House of Commons - Health Committee

Commissioning - Health Committee Contents

Supplementary written evidence from Age UK (COM 142)

1. INTRODUCTION

Age UK was pleased to be invited to speak to the Committee on the future of NHS commissioning and be able to describe some of the serious problems that must be addressed to enable the NHS to deliver appropriate, high-quality healthcare services to people in later life.

The NHS clearly faces extreme challenges with; a huge programme of structural reform alongside the unprecedented goal of 4% annual efficiency gains. Given the scale of the productivity savings required and the context in which they will have to achieved, the "Nicolson challenge" set out by the Committee is no small undertaking.

Further to Andrew Harrop's oral evidence to the Committee on 7 December 2010, Age UK would like to take this opportunity to set out what we believe to be the scale of these challenges in relation to the care of older people, and provide more detailed insight into the views of older people regarding proposed NHS reforms. The information regarding older people's views is derived from the results of an omnibus survey asking a range of questions related to the Government's proposals commissioned by Age UK in October 2010.

2. EFFICIENCY AND PRODUCTIVITY CHALLENGE

Demographic change will be one of the single greatest contributors to NHS cost growth over the next five years. The King's Fund report, How cold will it be?: Prospects for NHS funding 2012-17, estimates that demographic pressure alone will drive spending increases of between £1 and £1.4 billion per annum. This demographic pressure partly reflects overall population increases, but it is largely growth in older age groups that will drive increased demand.[63]

The number of people aged 65 and over is expected to rise by 65% in the next 25 years to almost 16.4 million, while the number of people over the age of 85 is predicted to double.[64] The combined effect of an ageing population and increasing life expectancy will bring with it a higher prevalence of people living with multiple long-term conditions, complex co-morbidities, mental health conditions, dementia and increased health need through physical frailty. Overall, it is likely that a greater number of people will be living for longer with chronic illness leading up towards the end of their life.

This is not a new issue, rather the intensification of a long existing trend cast into the spotlight by the current financial climate. Older people already represent the largest patient cohort for the NHS, accounting for over three quarters of all NHS patients[65] and 60% of hospital admissions.[66] It is, therefore, frustrating that the NHS frequently fails to design and commission services that centre on the requirements of those who need and use it most, the elderly and frail. The results of these failures are hidden in plain sight: poorer outcomes for older patients; poor management of long term conditions; substandard care that too often pays scant regard to people's dignity; pressure on acute beds and A&E; increased demands on social care; and above all increased and unnecessary suffering for some of the most vulnerable at a time of need. Yet, seemingly because these problems cannot be ascribed to a specific condition or care pathway they are marginalised, with attitudes towards standards of care and treatment for older people often characterised by apathy and outdated fatalism.

Age UK has identified five key themes for reform which we hope the Committee will reflect in its final report.

Commissioning services appropriate to older people's needs

The NHS continues to under-commission vital community and preventative healthcare used mainly in later life, such as audiology, chiropody, ophthalmology, falls prevention services; and care and support for people with incontinence, depression, osteoporosis and arthritis. The reasons for this are varied but must ultimately point to poor needs assessments and service planning as well as overemphasis on the acute sector. Overall, it points to a failure to focus on the needs and long-term wellbeing of older people. There are also serious gaps and inequalities in service provision, most notably in relation to primary care in care homes where evidence suggests nearly 400,000 older people have difficulty accessing the services of a GP or other primary care professional.[67] These services have a huge impact on keeping people well, in their own homes and avoiding the need for expensive, acute care.

