPs
Contractual measures: improve hospital/GP interface
Support people living with long term conditions to self care: early frailty
Care planning
Local community pharmacy pathways to promote self care
Voluntary sector organisation support to GP through social prescribing: call off services
Develop digital interoperability to give access to a shared primary care record
Summary care records access in community pharmacies
Accelerated access to patient records across different services
Permit healthcare professionals in different settings to update & inform practices

14. This is not just about now…
The demand of care for older people will continue to increase
Many of these will have frailty, multi-morbidity, and/or disability
Care systems must be equipped for complexity to manage flow
The only feasible approaches to this are:
Reduce demand through prevention (attenuation)
Optimise current care systems to keep them effective

15. What do NHS England mean by frailty?
A long-term condition characterised by lost biological reserves across multiple systems and vulnerability to decompensation after a stressor event
‘The most problematic expression of human ageing facing the NHS today’ (Clegg)
‘MINOR ILLNESS’
INDEPENDENT
FUNCTIONAL ABILITY
DEPENDENT
Unpredictable recovery

16. CARE & SUPPORT PLANNING
Frailty as a Long Term Condition
A long term condition can be diagnosed, is not curable but can be managed and persists
As resilience is lost, care and support planning assumes greater importance through to the end of life
PREVENTION
CARE & SUPPORT PLANNING
END OF LIFE
RESILIENCE
INCREASING FRAILTY

17. The Frailty phenotype People aged >60: 14% & those >90: 65%
More common in women (16% v 12%)
In England1.8m people >60 and 0.8M people>80 live with frailty
93% frail people have mobility problems
63% need a walking aid
71% frail people receive help
Fried et al. J Gerontol (2001) 56(3): M146-M157
Gale et al. Age Ageing 2015;44:

18. Frailty as a Long Term Condition
NOW
FUTURE
‘The frail Elderly’
‘An Older Person living with frailty’
A long-term condition
Late
Crisis presentation
Fall, delirium, immobility
Timely identification preventative, proactive care
supported self management & personalised care planning
Community based person centred & coordinated
Health + Social +Voluntary+ Mental Health
Hospital-based episodic care
Disruptive & disjointed

19. ‘What’s the matter with you?’
Changing the script..
FROM
‘What’s the matter with you?’ TO
‘What matters to you?’

20. Prevention..upstream

21. Routine frailty identification
Routine frailty identification in primary care has 2 potential merits:
Population risk stratification
Targeted individualised interventions for optimal outcomes

22. Frailty identification
Distinguishing fit from frail & frail from fit…
…is the most pressing clinical task of our age
Frailty is linked to acquisition of multiple Long Term Conditions
Can be achieved for individuals or populations
Can therefore help target interventions more effectively

23. Frailty prevention? Potentially modifiable risk factors Alcohol excess
Cognitive impairment
Falls
Functional impairment
Hearing problems
Mood problems
Nutritional compromise
Physical inactivity
Polypharmacy
Smoking
Social isolation and loneliness
Vision problems
Targeted interventions for those at most risk :
Good foot care
Home safety checks
Vaccinations
Keeping warm
Readiness for winter
Stuck et al. Soc Sci Med. 1999(Systematic review of 78 studies)

24. Electronic Frailty Index (eFI)
Clegg et al: Age Ageing2016: 45:

25. Electronic Frailty Index (eFI)
The eFI has robust predictive validity for predicting outcomes (age 65-95)
1,3 5 year risk mortality, hospitalisation, nursing home admission
The prevalence of people who were fit, had mild, moderate or severe frailty was 50%, 35%, 12% and 3% respectively
Severe frail had on average 2.2 comorbidities and were taking 8 medications
One year risk almost doubles for mild frailty and quadruples for severe frailty
Routine implementation of the eFI will support delivery of evidence-based interventions to modify frailty trajectories
One year outcome
(hazard ratio)
Mild
frailty
Moderate frailty
Severe frailty
Mortality
1.92
3.1
4.52
Hospitalisation
1.93
3.04
4.73
Nursing home admission
1.89
3.19
4.76

27. GMS GP Contract 2017/18
Practices will use an appropriate tool e.g. Electronic Frailty Index (eFI) to identify patients aged 65 and over who are living with moderate and severe frailty
For patients identified as living with severe frailty, practice will deliver a clinical review providing an annual medication review and where clinically appropriate discuss whether the patient has fallen in the last 12/12
Where a patient does not already have a Summary Care Record (SCR) the practice will promote this seeking informed patient consent to activate the SCR
Practices will code clinical interventions for this group

