Will we rise to the challenge of an ageing society?
We all need to do more, across the whole system, to help people with long term conditions.
Introduction
I would like to begin with a thank you to Age UK for inviting me here to speak to you in the week that would have actually been William Shakespeare’s 449th birthday.
William Shakespeare died when he was 52, which was actually pretty good for someone who lived in Elizabethan London where most people died in their mid-30s.
Compare that to one of his most famous characters, King Lear. Lear lived till he was 80, and was arguably the first major literary figure not just to get dementia, but terrible care to go with it.
In the twenty-first century, everyone expects to live as long as Lear. And no one wants the care he got.
Many in fact will live even longer.
My daughter was born last year and has a one in four chance of living till she is 100 - whereas I have only a one in 10 chance. In fact the number of over 85s will double in the next two decades. But long before then the number of people with dementia will exceed a million for the first time.
This government has taken some bold decisions to address the challenges of an ageing society: protecting the health budget, auto-enrolment for pensions, a single tier state pension and implementing Dilnot.
But inside the NHS too we need to make some profound changes. And if we fail to face up to them, the pressures created will put at risk the very thing we cherish most about the NHS - its unique ability to deliver high quality care to all with dignity and compassion.
The rise of long-term conditions
Let’s look at the biggest operational challenge facing the NHS right now – the pressure on A & E departments.
When I have been visiting A & Es in the last few weeks, hard-working staff talk about the same issues: lack of beds to admit people, poor out of hours GP services, inaccessible primary care and a lack of coordination across the health and social care system.
The decline in the quality of out of hours care follows the last government’s disastrous changes to the GP contract, since when we now have 4 million more people using A & E a year compared to 2004.
We must address these system failures – and look at the causes rather than just the symptoms as has happened too often in the past.
But those same A & E staff also talk about a societal change that is behind much of this pressure - the dramatic rise in the number of people with complex long term conditions.
Because of the ageing population, fully one quarter of the population - that’s 15 million people - have a long term condition like diabetes, dementia or asthma. Although these conditions can’t be cured, they can be alleviated, treated and sometimes kept at bay.
This is a huge challenge for an NHS set up primarily to deal with one-off episodes and curable illnesses - whether cancer, a new knee or a broken leg. Because unlike when the NHS was founded 65 years ago, now half of GP appointments and two thirds of outpatient/A & E visits are for people with long term conditions.
Indeed this group, many of whom are older people, are now responsible for 70% of the total health and care budget, over £70 billion every year. And that number is growing - which is why a recent review by Professor Carol Jagger said, the way we care for people with long-term conditions is unaffordable and unsustainable.
Nor, I would say, is it acceptable for those of us determined to ensure the NHS offers the best care in the world.
There are simply too many cases where people with long term conditions don’t get the medicines, the checks or they support they need. They or their relatives end up having to put their energy into fighting the system instead of fighting their illness.
Indeed the system itself has a long term condition – an outdated way of doing things that puts up silos, creates bunkers and too often gives people the minimum rather than the total support they need. This is what dedicated NHS staff across the system are demanding needs to change. So today I want to set out four areas that need to be addressed if we are to do this.
1. Treat the person not the condition
The first challenge is to treat the person and not the illness.
Sometimes, despite the best intentions of doctors and nurses, the NHS can send patients from pillar to post for referrals and appointments and follow-ups, while their own individual wishes are ignored.
I imagine every GP in the country has a story about sending people for a referral, only to have them sent back with an unhelpful note or a demand for a new diagnosis. The perverse thing is that payment by results actually encourages that.
What makes it so frustrating is that the answer can sometimes be right there in the form of excellent community services – which become a nightmare to access.
The buzz word for this is “integration.” I agree with Chris Ham of the Kings Fund that integration is today what waiting times were a decade ago – the central challenge that defines modern healthcare.
One of the best examples of a bold and new approach is here in London. Hammersmith & Fulham, Kensington & Chelsea and Westminster councils are working together with local NHS clinical commissioning groups to change what they describe as a ‘perverse, costly and uncoordinated’ status quo. Council officials, clinicians, social workers and others have reformed services for the one-fifth of local people who take up almost four-fifths of care costs.
By doing more around prevention, they reduce falls. By changing their IT, they identify people who are at risk. By re-evaluating their hospitals, they discharge people much faster.
But in too many places this kind of care does not happen.
Hospitals know that the moment of greatest risk for patients is during handovers, those critical moments when doctors and nurses share vital information at a shift change.
But what sort of handover happens at a moment of far greater risk - when a frail elderly person with multiple long term conditions is discharged from hospital?
Wrangling between local authorities and NHS Continuing Healthcare as to who will pick up the tab.
A discharge summary that may not be seen by a GP for weeks.
Someone sent home in the middle of the night with no one calling to check how they are the next day.