Commissioning for multiple conditions and complex care

Our health services are failing to adequately support people with complex needs—often in late old age, coming towards the end of their lives. With so many older people using services, every health professional can expect to see people with complex, overlapping health problems; acute frailty; and cognitive impairment. However, we organise too much of our healthcare, and train our workforce, on a "condition specific" basis, rather than expecting everyone to be able to adopt a geriatric care perspective, focused on the whole person and not the presenting health need. The findings of the National Confidential Enquiry into Patient Outcomes and Death 2010 provide a clear recent example of systemic problems. A key issue highlighted was the lack of routine input from specialists in geriatric medicine when an older person was admitted into acute care. Lack of experience on the part of many acute clinical teams in dealing with the additional clinical complexities caused by co-mobility, polypharmacy and frailty combined with insufficient input at an appropriate stage from appropriate specialists can reduce the likelihood of a patient being restored to health and discharged home safely.

Promoting integration

In too many places services still operate in silos and fail to offer people a coherent package of support across organisational boundaries; the most obvious example being the lack of integration between social care and the health service. Recent announcements on the tariff for emergency readmission and NHS spending for re-ablement are welcome but address only a part of the problem. Problems also exist in the interaction between primary, community and acute services within the NHS, and between services and individual professionals focused on different health conditions. We need a fundamental change in the patient journey, so that people receive a coherent range of care and support, closer to home, with the support to manage their own health conditions and retain as much control as possible over their own lives. In driving improvement and progressing reforms Government and local commissioners must focus on preserving what good practice does exist and make the most of the opportunity presented to finally embed the culture and organisational relationships required to sustain integration.

Narrowing the gap in treatment outcomes for older people

People in late old age have not fully shared in improved health outcomes with respect to the main "killer" diseases of cancer, heart disease and stroke. Death rates for younger ages now fair well compared to other developed nations, but fall behind in a number of areas for people aged over 75.[68] This indicates a system with in-built age discrimination. Indeed, a recent report commissioned by the Department of Health concluded that "evidence of under-investigation and under-treatment of older people in cancer care, cardiology and stroke is so widespread and strong that, even taking into account confounding factors such as fragility, co-morbidity and polypharmacy, we must conclude that ageist attitudes are having an effect overall impact on investigation and treatment levels".[69] More explicit age discrimination continues in pockets too, most noticeably in access to mental health services. It is clear that commissioners and healthcare professionals need to challenge their own perceptions of older people, abandoning the anachronistic notion that poor health and disease are an inevitable part of old age. We know that more can and should be achieved to treat and delay the onset of disease amongst this age group, yet the NHS has not focused on improving treatment outcomes and quality of life for this cohort. The first draft of the NHS outcomes framework perpetuates this view, by proposing upper age limits to some indicators of clinical outcomes. We are anxious to see these removed in the final version of the framework.

Safety, dignity and improved patient experience

The NHS still does not put dignity and patient experience at the heart of all that it does. People using services and their families still too often feel like an afterthought, with poor communication and lack of involvement in decisions. There are also persistent inadequacies in basic care; falls in care, pressure ulcers, lack of assistance for patients to eat, drink and use the toilet are far too commonplace. Resolving many of these issues should be comparatively simple; solutions are rooted in ensuring adequate resourcing, service planning and staff training. For example, in their recent report Safe Nurse Staffing Levels in the UK, the Royal College of Nursing highlighted the strong correlation between appropriate staffing levels and skill mix on wards and patient outcomes (mortality and adverse events), patient experience, quality of care and efficiency of care delivery.[70] The report also raised questions around the wisdom of higher register nurse to patient ratio on elderly care wards (an average of 11.3:1 compared to 9.1:1 on general adult wards).[71] However, as the report also suggests, too many providers fail to sufficiently get to grips with the problem. Therefore, without a strong steer from commissioners that the patient experience and patient safety really matters, under financial pressure they will always risk being forced down the list of priorities.

Successfully implementing QIPP

The Quality, Improvement and Productivity Programme (QIPP) has identified five workstreams in response to the "Nicolson challenge" designed to drive gains in safe care, long-term conditions, appropriate care, emergency and urgent care, and end-of-life care. Age UK supports the overall thematic approach of the QIPP programme and we are cautiously optimistic about the potential for success, but we would stress that, when set in the context of a growing elderly population, it is clear that improving care for older people will be intrinsic in meeting the scale of those challenges.

