1. Ageing Well
Positioning digital technologies within healthcare policies to meet the needs of an ageing society
Martin Vernon
NCD Older People
29th March 2017

2. ‘Its not how old we are, but how we are old’

3. UK Ageing Population Emphasis the very old increase
Evidence from the 10 BBC charts:-
Medical advances mean that people are living longer
Life expectancy in 1948 (when the NHS was created), was 13 years shorter than now
This has come at a cost, significant increases in people living with an LTC (diabetes, heart disease, dementia, etc)
What older people need now is more CARE than CURE – patients need support
Average 65 year old costs the NHS 2.5 times more than the average 30 year old. At age 85, this is 5 times as much!
At the same time, increases in NHS spending has slowed
Institute for Fiscal Studies – over the 10 years to 2020, the NHS budget will not have increased enough to keep pace with the growing ageing population
UK compares unfavourably on health spending against other OECD countries with less than 10% of GDP spent on health – fewer beds and fewer staff in the UK than other OECD countries ((Sweden, France and Germany)
Source: Office for National Statistics, National Records of Scotland, Northern Ireland Statistics and Research Agency

4. Projected UK age structure
Foresight, 2016

5. Ageing population
Older population expansion in England will accelerate next 20 years
Over 65s will  from 17% (2010) to 23% by 2035
England in 2014: 9.5 million aged 65+; 471K aged 90+
By 2035 there will be 14.5 million 65+ and 1.1 million 90+

6. Ageing 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. Acute bed numbers
8% reduction in general and acute beds since 2010: NHSB 2017

8. 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%)

9. Health and unpaid care
Over 65s report poorer health and provide a growing amount of unpaid care
73% people >65 with disability receive care from a family member
‘Verticalised’ families: more generations are alive simultaneously
2007 to 2032 people >65 who require unpaid care is projected to have grown by >1 million
For people >70 the primary challenge will be maintaining physical connectivity
2011 Census & Foresight Report 2016

10. Health and unpaid care
Over 65s report poorer health and provide a growing amount of unpaid care
73% people >65 with disability receive care from a family member
‘Verticalised’ families: more generations are alive simultaneously
2007 to 2032 people >65 who require unpaid care is projected to have grown by >1 million
For people >70 the primary challenge will be maintaining physical connectivity
2011 Census & Foresight Report 2016

11. Health and unpaid care
Over 65s report poorer health and provide a growing amount of unpaid care
73% people >65 with disability receive care from a family member
‘Verticalised’ families: more generations are alive simultaneously
2007 to 2032 people >65 who require unpaid care is projected to have grown by >1 million
For people >70 the primary challenge will be maintaining physical connectivity
2011 Census & Foresight Report 2016

12. Health and unpaid care
Over 65s report poorer health and provide a growing amount of unpaid care
73% people >65 with disability receive care from a family member
‘Verticalised’ families: more generations are alive simultaneously
2007 to 2032 people >65 who require unpaid care is projected to have grown by >1 million
For people >70 the primary challenge will be maintaining physical connectivity
2011 Census & Foresight Report 2016

13. Health and unpaid care
Over 65s report poorer health and provide a growing amount of unpaid care
73% people >65 with disability receive care from a family member
‘Verticalised’ families: more generations are alive simultaneously
2007 to 2032 people >65 who require unpaid care is projected to have grown by >1 million
For people >70 the primary challenge will be maintaining physical connectivity
2011 Census & Foresight Report 2016

14. Ageing population: key outcomes
Foresight, 2016

15. Ageing population: key outcomes
KEEP THESE PEOPLE HEALTHY AND WORKING
Foresight, 2016

16. Ageing population: key outcomes
KEEP THESE PEOPLE AGEING WELL
KEEP THESE PEOPLE HEALTHY AND WORKING
Foresight, 2016

17. Policy: increase disability free life expectancy
We are here
We are here

18. Policy: increase disability free life expectancy
We want to be here

19. NEEDS, PREFERENCES, CHOICES
Age Well
PREVENTION
TAILORED CARE
SUPPORTIVE CARE
LIVE WELL
AGE WELL
DIE WELL
NEEDS, PREFERENCES, CHOICES

20. 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

21. 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

22. Burden vs benefits of technology
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.

23. Typology of digital health*
Telemedicine and telehealth: consultation, diagnosis and healthcare delivery remotely
Digital support tools: diagnostic, genomic, risk-assessment and decision-making technologies
Digitised devices: delivering medicine, regulating/enhancing bodily functions
Health informatics: electronic patient records and other online health information, triage, appointments
Digital health promotion: health education messages disseminated via digital technologies
Biometric tracking, patient self-care and monitoring devices: smartphones, smart objects, wearable
Dedicated platforms for information exchange : blogs, forums, enrolment, crowd funding
Digital epidemiology: tracking disease outbreak and spread
Sensor-based environmental monitoring
Digital health games: health promotion and health education
Its all important!
Sociology Compass 8/12 (2014): 1344–1359, /soc

24. Of key importance
Ways of keeping people connected (socially, to health care)
Ways of activating people to manage their conditions
Identification of people at risk (of unwarranted outcomes)
Outcomes measurement to drive improvement & assure value
Efficient & effective recording & sharing information

25. Connectedness?
Use of the Internet by seniors as a communication technology
Online questionnaire to survey 222 Australians over 55 years of age*
Internet primarily used for communication, seeking information, and e-commerce
Negative correlation between loneliness and well-being.
Greater use of Internet as a communication tool associated with lower social loneliness
Greater use of Internet to find new people associated with greater emotional loneliness
Its important not to make assumptions about what people want
*Sum S et al. CyberPsychology & Behavior. April 2008, Vol. 11, No. 2:

