As usual, many people will have ignored the blizzard of pleas, posters and tweets promoting the virtues of self-care and urging us to visit A&E only for serious illness and emergencies. The pressures on emergency and urgent care are real enough, but they are just the tip of a much bigger iceberg.
Beyond the frantic portal of A&E, most acute beds will be occupied by older people, many of whom end up in hospital not because it's the right place for their needs, but because it's the only place they have in the absence of family and community support or alternative clinical options. And as our latest data briefing shows, once admitted, they are likely to stay in hospital for much longer than may be clinically necessary, at substantial cost in human and financial terms: while only 10 per cent of patients admitted as emergencies stay for longer than two weeks, they account for 55 per cent of overall bed days – and 80 per cent of them are patients over 65.
The hospital environment is not a good for one for frail older people – it exposes them to the risk of hospital-acquired infection, depression and loss of functional independence. It can be immensely frustrating and distressing for patients and relatives, and it isn't easy for staff either. The first National Audit of Dementia has exposed the poor treatment of people with dementia admitted to hospital for the treatment of physical illnesses as a result of under-trained staff and the high use of anti-psychotic medication. The keys to delivering the right care for frail older people in the right place at the right time are: keeping people out of hospital unless they have a clinical need that can only be met in that setting; a care environment that combines effective treatment with sensitive and dignified care; and timely, well-planned discharge.
These principles are not just for Christmas, when ties of affection or duty may colour our attitudes to older family members. For many, spending Christmas with family is but a temporary sojourn from year-round isolation. Over a third of men over 75 live alone – and nearly two-thirds of women. Demographic changes are likely to increase levels of social isolation and depression. Squeezed social care budgets will accelerate the trend for fewer people to receive social support to remain at home, with most councils responding only to the highest needs. It will also be harder for councils to invest in preventive services that help people to stay healthy and avoid the need for hospitals or care homes. In these circumstances it doesn't need much of a social or clinical crisis to precipitate the trip to A&E and another emergency hospital admission. The Nicholson challenge just became a bit more challenging.
So as the pressures and pleasures of Christmas recede and we begin a new year, the prospects for older people – in hospital and at home – are uncertain. As the late dictator Enva Hoxha declared in his New Year's address to the Albanian people in 1967, 'this year will be harder than last year... it will however be easier than next year.'