Resolving the health and social care crisis requires a focus on care for older people

This January, the UK secretary of state for health and social care announced £250 million for the NHS to purchase additional capacity in English care homes to relieve hospital bed pressures.1 The Scottish Government outlined similar measures.2 This funding is important recognition of the existential crisis our health and social care system faces. Ambulance response times, handover delays and emergency department trolley waits are at an all-time high.3 An estimated 13 000 and 1,700 hospital beds in England and Scotland respectively, are currently occupied by patients described as being medically stable for discharge, but awaiting rehabilitation, domiciliary care, or care home.

On the face of it, there is some logic to the announced funding. Delayed transfers of care and the resulting record high bed occupancy, are one of the most important system constraints for acute hospitals.4 Facilitating discharge would, if successful, free up bed capacity, allowing better flow through the hospital system to relieve overstretched emergency departments and ambulance services. However, for several reasons, it might not be so straightforward. Firstly, care home places in the UK are shaped by market forces. Care home leaders have highlighted how the cost of supporting patients discharged from hospital exceeds what the NHS is currently able to pay.5 Secondly, care home capacity is unevenly distributed geographically. Spot-purchased care home placements far from patient’s homes can lead to longer stays with dire consequences for the health and wellbeing of patients and their families.6 Thirdly, and perhaps most importantly, while care homes usually provide excellent day-to-day residential care, they do not universally provide nursing care or rehabilitation facilities.

NHS community rehabilitation provision is already desperately overloaded and the British Geriatrics Society hears daily from members who struggle to recruit to community rehabilitation vacancies. Asking overstretched teams to support rehabilitation for a greater number of even more geographically dispersed patients increases the likelihood of patients receiving no rehabilitation at all. This will result in higher care needs, potential for deconditioning and higher cost for health and social care. Relocation without rehabilitation is oddly reminiscent of the 1930s workhouses where geriatric medicine first found its feet.7 This would be a sad regression for a 21st century healthcare system.

The root of these difficulties lies in long-standing failures to grasp the nettles of social care reform and rehabilitation. Social care, as it stands, is plagued by funding inequities. The Health and Social Care Act, which promised client side reform, has been postponed by the UK government. The promised National Care Service in Scotland, meanwhile, remains underspecified. Rehabilitation has suffered from sustained deprioritisation and underinvestment. A decades long shift away from bed based services, driven by a commendable desire to reduce institutionalisation, has not been accompanied by relocation of resources to community settings.

So, what next? Firstly, the government must acknowledge that effective care for older people lies at the heart of an equitable, effective, and ethical health and social care system. Secondly, we need recovery plans to be based upon evidence-based approaches. The British Geriatrics Society has outlined, with support of the Royal Colleges of Physicians of London and Edinburgh, seven evidence based short term actions to help us through the current crisis.8 Firstly, we need to build comprehensive multidisciplinary assessment for older people with frailty into all emergency and admission units. Secondly, a focus on preventing, identifying, and managing deconditioning and delirium in hospital will protect older people from hospital-acquired harm. It is essential that we protect the right to rehabilitation and ensure access to multidisciplinary rehabilitation teams for all older people who need it. This will be complemented by continued investment in urgent community response to provide intensive short term hospital-level care at home through virtual wards and hospital at home. Investment in high quality healthcare for care home residents and ongoing proactive and anticipatory healthcare for older people with multiple long term conditions will help maintain the wellbeing of those living with frailty in the community. Given the centrality of older people to the issues currently facing health and social care, it is essential that those with expertise in their care are involved in any and all system plans for recovery. Some of these plans may require temporary relocation or secondment of existing workforce to concentrate resources around designing and delivering integrated care for older people. Given the existential nature of the current crisis, radical solutions are required but must be informed by patients, their carers and those who understand and work across the care system, spanning community, primary and hospital settings.

Once we emerge from the winter, we must never allow our system to decompensate to such a level again. Legislation to address the complexities and inequities of social care is essential, as is strategic planning that recognises and protects the right to rehabilitation. These challenges have international relevance. Long term health and social care is in a precarious state in many countries.9 These failings are nothing short of a global humanitarian crisis, placing all our health and wellbeing at risk. We, of all ages, should be in this together.