Issue 2: March 2012

ANTICIPATING THE ILLS OF AGEING

By Dr Adrian Baker, Clinical Lead, Nairn and Ardersier

One of the key themes of the Christie Report on The Future of Scottish Public Services is the argument that we should invest far more thought and energy - and divert some money - into preventative action rather than simply retrieving the failures of the system as it currently operates.

That was and is a brave claim, as it can sometimes point policy makers toward intervening into people’s lives in a very intrusive and probably unwelcome manner. We have images of how children can be removed from parents; others might be advised on everything from their diet to their sexual behaviour.

Yet there is one life critical aspect of the public services where we can find good evidence of success in preventative health care that can be enthusiastically welcomed by the immediate beneficiaries and their families. Providing ‘anticipatory care planning‘ for older people appears to have huge benefits for not just those immediately involved.

Providing 'anticipatory care planning' for older people appears to have huge benefits for not just those immediately involved

If successful and if developed across Scotland these developments will be even more enthusiastically received by Scottish Ministers and health service managers, not simply as a great benefit for those older people but also as a way of tackling the huge costs involved in making conventional and traditional provision for people in the later decades of their lives.

We know from readily available data and evidence that in the acute hospital sector, some of the greatest costs are incurred through unplanned admissions – perhaps a fall and a broken hip – and that unplanned rates of admission for elderly people are particularly high. We also have data that shows that for older people there is a greater likelihood of falling than for the young and far more severe consequences - in both breaks and hospital outcomes - can be anticipated and action taken to reduce the risk of this happening.

One of the best examples of this anticipation can be found in Nairn, in a small town practice based on a community hospital at some distance from any of the leading Scottish teaching hospitals. Adrian Baker , a doctor there and clinical lead for Nairn and Ardersier described developments in the area to a recent MacKay Hannah conference on ‘Care'.

The practice team of mixed professionals developed and used a ‘case finder‘ as a means of highlighting older patients at a high risk of hospital admission by assessing known data about them and then discussed with those people and their families the preparation of an ‘Anticipatory Care Plan’. A case manager was in place to run the process and ensure collaboration amongst a potentially wide of range of professionals, statutory agencies and voluntary organisations that might be able to help the person.

One key aspect of the process was the extent to which a detailed enquiry that centred on health and potential illness was able to cover some questions that are sensitive and possibly hard for other statutory agencies and either partners or younger family members to ask. Someone’s preference and personal views on resuscitation choices and the ‘preferred venue if health deteriorates seriously’ are always tough questions to ask but perhaps better done as part of an overall prior assessment than hurriedly as they are taken into hospital as one of those unplanned admissions.

It is often claimed – understandably so – that if the option is available people prefer to die at home than in a hospital bed. The evaluation research data collected by the Nairn team, colleagues elsewhere in Highland and their research collaborators shows, amongst many other beneficial outcomes, that significantly more Nairn deaths are at home rather than in a ward at a hospital.

For the wider health service, the financial benefits are high. Home care for an older person with low intensity demands can cost in the order of £6000 - £7000 per annum, but compared to long stay care costs of up to £40000 p.a. the savings are high.

More cheerfully, the evaluation of the Nairn & Ardersier project shows major improvements in reduction in hospital admissions, improvements in delayed discharge and fewer falls – one of the classic health problems that affect older people.*

The health consequences for the people assisted will be obvious; better to die at home than in a hospital; better to get out of hospital more quickly than linger there; better not to fall than to break a hip. For the wider health service, the financial benefits are high. Home care for an older person with low intensity demands can cost in the order of £6000-£7000 per annum, but compared to long stay care costs of up to £40000 p.a. the savings are high.

The reasons we know of these achievements in Nairn are because of a robust collection by the team of empirical data, compared to other comparable health sites amongst Highland community health partnerships and to control practices within Highland. The achievements are not just a signal of success for health care innovation, but also for the use of evidence in considering the benefits of such innovation.

Such evidence poses many challenges for those same ministers and health decision makers in considering how embedded costly health resources might be adapted and better used.

 

* The full paper by Dr Adrian Baker and colleagues can be read at: http://www.rcgp.org.uk/bjgp

By Dr Adrian Baker, Clinical Lead, Nairn and Ardersier

Issue 2: March 2012

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