Nice one NICE: developing the policy narrative on preventing disability, frailty and dementia in later life

As we commemorate the 100th anniversary of the outbreak of the First World War, it is easy to forget that in 1914, UK life expectancy at birth was only 49 for men and 53 for women. Advances in societal wealth, nutrition, employment, environmental health, housing, perinatal care and preventative and curative medical treatment mean that the era in which those servicemen and their families lived is almost unrecognisable. Life-expectancy is now 79 for men and 83 for women, and when we reach the age of 65 we can expect to live another two decades on average.

Living longer lives is a cause for celebration but there are still major inequalities in life expectancy and healthy life expectancy at birth, in rates of premature deaths, and in life expectancy at 65 between different socioeconomic groups. We also face a rising prevalence of long-term conditions, dementia, disability and frailty related to rapid population ageing, which has big implications both for individuals and for health and social care systems.

The holy grail of prevention would be to reduce inequalities in the health of older people, to improve their overall health and to ‘compress morbidity’, delaying the onset of poor health until the last few years of life. The King’s Fund has contributed to this debate with its work on adult behaviour change and improving care for older people, and its Time To Think Differently programme of work. But now, somewhat surprisingly, the National Institute for Health and Care Excellence (NICE) has added its voice, in the guise of guidelines released for consultation on preventing disability, frailty and dementia in later life. 

‘So what?’ you cry, yet another bunch of stuff to wade through. But this time it’s different – what is so interesting about these guidelines is not so much the detail but the principles and linking themes behind them, and the fact that, instead of just advising clinicians, the guidelines include direct advice to the government on health and wider social policy.

So what’s in it? For starters, NICE calls for government interventions to make smoking and drinking less affordable and accessible; and to make the maintenance of healthy weight and regular exercise more affordable and accessible. Hardwiring these recommendations on affordability into local and national public health strategies is a challenge to those, of any party, who do not see price as a policy lever on behaviours other than tobacco use. Given that Public Health England also supports minimum unit pricing of alcohol, two important government health bodies have now put their cards on the table.

But beyond this, in these guidelines NICE has developed a policy narrative for integration and prevention that is more convincing than much of what the political parties have thus far committed to print. NICE’s vision encompasses the NHS and local government but goes beyond that to house-builders and architects, businesses and employers, as well as individuals themselves. It starts to flesh out a story that – at last – links the policies and roles for public health and prevention with those for long-term conditions, co-morbidities and integration. These areas have been left to develop in their silos for too long, partly, but not solely, due to the fragmentation of the reforms. Integration cannot just be about treating frail older people, we need to think beyond health and social care, and NICE is leading the way with this thoughtful contribution.

So will any of this be taken on board? Watch this space. But our view is that the consultation is not just for clinicians and academics, it is something that politicians and those seeking to influence them really should engage with too. If you have time do read the guidelines and respond.

This blog was co-authored by David Buck, Senior Fellow in Public Health and Inequalities at The King's Fund.

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Comments

#42394 June Andrews
Professor
Dementia Services Development Centre

Recent audit of Nice dementia guidline in Northern Ireland (which has the best record for diagnosis in all of the UK, leaving England far behind) by the RQIA, their regulator, shows roughly that most clinicians do as well as the guideline but most front line staff are unaware of it/don't read it/don't follow it/other. Is it time we checked whether the effort put into guidelines is the best thing we can do with our time? The clinicians who don't have time to take part in consultations or bother to read the result might agree! Even if hospital systems make them sign to say they've had the NICE stuff given to them.

#42405 Geoffrey Cox MS...
MD
Southern Healthcare

More new guidelines? - the NICE guidelines are welcome of course, and the hope is these will be politically popular, astute and considered essential by our political leaders. They need to embrace them now, act decisively and develop robust strategies to prevent disability, dementia and frailty wherever possible.

But what about the political will? This has been far from decisive, and the fear is one of continued dithering. Political vision is not just weak, but more geared to electoral cycles than to complex long term challenges and more prone to looking backwards and blaming others than looking forward and taking on these challenges.

For example, in terms of challenging smoking, reducing alcohol intake and tackling unhealthy packaged food contents, successive governments have been less than decisive, despite the clear and well publicised correlation between poor consumption and poor health.

So where are now? We need to be crystal clear that the rising prevalence of long-term conditions, dementia, disability and frailty related to rapid population ageing, does not merely ‘carry big implications for the future’, as these are significant challenges upon us already, as a result of which we are falling increasingly behind all reasonable expectation, and as the austerity drive trumps progress. The reality is that our health and social care systems are not coping now, and thus as a society we are failing larger and larger numbers of people ongoingly.

Prof Andrews makes a powerful point in highlighting how far behind we are in England compared to Northern Ireland in terms of dementia diagnosis rates. One can add other key comparisons between the two regions such as post dementia diagnosis support which is also more challenged, and, should hospitalisation be necessary, staffing levels, which are seriously challenged too.

We might have learnt from Mid Staffs by 2009 after 1,200 people died avoidably, that short staffing our hospitals has been disastrous, yet we are still dithering over staffing levels in England across the board in 2014, whether that is in hospitals, Care Homes or even the inadequate time allowed for home care visits. In Northern Ireland minimum staffing levels were set in 2009. We seem reluctant to learn.

#42408 Carol Munt
Patient Partner & Advocate
Voluntary

Thank you, David, for putting your views across in a way that can be understood by the general public. I don't have to resort to my NHS speak dictionary.

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