To take long-term conditions as an example, prevalence amongst the older population is, as would be expected, significantly higher than amongst other age groups. 39% of people over 65,[72] rising to 67% of people aged over 85,[73] have a limiting long-standing illness. Older people are also at significant risk of suffering from mental health conditions with depression affecting 22% of men and 28% of women over 65.[74] The impact on the NHS, particularly the acute sector, is clear. People over 65 with two or more long-term conditions account for the majority of adult bed days.[75] Older people also account for nearly 150,000 emergency readmissions to hospital each year (a rise of nearly 70% during the past decade).[76] Indeed, the Nuffield Trust have identified improvements in the care of older people in relation to avoidable emergency admissions as one of the "biggest `efficiency frontiers' for the NHS"[77] with scope, therefore, for some of the greatest savings to be made.

When considered in context it is clear that improving care of older patients should be an urgent priority for the QIPP programme. Aside from issues of underperformance in relation to elderly care, financial pressures will ensure that continuing the same patterns of care and service delivery is not a viable option. However, the scale of this challenge means that future NHS improvements and efficiencies will not be achieved through relatively minor adjustments but will require fundamental changes in the way in which services are commissioned and delivered. It will also require the NHS to challenge outdated and unhelpful attitudes towards people in later life. At present it can only be concluded that NHS commissioning is not fit for the major client group it serves. As a result Age UK has called for Government to set a full review of the commissioning and delivery of older people's care as an early priority for the NHS Commissioning Board once it is established.

3. NHS REFORM PROCESS

In October 2010 Age UK commissioned an omnibus survey of over 1,000 people aged 65+ covering a range of questions relating to the Government's proposed NHS reforms. The views raised in response to the survey have been further augmented by a series of in depth listening events with groups of people in later life across England. The themes and trends identified have informed Age UK's overall response to the proposed reforms and our comments to the Select Committee. We, therefore, hope that the Committee will find further analysis useful in providing additional background and depth to the oral evidence provided on 7 December 2010.

Attitudes towards GPs and GP commissioning

People aged over 65 generally have a very positive view of their GP. A large majority (87%) think their GP has a good understanding of their health needs as an older person. A similar proportion (89%) trust their GP to provide them with the best healthcare that is available to them. This confidence in GPs as clinicians, however, does not always translate into wider support for greater involvement in commissioning on two key counts; the survey revealed some ambivalence about how well GPs would champion older people's health services specifically and a strong view that commissioning may not be an appropriate use of GPs time and skill.

A high proportion (79%) have confidence in their GP to make the right decisions on the health and care services in their area. However, views were mixed with respect to services for older people. 34% felt worried that older people's health and care services would get worse if their GP had more control as opposed to 36% who were not.

When asked to rate whose views should be taken into account when making decisions about local health services most older people ranked GPs top, followed by hospital staff and other health professionals. In contrast local people, patient groups and local authorities performed relatively poorly. NHS managers, who are currently responsible for this work, came second from last with most people (25%) ranking national government in bottom place. This is the clearest evidence from our survey that older people support the principles behind the Government's reform agenda.

On the other hand, responses revealed concerns about the practicalities of GP commissioning. Barely half (52%) think that GPs have the skills to take some responsibility for management of the NHS, and 51% are worried about new responsibilities encroaching on the time available for their care. Furthermore, when people were asked specifically about different areas GPs should spend some of their time on, only two in five supported GP involvement in making decisions on how to improve the health of the whole community (38%), and only one in five (22%) thought GPs should spend any time on decision making over NHS funding. Meanwhile, only 9% said their GP should spend any time on commissioning services and managing contracts. What this perhaps tells us is that there is broad appetite for GPs to have more influence on services, but doubt as to whether they should be involved in the detail of decision making, especially if they lack the time or skills.

Localism versus nationalism

The same ambivalence towards GP commissioning is also clear in issues around local variation and national entitlements. The survey found a number of mixed messages around the opportunity to define services at a local level.

