Old Age Concerns: BGS Scotland Manifesto
The next 20 years will see an ageing population, a continuing shift in the pattern of disease towards long-term conditions, and growing numbers of older people with multiple conditions and complex needs, and the impact of this on them and their immediate carers. There will be more older family carers — many of whom will have their own health needs. These demographic changes and associated shifts in the pattern of ill-health will increase the demands on the whole healthcare system.[i]
The healthcare quality strategy for NHS Scotland [ii]
The British Geriatrics Society (BGS) is a multi-disciplinary professional membership association that promotes better health and care for older people. Its membership includes the vast majority of specialist health professionals who shape and delivery healthcare to older people in Scotland.
This manifesto sets out BGS Scotland’skey priorities for the 2011 election to the Scottish Parliament. By identifying what BGS Scotland and its members believe are the priorities for health, we hope political parties and individual candidates will enter the 2011 elections armed with information on how to improve the quality and delivery of health and care services for older people across Scotland.
Context: Ageing Scotland
There are slightly more than a million people aged 65 and over in Scotland.[iii] They make up just under a fifth of the Scottish population.[iv] This population is projected to grow by 62% by 2031. The number of people aged 85 and over will rise by a projected 144% by 2031.[v]
As the population ages, so does the prevalence of illness and disability. Of the population aged over 65, 40% aged 65—74 have an illness or disability; this rises to 55% for people aged 75—84 and to 67% for people aged 85 and over.[vi] Two in five people in Scotland live with a long-term condition.[vii] Many of these are older people. Expenditure on healthcare for older people in Scotland is expected to rise from the current spend of about £4.5 billion to £7.5 billion by 2031.[viii]
The NHS is facing unprecedented financial challenges at a time of increasing demand. Rising to meet this challenge will be complex and difficult. But looking after older people well is cheaper than looking after them badly.
Principles of care
The BGS believes that to treat and care for people effectively, respect their dignity and treat them as equal citizens, the NHS must structure and deliver healthcare on the following principles.
The BGS believes that care should:
- promote independence, and allow older people to live the lives they choose and be fully involved in their care and treatment plans, including at the end of life;
- be holistic and person centred;
- be evidence-based and focused on outcomes, not outputs;
- be based on a full and complete assessment and diagnosis;
- be compassionate and caring;
- be based on need, not age, and promote fair and equal treatment for older people;
- be multidisciplinary, regardless of setting, and integrate the services of health, social and community care professionals to provide a seamless service.
Priorities for action
These principles must be addressed through action on the following policy priorities:
- Building a health and social care workforce to meet the needs of an ageing population. If current patterns of care continue, there could be an additional 23,000 older people requiring care by 2016 and an additional 83,000 by 2031 – almost double the number of older people receiving formal care services today.[ix] However, a recent census by BGS Scotland found that 10% of the 146 consultant geriatrician posts in Scotland were vacant and that between 28 (20%) and 38 (25%) could become vacant through retirement and existing vacancies in the near future.[x] Geriatricians are one of the key clinical groups that will help improve the health of Scotland’s ageing population. These posts need to be filled; and future workforce planning should reflect the increased demands of an ageing population in Scotland.
- Improving medical support for care homes and their residents. There are around 33,000 residents in around 1,000 care homes in Scotland.[xi] Care home residents can be highly vulnerable to illness and disability, often requiring constant medical support. Around 70% of residents have dementia;[xii] around 40% of residents fall twice or more in a year;[xiii] and more than 10% are malnourished.[xiv] The BGS wants to see the recommendations of the 2008 report Frailty, older people and care homes: can we do better?, co-authored by the BGS and the Royal College of General Practitioners Scotland, implemented .[xv] This report observed that training for care home staff is often inadequate; GPs do not routinely provide proactive support; and prescribing practice is sub-optimal.[xvi] The report recommended that all residents undergo a full comprehensive geriatric assessment on admission to a care home and that they receive full multidisciplinary medical support from primary and secondary care staff.[xvii]
- Tackling age discrimination and prejudice against older people. In 1969, US doctor Robert Butler introduced the term ‘ageism’, defined as ‘a process of systematic stereotyping, prejudicial attitudes and direct or indirect discrimination against people because they are old’.[xviii] A 2009 British Geriatrics Society survey of 200 doctors found that more than half would be worried about how the NHS would treat them in old age. Almost 75% said older people were less likely to be referred for essential treatments.[xix] While the Equalities Act in 2012 will make discrimination on the grounds of age illegal, we need to change attitudes and culture as well.
