Professor John Young is a geriatrician and National Clinical Director for the Frail Elderly and Integration, NHS England.
It’s widely recognised that our health and care system is poorly configured and organised to deliver acceptable care to its majority user, older people. Older people are not a category separate from their fellow citizens. They equally value good health, wellbeing and independence. But increasing age brings the twin threats of multiple long-term conditions – the majority of people over 70 have two or more chronic conditions – along with a greater risk of frailty, which affects one in ten people over 65 and up to half of people aged over 80. Our health and care system is undergoing fundamental changes to address these issues.
Patient groups have come together under an umbrella organisation called National Voices. They have made clear arguments for a more joined-up, integrated system – these views are now embedded at the heart of new delivery expectations for health and social care. This approach is especially important for older people who are particularly susceptible to the effects of multiple assessments, system delays or the simple abandonment that are the characteristics of poorly integrated services.
What does this mean for current and future doctors?
First, it implies that all doctors who have daily contact with older patients – all GPs, and most physicians and surgeons – need to acquire the knowledge and skills appropriate for safe and competent care of older people with comorbidities and frailty. These will include effective communication styles that are sensitive to the particular circumstances of individuals, communication that promotes genuine involvement of people living with complex problems.
To be effective in stimulating these better quality conversations, doctors will need to be more skilful in recognising comorbidity health states, and in recognising frailty. Not to do so will lead patients into making poor decisions, and potentially expose them to risks of harm, for example polypharmacy or inappropriate chemotherapy or surgery. Doctors will need to avoid the trap of compartmentalising physical and mental health. This means that they need to acknowledge that people with multiple comorbidities often have a dynamic interaction between physical and mental health issues.
Care and support planning – working better together
Second, there will be greater emphasis on joined-up working between primary, community and secondary care. Cross-sector team working and an emphasis on shared records, that include ownership by the patient, will become the norm. Doctors will find themselves working in much larger and multi-agency teams. This new way of working, consistent with the complexities of older people with multiple long-term conditions and frailty, will be encapsulated in the Coalition for Collaborative Care‘s care and support process.
Work to introduce this process across the UK’s health and care system has already begun. Although an up-to-date understanding of evidence-based medicine will always be the foundation for competent practice, the care and support planning process will increasingly become the delivery mechanism for this evidence. This will happen as competing choices and decisions are more fully explored and tailored to the context and needs of an individual who will be a fully informed partner in this process, rather than a passive recipient of advice and care.
Realistic care design
The current health and care system can be aptly summarised as a system of care largely designed for people who have only one thing wrong at once, but which is chiefly used by people who have many things wrong at once.
Doctors must play their part in the redesign of a health and care system that is identified by the skilful, compassionate and joined-up care required by people who have several things wrong at once, that is older people with comorbidities and frailty. The GMC has guidance, resources and signposts to help doctors deal with issues related to the care of older people. Find more at Better care for older people.