At a conceptual level there is general agreement (67%) that flexibility at local level leads to better services. As outlined above, in terms of whose views should be taken into account when deciding about local services, Doctors/GPs are ranked highest and national government lowest. Equally when asked to choose between two statements, 63% of older people endorse: "Local decision makers (such as GPs and local authorities) should decide what services are available in their area rather than a `one size fits all' approach" over the alternative statement which 27% chose: "National government should decide what services are available and make sure they are available to everyone regardless of where they live".

However, on a personal level and thinking about their own lives, older people contradict the above view with 67% choosing the statement: "If I moved, I would expect to have the same health services in my new neighbourhood as I had in my old one" over the alternative statement endorsed by 24%: "If I moved, I would expect to find different local services according to the local needs". So there is fairly broad agreement that local services should reflect local needs, but also an expectation that individuals should receive the advantages of a universal NHS offer.

We also asked about local engagement and influencing of decisions. Although a clear majority (71%) think local people should have a say over what health and care services are funded in their area, only 31% of older people were willing to play a role in decision making themselves. Around half (51%) were not willing to play a role, 30% emphatically so. Increasing age also made it less likely that people would be willing to be involved. Awareness of ways of getting involved with healthcare decision making was low as well. Some 68% have never heard of Patient Participation Groups, Local Involvement Networks, or any other public involvement groups. There was some social class variation with socio-economic groups A and B generally having greater awareness (34% had heard of Patient Participation Groups compared to 20% across all groups). We believe this highlights an important issue for Government in advancing their proposed reforms given that they rely heavily on local engagement. Steps must always be taken to appropriately and proactively seek the views of all parts of the community, in particular those individuals who may be socially isolated and excluded, as for example the very elderly and frail.

Choice and competition

A majority of older people are wary of increased competition between health services—61% disagree that health services should have to compete for patients and 57% think standards of care would decline if health services had to compete. This position was supported by views and concerns expressed by older people during our listening events. Although many of the event participants valued choice in when, where and how they received treatment as an individual patient, there was a strong view that expecting patients to "vote with their feet" was not an acceptable mechanism for improving quality. In particular, participants in rural areas felt those unable or unwilling to travel further would find themselves stuck with "second rate services".

More positively, the majority of older people think they would find it easy to exercise choice between different providers.

When asked to rank the most important considerations for them if they need to choose a health services, 50% rated how quickly they could get treatment as most important. This was closely followed by how close it was to home (29%) and reputation or performance standards (23%). Friendliness of staff was not seen as very important with only 6% of respondents rating this top of their list. These trends provide interesting insight into how older patients may respond to greater choice of health providers and influence market mechanisms. A number of examples offered in the choice and competition consultation are predicated on individuals waiting longer to get the most appropriate care which may not prove to be the case.

January 2011

63 p16, How cold will it be?: Prospects for NHS Funding 2012-17: J Appleby, R Crawford, C Emmerson (2009) Back

64 National population projections, 2008-based, Office for National Statistics (2009) Back

65 Based on Health Development Agency Annual Report 2005 Back

66 "Acopia" and "social admission" are not diagnoses: why older people deserve better: D Oliver, J R Soc Med 2008: 101: 168-174 Back

67 p20, Ageism and Age Discrimination in Primary and Community Healthcare in the UK: A Clark, Centre for Policy on Ageing (2009) Back

68 pp36-53, Ageism and Age Discrimination in Secondary Care in the UK: N Lievesley, Centre for Policy on Ageing (2009) Back

69 p59, ibid Back

70 p19, Guidance on Safe Nurse Staffing Levels in the UK: Royal College of Nursing Policy Unit (2010) Back

71 p22, ibid Back

72 The estimate is for the UK, based on Great Britain data from the General Lifestyle Survey 2008, Office for National Statistics (2010) Back

73 Family Resources Survey 2007/8, Department for Work and Pensions (2009) Back