On Tuesday the Health Select Committee inquiry on NHS commissioning heard from Age UK, alongside Mind, National Voices and the Patients’ Association. I was asked how the NHS could save £20 billion over the next four years, without harming healthcare. In my response I argued that savings on this scale would only be possible if we fundamentally change what and how the service commissions, in order to equip the NHS for an ageing nation. I set out five giant failings in NHS support for later life today:
- People in late old age have not fully shared in improved health outcomes with respect to the main ‘killer’ diseases of cancer, heart disease and stroke. Our death rates for younger ages now fair well compared to other developed nations, but fall behind for people aged over 75. This indicates a system with in-built age discrimination; a recent example was exposed in a study on GP referral decisions reported in the BMJ this month. More explicit age discrimination continues in pockets too, most noticeably in access to mental health services.
- The NHS continues to under-commission vital community and preventative healthcare used mainly in later life: audiology, chiropody, ophthalmology, falls prevention services; and care and support for people with incontinence, depression, osteoporosis and arthritis. None of these are glamorous ‘life or death’ services but together they have a huge impact on keeping people well, in their own homes and avoiding the need for expensive, acute care.
- Our health services are failing to adequately support people with complex needs – often in late old age, coming towards the end of their lives. With so many older people using services, every health professional can expect to see people with complex, overlapping health problems; acute frailty; and cognitive impairment. But we organise too much of our healthcare, and train our workforce, on a ‘condition specific’ basis, rather than expecting that everyone is able to adopt a geriatric care perspective, focused on the whole person not the presenting health need. Recent strategies on end of life and dementia are only starting to scrape the surface. The first priority now should be to address the scandalous under-commissioning of GP services for hundreds of thousands of care home residents.
- In too many places services still operate in silos and fail to offer people a coherent package of support across organisational boundaries. The most obvious failure is the lack of integration between social care and the health service, despite recent announcements on the tariff for emergency readmission and NHS spending for re-ablement. But there are similar problems in the hand-off between primary, community and acute services within the NHS, and between services focused on different health conditions. We need a fundamental change in the patient journey, so that people receive a coherent range of care and support, closer to home, with the support to manage their own health conditions and retain as much control as possible over their own lives. It’s not an original point, but turning rhetoric into reality is painfully slow, with a strong cultural and institutional bias in favour of acute hospital care.
- Finally, the NHS still fails to put dignity and patient experience at the heart of all that it does. People using services and their families still too often feel like an afterthought, with poor communication, lack of involvement in decisions, and inadequate support for basics such as eating, drinking and using the toilet. Much of this is down to attitudes and common sense at the frontline, but without a strong steer from commissioners that the patient experience really matters, dignity will always remain way down the list of priorities.
It reads as quite a depressing list. But in some cases there are obvious solutions. It is imperative, for example, that the Department of Health revises its proposals for the NHS Outcome Framework which would currently only prioritise ‘premature’ deaths up to the age of 75. But many of the answers are more complex and far reaching. In our view the solutions require national leadership, and sustained professional collaboration and commitment at local level – with a greater role for experts in older people’s care at both levels. I worry that the proposals for NHS commissioning reform will at best be a distraction, and at worst could strip the service of its ability to respond to complex, strategic challenges, such as ageing.
To mitigate this risk, we hope the new NHS Commissioning Board will be tasked to take on big-picture system-wide issues, by launching fundamental reviews that set out how and why to achieve transformational change in the services the NHS commissions. A good place to start would be an inquiry on the NHS’s response to ageing.