That is one of the questions posed by Time to Think Differently, which, refreshingly, dwells less on how many of those people there might be and more on how their health and needs might be different and more complex than we have been used to. Technically we certainly can do more, but we have all changed our expectations, failure has been made more public, and the current building blocks of our systems of care are creaking.
So, time to think differently? Let’s start by challenging some assumptions in the new orthodoxy!
Assumption one: primary care can be sufficiently flexible both to take on the community-based care of greater numbers of frail older people and to undertake minor surgery on a sufficiently industrial scale to actually make a difference. Moving care into the community does not equate to moving the skill set into primary care. Few GPs have developed a special interest in older people, and the pioneers of GP-run intermediate care have retired.
Assumption two: ambulatory care-sensitive conditions in older people with multi-morbidity are best (ie, more safely and efficiently) managed outside acute hospitals. But what are the appropriate skills, numbers and availability of staff to make this true? At what scale does this begin to look like bespoke mini-acute wards without the plurality of responsiveness that hospitals can offer? What are the opportunity costs in the context of human resource capacity?
Assumption three: significant numbers of new clinical service providers enable innovation to emerge without disrupting better integration of provision. Most new providers focus on well-defined and predictable clinical interventions, such as a discrete episode of surgery in otherwise well people. But for frail older people with a number of health issues, separating out treatment for different conditions in a piecemeal way is counter-productive to overall efficiency.
Assumption four: pro-active preventive services are better than the traditional responsive NHS services. But there is evidence, eg, from falls prevention clinical trials in UK, that community-based approaches initiated in primary care are significantly less effective than integrated and reasonably expert responses to emergencies – eg, initiated by A&E staff or ambulance services. Why? Maybe those who present themselves as emergencies are subtly different from those who don’t, in a way that increases potential for benefit. Or maybe they are more risk averse, which encourages them to take up and adhere to interventions? We know that acute–community integration can be done, because the Kaiser Permanente health group did it in the United States – but how? Did they do so by preventing acute relapses through secondary prevention or by responding to them more quickly, better, differently?
Assumption five: NICE guidance will help the management of people with multiple long-term conditions. Well, it might, given time. But how helpful can this approach be for the typical patient who presents to acute or intermediate care, eg, an 82-year-old woman, living alone, with hypertension, mild dementia, non-insulin-dependent diabetes, two falls in the past year, uncomfortable ankle swelling? We can start by borrowing evidence from research populations – generally not like our patient – about the relative risk reduction associated with condition-specific treatments. Then we extrapolate those reductions over the estimated life expectancy (large margin of error here). We then turn to the burdens of the treatments (monitoring, hassle, side effects, etc). And so to the magic moment: establishing the patient’s preference in the light of all this uncertainty. Simple? No wonder a wise GP is offloading this to the nurse or pharmacist!
So I think we need to think through the nature of this complex work, and clarify the respective roles of specialists and generalists. Both need to work differently to a common purpose, sharing responsibilities for outcomes. The prospect of developing this while negotiating with a plethora of small-scale providers and new entrants to the market is a little daunting. Back to Kaiser Permanente: how much integration can you achieve without limiting autonomy and imposing collective responsibility for clinical governance on all providers?
Finbarr is a Consultant Geriatrician at Guy's and St Thomas' NHS Foundation Trust and Professor of Medical Gerontology at King's College London. He is also former President of the British Geriatrics Society.