- Ensuring every older person gets a comprehensive geriatric assessment (CGA). The CGA is a multidimensional interdisciplinary diagnostic process focused on determining a frail older person’s medical, psychological and functional capability in order to develop a coordinated an integrated plan for treatment and long-term follow-up.[xx] Research has shown that CGA reduces the length of stays in hospital, mortality, and the need for institutional care. Older people who undergo a CGA are more likely to return home.[xxi] The BGS recommends that a CGA is carried out for every older person admitted to a care home.[xxii]
- Working together to tackle key conditions and areas of care that adversely affect older people.
The evidence of poor nutrition at home can be seen in the fact that as many as 40% of older people admitted to hospital have malnutrition on arrival. As a result of this and problems with hospital nutrition, some 60% of older hospital patients are at risk of becoming malnourished, or becoming more malnourished, during their hospital stay.[xxiii] A study from Glasgow Royal Infirmary showed that in 2000 malnutrition in acute hospital admissions went unrecognised and unmanaged in 70% of cases.[xxiv]
Hospital acquired infection
The recent reported deaths at the Vale of Leven[xxv] and Ninewells hospitals[xxvi] have been attributed to C.difficile infection. People aged 65 and over are particularly vulnerable to hospital-acquired infections, with four out of five cases being reported in this age group.[xxvii]
A third of women and one in seven men aged 65 and over suffer from incontinence.[xxviii] That translates into just under 172,000 Scots.[xxix] Modern medicine can often effectively diagnose, treat and manage the condition. It is of concern that millions of older people are suffering from an undiagnosed and untreated but often avoidable condition that causes distress, suffering and humiliation.
In 2010, approximately 71,000 people had dementia in Scotland. [xxx] Around 97% of these were aged 65 and over.[xxxi] The number of people with dementia is expected to rise to 127,000 by 2031.[xxxii] At present only around half of people with dementia are currently recorded on primary care registers in Scotland.[xxxiii] A recent Glasgow survey showed that 89% of people in care homes had cognitive impairment, but that only half had been given a formal diagnosis and none was taking cholinesterase inhibitors.[xxxiv]
End of life medicine
The Scottish Care Commission found that 43% of care homes for adults and older people did not always recognise or support residents’ palliative care needs.[xxxv] The commission also found that 36% of care homes had not assessed their services to ensure they recognised and met residents’ palliative care needs. The majority (54%) of services had not trained staff to deal with the sensitive issues surrounding death and dying, such as how to cope with the emotional effects of living with a life-limiting illness. Many care home staff told us how inadequate they felt when discussing sensitive issues about death and dying with residents. Only 44% of care homes have policies in place to guide staff on when and how to contact members of the primary healthcare team, such as district nurses, GPs or specialist palliative care services, such as Macmillan nurses.[xxxvi]
About the BGS
The British Geriatrics Society (BGS) was founded in 1947 for “the relief of suffering and distress amongst the aged and infirm by the improvement of standards of medical care for such persons, the holding of meetings and the publication and distribution of the results of research”. It has branches throughout the UK. The BGS has more than 2,500 members, including doctors practicing geriatric medicine, old age psychiatrists, GPs, nurses, therapists and scientists. For more information on the BGS visit www.bgs.org.uk or contact Tom Thorpe MCIPR, Press, PR & Parliamentary Affairs Officer on 07779 269 182 or firstname.lastname@example.org
[i] The Scottish Government, The healthcare quality strategy for NHS Scotland, May 2010, 18.
[iii] There are 5.1million people in Scotland and 1 million aged 65 and over. Compiled from National Office of Statistics, mid-year estimates, 2009.
