“The crisis in the NHS is largely a crisis in older people’s preventive care, and if we’re to avoid another catastrophic winter in nine months’ time we need to act now to fix it” warns Age UK
Published on 17 February 2023 08:02 AM
A new in-depth report from the Charity Age UK, ‘Fixing the Foundations’, reveals how our under-funded and overstretched NHS and social care system is struggling and sometimes failing to cope with the needs of older people. Longstanding problems, predating the pandemic but exacerbated by it too, are piling pressure on families and carers and leaving the NHS in constant crisis mode, contributing massively to ambulances being stacked up outside hospital emergency departments at the moment, and long waits for people of all ages to access urgent care.
- Half (49%) of all people arriving in A&E by ambulance are over 65 and a third (35%) over 75[i]
- The proportion of older people feeling supported to manage their health condition has fallen by a fifth (almost 20%) in relative terms since 2016/17
- One in five (21%) over 80s have some unmet need for social care
‘Fixing the Foundations’ provides a first-hand account of older people’s difficulties in getting the good, joined up health and social care they need to manage at home, leaving them at risk of crisis which often results in being admitted to hospital. Yet the evidence is clear that with the right care at the right time many of these admissions could have been avoided.
The report also includes perspectives from professionals and unpaid carers. It also shows how living with multiple long term health conditions, as a significant proportion of older people do, including more than two thirds of those aged over 85[ii], makes it especially hard to navigate health services which are still usually organised around individual illnesses and diseases. Meanwhile social care was often inadequate or absent in these older people’s lives. Age UK estimates that astonishingly, over 1.6 million older people have some level of fundamental care and support need[iii], such as help to get dressed, washed or getting out of bed, that is not being fully addressed.
For those older people who do receive care and support it is often coming from unpaid family carers, who provide a far greater volume of care in our country than formal services. However, the latest figures from 2019 estimate that 3.3 million older people now live alone[iv], up from 2.8 million a decade earlier. 1.5 million older people are ageing without children in our society and their numbers are expected to rise significantly in the coming years as our population ages. This trend is certain to increase the demand for formal social care services, so we need to plan for this by expanding their availability now – yet sadly the trend has been going in the wrong direction.
Between 2016/17 and 2021/22 the proportion of older people receiving long term support from their local authority went down by 13.5%[v], We know from our many conversations with older people that accessing support is harder than ever. When care is rationed for older people, those pressures will ultimately bear down on the NHS, and particularly our hospitals as we have seen this winter. This is therefore a terrible false economy in the charity’s view, reflecting how thresholds for support have risen as a result of council budget shortfalls.
Today the Charity reveals that:
- Half (49%) of all the people arriving in A&E by ambulance are over 65[vi].
- A third (36%) of all the people arriving in A&E by ambulance are over 75.
- Unplanned hospital admissions have been rising and have become more frequent, particularly for the oldest old[vii].
- The proportion of older people feeling supported to manage their condition has been falling consistently, almost 20% in relative terms since 2016/17[viii].
- 2.6 million people over 50 have unmet social care needs increasing to 15% of people in their 70s, and 21% of people in their 80s[ix].
- In 2022, there were 165,000 vacant posts in social care- an increase of 50% and the highest rate on record[x].
Five years ago Age UK published a report called The Failing Safety Net, which looked at many of the same issues covered in this new report and made many similar recommendations. Unfortunately, during the intervening period our health and social care system for older people has become weaker. Much of this can be attributed to a lack of work force planning and a decade of under investment, with the pandemic also leading to older people experiencing more ill-health and developing care needs more quickly, often because of ‘deconditioning’.
These factors in turn have contributed to lengthening NHS waiting lists, left hundreds of thousands of older people who rely on care and support going without, and to significant numbers getting stuck in hospital because, in order to be safely discharged, they need social care at home that is simply not there for them.
This winter some older people who have become seriously unwell have been badly let down, and we have all viewed scenes in hospital emergency departments on television that we hoped never to see, as exhausted NHS staff try to respond to an overwhelming tide of need. Yet the path to a better future is clear: proactive, joined up health care and social care delivered to older people in their own homes, before their health worsens, could avoid the need for appreciable numbers to require crisis hospital care and make it much easier for those who do need in-patient care to be discharged safely, without a low risk of readmission. It is now more important that ever that the NHS and social care system receives the support and investment it needs to transform services and deliver on the ambitions originally set out in the NHS Long Term Plan and again in the Urgent and Emergency Care recovery plan.
On the back of its new report Age UK calls for:
Integrated Care Systems (ICS) to develop comprehensive strategies for meeting the health and social care needs of older people at home, and in care homes, living in their areas. This must include major efforts to embed prevention in their work so older people can avoid the need for crisis care and maintain their independence. We know from the pandemic that when local services are freed up to work across health and care boundaries the experience and outcomes for people are much better. One example was the discharge support fund that supported people out of hospital with packages of care in the community. The Government’s decision to stop the fund in March 2022 certainly contributed to the challenges this winter. ICSs must expand examples like this but start to think much bigger, supported by Government.
Social care reform and a major and sustained increase in funding. The NHS cannot deliver these improvements alone. The lack of adequate social care for basic daily needs simply stores up problems, leaving older people less able to care for themselves and arriving in hospital with serious health problems that could have been avoided.
Multidisciplinary working to become the default method of delivering health and care services to older people. Older people are too often left to fall between the cracks of disjointed services and professionals who don’t communicate well with each other. For ICSs, this means making sure that social care services – and by extension the local authorities that are responsible for them - are central to their leadership and decision-making.
