Transcript Implications for palliative care?

Making systems fit for an ageing
population
Implications for palliative care?
Thames Valley Workshop. Madejski October 8th 2015
Prof David Oliver
Consultant Physician, Royal Berks
President, British Geriatrics Society
ECIST Speciality Advisor
Senior Visiting Fellow, King’s Fund
Professor, City University, London
Before I start
A personal view from my “day job”
In the ED and AMU
On the “deeper wards”
In planning discharge
Working with Palliative Care
& Other services e.g. Mental Health/COCOC
At interface with community services
– Care Homes
– Intermediate Care
– Social Care
Continuing Care Assessment and Funding
NHS Benchmarking 2014. Continuing
care & delays
I: A scheme for thinking about
integrated services for older
people
Always putting the person and their
families in the centre of our thinking in
how we deliver and design services
Check out the “I statements”
from patients view
Older people and the integration and
care co-ordination agenda
Older people
Especially with complex needs/frailty
Most likely to use multiple services
See multiple professionals
And suffer at hand offs between agencies
And from disjointed, poorly co-ordinated care
Loads of evidence that they do (I can share
references)
Palliative Care &
Care Planning
Cross All
Domains
SAM
Oliver D, Foot
C, Humphries R
et al King’s
Fund 2014
Mrs Andrews’ Story
( Which I wrote for HSJ Commission on Frail Older People
HSJ Nov 2014/March 2015)
Please watch actively
https://www.youtube.com/watch?v=Fj_9HG_TWE
M
And reflect at each stage, what could/should
have happened differently
This shows essentially caring people trying to do
the right thing
But the system letting her down
There’s a second “what went wrong” on youtube
with solutions
II: Population Ageing
A success story, not a catastrophe
A success for society, preventative and
curative medicine
From “rectanguralisation” to
“elongation” of survival curve.
1947 NHS
Founded, 48%
died before 65. In
2015 its c 14%
Distribution of death England 1841 - 2006
100%
90%
1981
1991
80%
1941
70%
2001
60%
50%
1841
2006
40%
30%
20%
10%
0%
1
5
9
13
17
21
25
29
33
37
41
45
49
53
57
ONS
61 65
69
73
77
81
85
89
93
97 101 105 109
By 2030 men aged 65 will live on average to 88 and women to 91
By 2030 51% more over 65, 101% more over
85
Ageing, Carers & care-workers
Already around 6 million people in the UK are carers for
an older relative
By 2022, the supply of carers will be outstripped by
demand
1.5 m carers are over 65 often or poor health themselves
House of Lords “Ready for Ageing” report 2013
<5% receive statutory support
Age UK 2014
Always “Older People and their carers”
Demographic transition & dependency ratio has major
implications for workforce to support our older citizens
(e.g. currently in general practice & community nursing)
And retirement age of health and social care staff
Following the money.
NHS Constitution Technical Handbook
III: What ageing means for
population health. Reality.
However much we invest in prevention
& wellbeing, people will get ill. & Even if
more older people stay well for longer,
there will be more older people to
compensate.
Language, labelling and perceptions
“Grey Tsunami”
“Time Bomb”
“Burden”
Older people invisible
Or “elite” (sky-diving
grannies)
Portrayal as dependent,
vulnerable, isolated, ill
Labelled “bed blocker” “social
admission” etc
Ageist values
Age discrimination (e.g. CPA
report 2009)
Even in health professionals
Values/priorities
In fact, most older people in decent nick and
contributing still (UK cohort studies/census)
70% M & 60% of F > 75 self report health as
“good” or “very good”
2/3 over 75 say they don’t live with life-limiting
LTC
Most over 75 remain in own homes with no
statutory social support
70-80 year olds self report highest levels of
satisfaction with life
Taking into account unpaid caring, granparenting,
volunteering, spending, paid employment, over
65s make net contribution to economy
(Sternberg Report)
Wider determinants count (e.g.Isolation/Housing)
Multimorbidity in Scotland
(Scottish School of Primary Care Barnett et al Lancet May 2012)
Scottish School of Primary Care Guthrie BMJ 2012
e.g. Only 18% with
COPD just have
COPD
Problematic Polypharmacy.
(10% over 75s on 10 + meds).
(See also Greenhalgh BMJ 2014 “Evidence-based medicine a
movement in decline?)
Melzer D Age UK 2015
Melzer D Age UK 2015
Melzer D et al Age UK 2015
Mobility
Clegg et al Lancet 2013 Frailty
Clinical Review
Frailty Syndromes (how people with frailty
present to services).
Clegg, Lancet. BGS “Fit for Frailty”
“Non-specific”
• E.g. fatigue, weight loss, recurrent infection
Falls/Collapse
Immobility/worsening mobility
Delirium (“acute confusion”)
Incontinence (new or worsening)
Fluctuating disability
Increased susceptibility to medication side effects
• e.g. Hypotension, Delirium
From Prof John Young. National Director for Integration and
Where should
geriatricians & specialist teams best focus
efforts?
Frail Older People – England.
IV: Some implications for care
planning, palliative care
You’ve seen some of the primary care
data and others will speak more re
general practice
Older people & families often can and
do get good end of life care
Despite some poor care, some it unacceptable
and bad experiences
In all settings
– home, care home, hospice, community hosp
Including acute hospitals
– where they often choose to stay
– despite alternative offers
– can’t always be predicted from community
Two recent tales to illustrate
Hospital
Median age of new acute admission 71
25% of all bed days are in over 80s
Delayed transfers rising
Re-admissions rising
Bed numbers falling
Admissions rising
Hospitals v close to capacity year round
c. 1 in 3 patients in acute hospital bed are in
last year of life
– Clark D et al Palliative Med 2014
Median age of intermediate care
patient = 82 (NHS Benchmarking)
Care Home Case Mix
16% die within 6 months and 25% within
12
Median survival 16 months
67% immobile or need help with mobility
78% dementia or other mental impairment
c. 20% Stroke
10% end stage cardiac/respiratory disease
8-12% documented depression
30-65% incontinent of urine/faeces or both
Average resident falls 2-6 times a year
Median medications per resident 9 (Barber N
CHUMS study) (high prescribing, admin,
follow-up error)
Acute admissions from care homes
(Quality
Watch 2015) – many are at or near the end of life and add
distress but little value to care. Many preventable through
good planning and support
Ombudsman
NHS Atlas of Variation 2015
V: Some very specific solutions
Some very specific solutions I
Use specific diagnoses, including & contact with
any health setting
This should include frailty and dementia
To initiate care planning/advance care planning
(see GSF, RCGP guidance, Coalition for
Collaborative Care, BGS “Fit for Frailty”)
This includes advance decisions, potential
appointment of attorneys
Adequate capacity and responsiveness in
community palliative care
Tailored support to care homes including GSF
accreditation
Some very specific solutions II
Look at impact of better planning and palliative care on
admission prevention, LOS, readmission, delays
Involve carers/bereaved in design, feedback, teaching
Learn from feedback and complaints
As palliative care can’t see everyone, ensure more people
have awareness, or training
Make access to palliative care quick and 7/7
Really put people & wishes at centre
In hospital, mustnt shy away from difficult conversation or
DNACPR
Better understanding of mental capacity & related
legislation
And end of life decisions over CPR, Artificial
Nutrition/Hydration
Culturally sensitive
Age Attuned and Non Discriminatory
Working together?..
Enjoy today and the challenge beyond.
Thank you
[email protected]
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[email protected]
@mancunianmedic