[iv] There are 5.1 million people in Scotland and 1 million aged 65 and over. Ibid.
[v] The Scottish Government, Caring together: the carers strategy for Scotland 2010–2015, July 2010, 22.
[vi] ‘NHS age discrimination ”common”’, BBC News, 27 January 2009, http://news.bbc.co.uk/1/hi/health/7850881.stm
[vii] Long Term Conditions Alliance Scotland manifesto. http://www.ltcas.org.uk/policy_manifesto.html
[viii] ‘Elderly care is ”big challenge”’, BBC News, 24 March 2010. http://news.bbc.co.uk/1/hi/scotland/8585451.stm
[ix] Age Concern and Help the Aged, Scottish government debate: reshaping the future care of older people, Wednesday 28 October 2009, 2.
[x] BGS Scotland, Consultant manpower survey, February 2008.
[xi] The Scottish Government, Scottish care home census, 2003—2007.
[xii] Remember, I’m still me: Care Commission and Mental Welfare Commission joint report on the quality of care for people with dementia living in care homes in Scotland, 2009, 10.
[xiii] ‘Key questions – falls’, Pulse, 2 February 2010.
[xiv] M Elia and R Stratton, ‘Geographical inequalities in nutrient status and risk of malnutrition among English people aged 65y and older’, Nutr 2005: 21,1100–1106.
[xv] BGS and Royal College of GPs Scotland, Frailty, older people and care homes: can we do better?
[xvi] ibid, 4.
[xvii] ibid, 5.
[xviii] Centre for Policy on Ageing, Ageism and age discrimination in primary and community healthcare in the United Kingdom: a review from the literature, 2009, 9.
[xix] ‘NHS age discrimination ”common”’.
[xx] BGS, Comprehensive assessment for the older frail patient in hospital, June 2005, 1. www.bgs.org.uk
[xxi] V Ellis and P Langhorne, ‘Comprehensive geriatric assessment for older hospital patients’, Br Med Bull, 2005: 71, 45–59 and W Wieland and V Hirth, ‘Comprehensive geriatric assessment’ , Cancer Control, Nov—Dec 2003: 10(6), 454–62.
[xxii] Frailty, Older People and Care Homes, 5.
[xxiii] European Nutrition for Health Alliance, ‘Malnutrition within an ageing population: a call to action’, quoted in Age Concern and Help the Aged, Scottish government debate.
[xxiv] IE Kelly, S Tessier, A Cahill et al, ‘Still hungry in hospital: identifying malnutrition in acute hospital admissions’, Proceedings of the Nutrition Society, 2000; quoted in Age Concern and Help the Aged, Scottish government debate.
[xxv] Vale of Leven hospital inquiry, http://www.valeoflevenhospitalinquiry.org/faq.aspx#q1
[xxvi] ‘Dundee’s Ninewells Hospital “covered up” C diff deaths of five patients for four days’, The Scotsman, 19 February 2010 http://thescotsman.scotsman.com/news/Dundee39s-Ninewells-Hospital–39covered.6086977.jp
[xxvii] BBC Health Infections, http://www.bbc.co.uk/health/physical_health/conditions/infections1.shtml#hospital-acquired_infections, accessed 7 January 2011.
[xxviii] JL Martin, KS Williams, KR Abrams, DA Turner et al, ‘Systematic review and evaluation of methods of assessing urinary incontinence’, Health technology assessment, 2006, 10 (6 ); Health technology assessment, NHS R&D HTA programme, February 2006, quoted in Help the Aged, Older people in the United Kingdom, May 2010, reference 147.
[xxix] Compiled from National Office of Statistics, mid-year estimates, 2009 and Martin et al, ‘Systematic review’.
[xxx] Alzheimer Scotland.
[xxxiii] The Scottish Government, Health in Scotland 2008: annual report of the chief medical officer, 2009, 28.
[xxxv] Care Commission, Better care every step of the way: report on the quality of palliative and end of life care in care homes for adults and older people, , April 2009, 1.
[xxxvi] ibid, 3–4.