A better paid health and social care workforce, with the skills and competencies to properly support older people would make a huge difference to the quality and availability of care.
A step change in the recognition of and financial and practical support on offer to unpaid carers, who are holding up many parts of the health and care system.
Caroline Abrahams, Age UK Charity Director, said:
“Last week Age UK was contacted by a woman whose ageing father had recently died while sitting alone on a chair in the emergency department of his local hospital. This was a tragedy for him, his family and for the hospital staff too, who were no doubt working as hard as they possibly could to try to help everyone who had come to them that day. Who knows if that man could have been saved or not, but the fact remains that far too many older people are ending up in hospital, needing crisis care, because we are failing to provide them with the joined up, more preventive health and care services that would help them to manage in their own homes. Then, too many are getting stuck in a hospital bed when medically fit to leave because there’s no social care to support them at home. It’s an entirely predictable vicious circle and one that’s causing enormous heartache and distress for our older population – and huge difficulties for the NHS too.
“As our new report shows, we need to turbocharge our efforts to recruit, retain and support all the brilliant professionals that older people depend on to help them stay well at home, especially if they are struggling to manage several serious health conditions, like heart disease and diabetes, as many are. We need lots more social care staff, and hugely important community health professionals like District Nurses and Occupational Therapists, as well as GPs. Then we need to get them working effectively together – not only at the point when an older person is at immediate risk of needing a hospital bed, as with urgent response teams and virtual wards, but well before they reach that point too.
“Although this winter is not yet over it won’t be long before next winter is upon us, and it’s imperative we start work now to make sure it’s a much better one for the NHS and social care, and for older people too. At Age UK we are committed to doing everything we can to support a major national effort to this end – the voluntary sector, including our wonderful local Age UKs, has a big potential role to play. As we have learned this year, and as our new report shows, if we can get it right for older people in the NHS and social care then we’ll go a long way towards making the whole health and care system work more smoothly for people of all ages.
“It would be terrible if Age UK had to publish another report in five years’ time that once again found these same problems were still to be addressed. The fact is we know what has to happen to unblock our jammed-up hospitals and give older people the dignified health and social care support they need and deserve, and it’s down to the Government above all, to provide the leadership and resources to make it happen.”
The Fixing the Foundations report can be downloaded here
Case studies in the report include:
Francette talked about her experience of trying to get help for pain in her foot:
“For months long, they didn’t do anything. Eventually one nurse did come to my house and took some blood, and they found out that I had gout. And that’s what caused me all that pain. But all the time I was treated for water retention, it’s ridiculous… it had been all those months where I struggled”.
“Once you’re a certain age you are a nuisance. Very often it seems you are swept under the carpet. I’m very dissatisfied with the whole thing. I’ve always had a very active life, having brought up six children and working… And when you’re 87 and you live on your own… it is not a very good way to live”.
Sheila’s shoulder injury – which was not diagnosed for several weeks – continues to cause her pain. The waiting list for treatment is currently 24 weeks long, so she is hoping for a cancellation. She was recently offered an appointment with 20 minutes notice:
“Even where I live, I think with the bad knee as well as the shoulder, there’s no way I could have walked there in 20 minutes. And I didn’t have anyone around me that could have dropped me off in the car.”
“I think the pain affects me from the osteoarthritis more than anything. Some nights I don’t sleep very well because of the pain, and you max out on the painkillers.”
Some quotes from professionals in the report:
“In our particular area at the moment, we have no social care. We have no care capacity whatsoever..... we’ve put an awful lot of burden on families, way more than we’ve ever had to.” An occupational therapist
“When I’m in hospital you can see people coming in and I’m like, oh this could have been sorted easily but for whatever reason, it didn’t happen. So yes, whatever the reasons are, people are still falling through the cracks.” A geriatrician
“It’s great if you happen to be lucky enough to have just diabetes or just cancer or just heart disease or just epilepsy, but if you happen to have heart disease, epilepsy, cancer, and you’ve had a minor stroke, you’re caught in the middle of all these different people doing different things to you who aren’t necessarily talking to you.” A GP
[i] NHS Digital (2022), 2.1 Proportion of people feeling supported to manage their condition (Link here)
[ii] Kingston, A. Robinson, L. Booth, H. Knapp, M., & Jagger, C. (2018). Projections of multi-morbidity in the older population in England to 2035: estimate from the Population Ageing and Care Simulation (PACSim) model. Age and Ageing, 47(3), 374-380.
[iii] Age UK. (2021). https://www.ageuk.org.uk/our-impact/campaigning/care-in-crisis/ - accessed June 2022
[iv] ONS (2020), People living alone aged 65 years old and over, by specific age group and sex, UK, 1996 to 2019
[vi] NHS Digital (2022), 2.1 Proportion of people feeling supported to manage their condition (Link here)
[vii] Kingston, A., Robinson, L., Booth, H., Knapp, M., & Jagger, C. (2018). Projections of multi-morbidity in the older population in England to 2035: estimates from the Population Ageing and Care Simulation (PACSim) model. Age and Ageing, 47(3), 374–380.
[viii] NHS Digital (2021), NHS Outcomes Framework Indicators - February 2021 Release
[ix] Age UK/Care and Support Alliance (2022), Analysis based on Wave 9 of the English Longitudinal Study of Ageing and Census 2021, see: link here - accessed October 2022
[x] Skills for Care (2022), The state of the adult social care sector and workforce in England report