26. NHS Digital Key Priorities: Interoperability
NHS Number: 97% localities using NHS No as primary identifier when sharing information
Transfers of Care: 66% Of localities sharing discharge summaries electronically
Directly working with localities & clinicians on needs & solutions – the “Community”
Not as national organisations in an ivory tower
Focus on opening up building blocks
Open structured APIs* for key clinical priorities based upon industry standards
Supporting localities to be more “informed customer”
implementing information sharing approaches, demonstrating this in reality
*Application Programming Interface

27. What are localities saying?
Locally, we need:
Simplified access to national services
Access structured GP records
Alerts and flags
Condition-specific views
Appointment booking
Clarity eg IG, Standards
Levers / Incentives
Alignment with STPs
Directory
Care Planning and Case Management
Integrated access,
Integrated workflows
Pathway support
- End of life,
- Cancer
GP Feds/
Clinical Hubs
What good looks like
Benefits
National Roadmap

28. Digital Interoperability Platform
Example: GP Connect
“Providers”
Federation admin
centre GP
Principal System GP
Principal System
Book appointment GP
Principal System
Shared Record Initiative
Send task
Digital Interoperability Platform GP
Principal System
Social Care System
View record
Trust System GP
Principal System
“Consumers”

29. Where is frailty in all this?
Identifying people at risk

30. Unpredictable recovery
What is 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

31. 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:

32. 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

33. CARE & SUPPORT PLANNING
Frailty through a different lens?
Economic, social, emotional, cognitive resilience
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

34. 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

35. Person Centred Care

36. Prevention..upstream

37. Address frailty systematically
Prevention up stream in the life course:
Effective management of LTCs
Healthy ageing
Delay onset of, or attenuate, pre or mild frailty
Manage optimally to attenuate, where feasible, the effects of:
Pre/mild Frailty
Multi-morbidity
Disability
Manage optimally to achieve best care for people living (& dying) with:
Moderate and severe frailty
Irremediable medical conditions

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

39. 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

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

41. Electronic Frailty Index (eFI)
Depression?
Clegg et al: Age Ageing2016: 45:

42. 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

43. Survival plots (n=227,648; >65y) (Clegg et al)
Population Risk Stratification Primary care electronic Frailty Index (eFI)
Survival plots (n=227,648; >65y) (Clegg et al)

44. 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

45. 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
Data will not be used for performance management purposes

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

47. The RightCare approach

48. Rightcarehttps://

49. Janet’s story
Her experience of a frailty care pathway, & how it could be so much better
Scenario examines a frailty care pathway, comparing a sub-optimal but typical scenario against an ideal pathway 1 2
At each stage we have modelled the costs of care, both financial to the commissioner, and also the impact on the person and their family’s outcomes and experience. 4 3
It shows how the RightCare methodology can help clinicians and commissioners improve the value and outcomes of the care pathway.
Document is intended to help commissioners and providers to understand the implications – both in terms of quality of life and costs – of shifting the care pathway

50. Janet and the standard pathway
No prevention
Pillar to post
Too late
Reactive
No education
No third sector
Damage done
Too much reliance on acute care
Traditional treatment
Many wards
Too much time
in bed
No risk profiling and identification
Inappropriate acute care
Insufficient home care support

51. 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?

52. Janet and the optimal pathway
Prevention Focus
Prevention focus
Fast
Appropriate
Bespoke treatment
Little time in bed
Greater understanding of need
Support mechanisms in place
Trusted system
Happier and healthier experience
Proactive
Education
Third sector
Risk profiling and identification
Great acute care
Great home care support

53. What we’re doing GP GMS Contract implementation
Promotion of electronic frailty index and additional information within summary care record
Economic modelling of impact of frailty
Care homes commissioning guidance
NICE multi-morbidity clinical guideline (and QS)
Serious illness care programme
Rightcare LTC Commissioning for Value
Age Well and Healthy Ageing
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.

54. Frailty Prevention

55. Frailty prevention: digital opportunity?
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)

56. What next…?

57. Where we’re heading ‘Best value health care for all’
What do we mean by Value?
Return on investment for the taxpayer
Experience and outcomes of care for people
What do we mean by All?
Multi-morbidity
Disability
Frailty
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.

58. Key areas for development (1)
Prevention
Delayed onset of MM, disability and frailty
Attenuation of progression
To prevent unwarranted outcomes at key stages
Care delivery
To maintain functional ability
To achieve ROI

59. Key areas for development (2)
Understanding the nature and scale of the problem
Identification of populations and needs
Trajectories
Monitoring and tracking: use of data
Outcomes
Process
Person centred
Delivery
Optimal interventions (how, where, when to achieve outcomes)
Optimal systems and mechanisms of delivery
Use of technology

60. Key areas for development (3)
Workforce development
Education and training
Skills development and maintenance
Resilience and diversification
Patients and carers
Self care and management
Education, learning and understanding
Activation
Occupation
Communication
Public: traditional and social media
Workforce
Environment
The built environment: housing, roads, infrastructure
Technologies

61. Final thoughts The ageing population is everyone’s business
Frailty and multi-morbidity are here to stay
Technology has a place in frailty care but will not replace judgment
Collect information once, use it many times (with permission)
Good data can drive quality improvement
Align care systems around patients: frailty as a diagnostic currency
Choose technology wisely and demonstrate a return on investment
Focus on the things most likely to benefit at scale
Technology evolves quickly: people don’t!

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