The new Clinical Commissioning Groups have a huge role to play in changing this. The managers who used to hold the purse strings rarely came into contact with patients. But clinicians do. They know what needs to change and how to change it – and I want to support them as they do.
2. The role of Primary Care
The second of my four challenges is to rethink the role of primary care, in particular its ability to prevent the need for emergency admissions.
The very nature of a long term condition means that you never leave hospital cured. So why do we tolerate a system which seems to perpetuate the myth that you do?
Too often people with long term conditions are left to their own devices, without the help, care and guidance that local services should provide.
Then something goes wrong and they end up straight back in hospital needing emergency care, at great cost to themselves as well as to the system.
Our primary care system has become reactive when it needs to be proactive.
Just as the objective of hourly rounds in a hospital ward is to reduce the number of calls on the buzzer by spotting problems before they get serious, should we not also be actively supporting our frail elderly population to manage health and care needs associated with long term conditions?
Not just those in a high state of dependency, who generally are picked up by the system.
But those at risk. Those who could be helped to stay out of hospital. Those who could be supported to live at home in reasonable health for much longer.
This is starting to happen.
Like the GP-led multi-disciplinary team in Kent who have worked far more closely with hospital matrons, involved mental health professionals from day one and made much better use of teleheath, and telecare. They have reduced A & E attendances by 15% and non-elective hospital admissions by over half among people with long term conditions. They have also saved almost a quarter of a million pounds.
But it needs to happen everywhere. We need to return NHS primary care to its root purpose – looking after people in the community so they don’t become ill and need to go to hospital, rather than simply acting as a gateway to the system when they do.
Sir Bruce Keogh will next month report on his review of emergency care. I know as part of that, he will look at the issue of demand for services and what needs to happen to make sure people with long term conditions are better looked after outside the hospital system, in a clinically appropriate way that reduces their need for emergency care.
Norman Lamb will be announcing shortly plans for local pioneer sites to lead the way on this. I have also asked NHS England to look at the system-wide operational incentives that need to change to make this happen.
But in the meantime I will play my role by promoting better integration between the health and social care systems and addressing the national barriers that need to be removed.
3. The third change: care and treatment
The third challenge comes in the wake of what happened at Mid Staffs.
The philosopher Rabbi Abraham Heschel said:
a test of a people is how it behaves towards the old…it is the true goldmine of a culture.
Old age should be celebrated, not dreaded. So we need an NHS and social care system where care is just as important as treatment.
That will be one of the main responsibilities of the new Chief Inspectors of Hospitals and Care: to make sure that people are treated with dignity and respect – and to shout loudly when they are not. Compassionate care, putting the patient first and looking at whether people would recommend the care they receive will be a central part of the new inspections regime starting later this year.
Indeed many hospitals and care homes understand that compassionate care and support does not just come from outstanding nurses and healthcare assistants. It also comes from friends, families, carers and the social networks that sustain all of us at our most vulnerable.
So I welcome the fact that more and more hospitals are removing stringent and inflexible hospital visiting windows. Visits can boost morale and help recovery – but relatives are also a vital source of information for nursing staff, especially about vulnerable patients who may not be able to speak for themselves.
4. The fourth change: dementia
The final of my four challenges relates to one specific long term condition – dementia.
One quarter of all the people in hospital and 80% of the people in care homes have dementia. One in three of patients admitted to hospital with a hip fracture, for example, have dementia.
But of all the long term conditions dementia is the one we are worst at dealing with. We only diagnose less than half of the people who have dementia –something that has improved admittedly over the last three years, but still nothing like good enough.
Quite simply we fail to give the majority of people with dementia access to the right treatment and care. And we fail to support to their families and carers in the way we should.
It’s not uncommon to find well over a dozen different professionals influencing one person’s care, even aside from day-to-day carers. Umpteen assessments and a Gordian knot of red tape for a partner or family member to deal with. There has to be an alternative.
Dementia sufferers need to know someone is responsible for their treatment and care plan. One number on the fridge that they can call – not just when things get unmanageable, but much earlier.
NHS England will shortly be announcing its new ambition for national dementia diagnosis rates alongside proper care plans for all those diagnosed.
But again when it comes to the joining up of care and services, commissioners have a key role in eliminating the interminable forms, the alphabet soup of different contacts and the feeling of being passed around the houses by different professionals.
Conclusion
Let me end though on a note of optimism.
Old age doesn’t have to be a ticking time bomb or a grey tsumami.
Shakespeare wrote about the torture of King Lear in his old age. But he also wrote about age ‘changing all griefs and quarrels into love’.
Changing things won’t be easy and we certainly face many obstacles in getting this right.
But we have many advantages too.
We have the NHS and its values.
We have the dedication and commitment of its staff.
And we have a new structure that liberates the NHS at a local level to form new partnerships, develop joined-up services and drive up standards of care.
Get this wrong and we will have flunked the biggest challenge facing our healthcare system.
But get it right - as I believe we can - and Britain truly will be the best country in the world to grow old in.