older people

We all know that we have an ageing population. In Lothian, as figures from the General Registrar's Office for Scotland show, the proportion of the population aged over 60 years is expected to increase by 20% between now and 2018 (see Figure 1).

The impact of such change is - at times - hard to assess. However, let us consider a simple example: the number of older people who are served by primary care doctors. As at September 2005 approximately 155,000 people aged over 60 years were registered with a GP. This equates to 18% of all people registered with a GP. If the elderly population does increase to the projected 20% over the next 13 years this number could increase to approximately 186,000 patients requiring primary care services. This means that we need to find primary care services to provide care for an extra 31,000 older people.

Data from the Lothian Health and Life Survey 2002 provides us with some insight into the use of such primary care services. The survey found that for those respondents aged 65 years and over, four in five of them had visited their GP or nurse at least once in the previous six months. It also found that over one in three had visited three or more times in that period. Whilst any extrapolation from this data is crude, it can be seen that this extra 31,000 older people could provide a significant increase in the number of visits to general practice. Similar analysis in relation to hospital and community care shows a similar pattern.

The message is clear: simple growth in the population of older people will mean that we must provide a health service that is more focused on the needs of older people. This is a message that is at the heart of Delivering for Health; but what sort of service should we be building?

Meeting the needs of older people: a vision for health and health care services

NHS Lothian, its stakeholders and its Community Planning partners have now started the process to create an updated joint strategy for older people's services. It has already been recognised that providing services for older people needs a more careful consideration of the whole system that provides care and the outcomes for older people that such a system should seek to achieve. A framework for such consideration has already been outlined in the work of the External Reference Group for Older People's Services that was commissioned by Lothian NHS Board.

The basis of the framework is that any service for older people should be focused on the type of outcomes that promote the independence of the older people and provide care in a way that respects the older person and treats them with dignity. In Better Outcomes for Older People, the Scottish Executive Health Departments sets out four "national outcomes" for older people:

However, these can be seen to be service-based, rather than focusing on the types of outcomes that older people, their relatives or friends might consider.

One area, therefore, which does need to be considered carefully in the new, joint strategy - in consultation with older people and their families and those who care for them - are the types of outcomes that might be said to constitute good health and wellbeing and maintain autonomy, dignity and respect. How the outcomes are framed will have implications for the principles upon which models of service delivery need to be based.

If we accept that the NHS must become more focused on caring for older people - as Delivering for Health highlights - then such key models for care will have an impact on the care of all people - of whatever age - within the NHS Lothian system. Creating a new outcomes base for the care of older people must filter back across the age groups to avoid creating a new form of ageist inequality. To help further this debate, the ERG* set out six characteristics of an outcomes based model for services which they considered were essential.

*External Reference Group

1. A whole person model of service: improving health for all

Improving health and wellbeing means more than simply providing services. It means tackling social exclusion on a broad front, from low incomes and poor housing to the promotion of good health and participation in society. This implies developing an approach that encompasses two dimensions of care:

This should be a principle that underpins the work of the Community Health Partnerships. However, it should be noted that the traditional partnership between the NHS and social care is likely to be a relatively small part of the service interfaces and partnerships required by this principle.

2. A whole system model for service: access and delivery

Joint working is an essential part of any future vision. The challenge is to refine this approach in order to meet the requirements of the socially inclusive model outlined above. The evidence base argues that this can only be delivered via a 'whole system' approach, though what constitutes the whole system has not yet been sufficiently articulated and needs to be developed.

For older people who use services, there is often confusion about service provision and a sense that accessing one service should provide an effective gateway to any part of the service, irrespective of which is the provider agency. Information is clearly part of the solution to this problem. However, a genuinely open system, that can provide straight-forward access to other parts of the system is also needed.

3. A comprehensive model for service: prevention, treatment and rehabilitation

Services need to be comprehensive. To effect sustainable change the starting point for a comprehensive approach is the realisation that immediate challenges, such as reducing hospital admissions, average lengths of stay, attendance at A&E and use of GP services, are best addressed within a whole system model. Any proposed change should also include what are now described as intermediate care services that provide interim or early intervention and maintenance rehabilitation. Where this has not occurred, or where there are competing demands for the resources, it is usually the preventive or rehabilitation services that tend to be disadvantaged.

The use of targeting to focus resources on those individuals or groups most at risk has been advocated. However, the epidemiology of health and social care needs of older people often presenting with multiple needs in primary and secondary care settings, linked to the demographic changes predicted, makes it difficult to sustain a highly targeted strategy.

4. A personalised model of service: partners in care and management

Experience shows that older people's circumstances can change rapidly. So rapidly that health, social and community care services may have difficulty undertaking the necessary reassessment and amending care packages. As a consequence, some people feel that they have had no choice but to manage their own condition, and only want more support at difficult times, which can exacerbate the situation.

Improvements in quality of life are arguably more likely where the balance of power is tilted in favour of the service user. Creating services that can support those who have a long-term condition and have become 'experts' about the management of their condition need to be encouraged in as wide a range of situations as possible. However, such approaches still need to be backed up by appropriate professional advice, treatment and care.

5. A reciprocal model of service: giving and receiving

We must also recognise the current and potential contributions that older people themselves make. For example, older people are often to be found making social contributions in areas such as volunteering and in citizenship and community roles such as local community representatives and organisers of community groups. Promoting social inclusion involves recognising and supporting people in these various roles. A relatively small amount of support may enable individuals to make disproportionately large social contributions to local communities and wider social networks.

However, in one area we must be proactive in supporting the social contributions of older people: many provide informal caring for grandchildren, relatives and neighbours. The demographic changes described above will also have the effect of making those who provide such care relatively older.

The work of the national Care 21 group on the future of unpaid carers in Scotland has set out a vision for supporting the needs of carers in Scotland. NHS Lothian needs to consider carefully how it ensures that older people who are carers can maintain a healthy quality of life.

6. An updating model for service: proactive and reflective

Successful achievement of services that encompass these principles will be reliant on establishing a whole system that genuinely values innovation, is capable of learning new skills and knowledge and promotes transformational learning to support effective practice development.

These six characteristics are ones which are to be found in many vision statements for older people's services, whether it is the WHO statement on Health for all in the 21st century or our own statements in Scotland. The challenge is to make such characteristics real for older people's services. Then our parents and grandparents can benefit from longer, healthier and more active lives.