28. GMS GP Contract 2017/18: Data
number of patients recorded with a diagnosis of moderate & severe frailty
number of severe frail patients with an annual medication review
number of severe frail patients recorded as having fall in last 12/12
number of severe frail patients providing consent to activate enriched SCR
NHS England will use data to understand nature of the interventions made
And prevalence of frailty by degree among practice populations & nationally

29. Why Falls?

30. Falls and older people Older people have highest risk of falling*
30% people aged 65+ fall at least once/year
50% of people aged 80+
*NICE CG161

31. Falls mortality Falls associated with  mortality in adults 65+
Ground level admitted falls +65: only 33% went home without assistance*
1 year mortality 33% for all admissions
1 year mortality for those discharge alive 24%
Those discharged to nursing facility had 3X risk of death in 1 year (HR=2.82)
*Ayoung-Chee et al (2014) Long term outcomes of ground level falls in elderly. J Trauma & Acute Care Surgery: 76 (2)

32. Why medications? Multimorbidity NG56 Tailoring care to the needs of individuals

33. Multimorbidity: what matters to you?

34. RightCare scenario: The variation between standard and optimal pathways
Janet’s story: Frailty

35. Questions for GPs & commissioners
In the local population, who has overall responsibility for: 1
Promoting frailty as a condition for which targeted interventions must be planned and delivered? 2
Identifying individuals living with frailty? 3
Planning care models to address key stages of frailty (pre/early, moderate or severe)? 4
Identifying and reporting on measurable positive and negative frailty associated outcomes? 5
Quality assurance and value for money of frailty care? 6
Getting best value for money from the investment by caring agencies re frailty? 7
How do we do the right thing for the patient and at the same time recognise that costs shift from health to social care?

36. Important for Older People Services
Supporting GP and primary care to promote Ageing Well
Acute frailty services
Embedded in urgent care
Peri-surgical
Oncology
Community services:
Intermediate care
Care Homes
Falls risk assessment and prevention
Supportive and palliative care in last years of life
FRAILTY PATHWAY
Healthy aging – supporting people to live well and independently for as long as possible
Risk assessment, diagnosis and registration of people at risk of, or living with, frailty
Proactive care and support – managing multi-morbidity and the trajectory of frailty as a long-term condition. Including supported self-management for people with mild frailty, and co-ordinated, person-centred care for people with multi-morbidity and/or moderate and severe frailty and support for older carers
End of life care – supporting timely, high quality, coordinated and compassionate end of life care
Delivery enablers – supporting an effective and coordinated approach to care for older people across local health economies including, for example, agreeing a standard metrics for quality and outcomes, and considering skills requirements and organisation of multi-disciplinary teams.

37. Collaboration towards End of Life
Frailty Care
*SPC Commissioning Guidance December 2012

38. What we’ve done so far nationally
Healthy aging – supporting people to live well and independently for as long as possible
Risk assessment, diagnosis and registration of people at risk of, or living with, frailty
Proactive care and support – managing multi-morbidity and the trajectory of frailty as a long-term condition. Including supported self-management for people with mild frailty, and co-ordinated, person-centred care for people with multi-morbidity and/or moderate and severe frailty and support for older carers
End of life care – supporting timely, high quality, coordinated and compassionate end of life care
Delivery enablers – supporting an effective and coordinated approach to care for older people across local health economies including, for example, agreeing a standard metrics for quality and outcomes, and considering skills requirements and organisation of multi-disciplinary teams.

39. What we’re doing nationally
Promotion of electronic frailty index and GMS Contract 2017/18
Economic modelling of impact of frailty
Rightcare LTC Commissioning for Value (Frailty and Multimorbidity)
Tailored Care for multi-morbidity and frailty
Community Services: Care homes, Intermediate Care, Falls
Healthy aging – supporting people to live well and independently for as long as possible
Risk assessment, diagnosis and registration of people at risk of, or living with, frailty
Proactive care and support – managing multi-morbidity and the trajectory of frailty as a long-term condition. Including supported self-management for people with mild frailty, and co-ordinated, person-centred care for people with multi-morbidity and/or moderate and severe frailty and support for older carers
End of life care – supporting timely, high quality, coordinated and compassionate end of life care
Delivery enablers – supporting an effective and coordinated approach to care for older people across local health economies including, for example, agreeing a standard metrics for quality and outcomes, and considering skills requirements and organisation of multi-disciplinary teams.

40. Thank you
Any other suggestions for what we can do (related to this work!) then