Rethinking approaches to care for older adults

Older adults are among the most frequent users of emergency care; Open Access Government explains why this is and the suggested measures to improve and diversify care delivery and support the recovery of health and social care systems

Population ageing is progressing faster than it has ever done before. According to the latest figures from the World Health Organization (WHO), by 2030, one in six people globally will be 60 years or over. By 2050, the world’s population of people aged 60 and older will double to 2.1 billion, and the number aged 80 or older is expected to triple, reaching 426 million by 2050. (1)

While this natural demographic shift is a positive reflection that people live in better health for longer, an ageing society is often cited as a significant burden on health and social care systems worldwide. In recent years, the rising demand for hospital inpatient care coupled with unprecedented workforce shortages and capacity pressures have significantly impacted hospitals and, most acutely, emergency departments.

Longstanding challenges in caring for older adults have put them at greater risk of needing acute hospital care. Open Access Government looks at the key drivers behind this and the necessary measures to improve access to services and, more generally, reframe the narratives around ageing.

Why are more older people using emergency care?

Many older adults spend their twilight years living with comorbidities such as heart disease, hypertension, diabetes, joint disease, sensory impairment, and mental health problems; complex needs coupled with challenges in referral pathways across care settings have led many people to resort to emergency care services. Figures from an in-depth report by the charity Age UK released earlier this year noted that half (49%) of all people arriving at A&E by ambulance are over 65, and a third (35%) are over 75. The report also noted that the proportion of older people feeling supported to manage their condition has been falling consistently, almost 20% in relative terms since 2016/17. (2)

Living with multiple health issues can make it difficult for older people to determine the health services they need, and this can be exacerbated if they live alone or have limited social support; as a result, they may dial emergency services when alternative services are inaccessible. Moreover, the number of older people living alone and at greater risk of crisis care is increasing. At the same time, the provision of care services that would enable them to be supported in their homes has decreased.

Social care services’ ability to support older people’s needs has become increasingly difficult due to the rise in vacant posts in the sector. In 2022, there were 165,000 vacant posts in social care in the UK alone, an increase of 50% and the highest rate on record. (3) Despite primary care practitioners working harder than ever, older people still attend hospitals and are re-admitted more frequently than other patient groups; they also typically stay longer and occupy more beds in acute care. (4)

The impact of increased demand for acute care

Often referred to as the barometer of how the health and social care system is performing, increased A&E wait times usually indicate challenges in other services such as primary care, community-based care, social care services and ambulance services. Workforce shortages and longstanding problems across care settings have directly impacted EDs. Staff burnout, retention challenges and increasingly overcrowded hospitals can impact care quality and make clinical assessments of older adults all the more challenging for time-poor physicians. Due to multiple and sometimes atypical health conditions, acute medical problems in older adults can often be difficult to diagnose compared to younger generations, who more likely present classical symptoms. (4) Unfortunately, many frail older people who end up in acute care find their condition can deteriorate if the entirety of their needs is not suitably addressed.

Diversifying care delivery following the COVID-19 pandemic has been advocated to tackle care backlogs, but it has also created barriers for some patient groups. For example, many primary care services offer online bookings and video and phone consultations, but this is not always an option for older or disabled people who struggle to navigate these systems and must wait longer for a face-to-face appointment.

How can challenges across the care pathways for older people be tackled?

Hospital overcrowding, workforce retention challenges, and overstretched and underfunded social care systems; there is no doubt that urgent reforms and collaborative approaches to care are needed across the board. Without this, patients and practitioners face more significant risks and healthcare costs will continue to soar. As well as trying to define and implement clear referral pathways, diversifying healthcare delivery so that more vulnerable adults can be treated safely at home has been a vital part of the UK Government’s agenda to improve urgent and emergency care performance. It has allocated almost £50 million towards achieving this goal. The measure includes rolling out new ambulance hubs and discharge lounges and scaling up community services, including falls and frailty teams with up to 50,000 people a month supported by clinicians at home in high-tech ‘virtual wards’. (5)

As in the UK, reforming social care and tackling workforce challenges is equally a top priority in Ireland. Skills and competencies training, fairer pay and recognition and support for unpaid carers have repeatedly been cited as vital measures to ensure older people and their carers are suitably supported. Ireland’s Report of the Strategic Workforce Advisory Group on Home Carers and Nursing Home Healthcare Assistants was launched at the end of last year with recommendations to mitigate the social care crisis. (6) These included supporting care workers’ professional development, enhancing the qualitative evidence base for policymaking in the sector and ensuring greater equity in pay and conditions for care workers across the public, private and not-for-profit sectors.

Reflecting on the Group’s recommendations, Ireland’s Minister for Mental Health and Older People, Mary Butler, said: “We need to show home support workers and healthcare assistants that we value the important work they do and make it a viable career option. I echo the Advisory Group’s call for all private sector and voluntary providers to commit to pay home support workers and healthcare assistants the National Living Wage at a minimum (currently €12.90), and for home support workers to receive payment for all time spent travelling between people’s homes and for other reasonable travel expenses.” (6)

While physical health issues are drivers of emergency care demands, addressing mental health issues is equally integral to improving care for older adults. During the COVID-19 pandemic many older people had to isolate, sometimes cut off from friends and family, to protect themselves from the virus.

To tackle the growing problem of loneliness, ministers in Ireland launched the ‘Hello Again World’ campaign. (7) Supported by Healthy Ireland, it aims to inspire and encourage older individuals to take proactive steps towards better health by reconnecting with their communities and enhancing their social interactions. Mary Butler said: “This campaign is especially aimed at older members of our society, who may have found themselves at a great risk of loneliness and isolation over the past couple of years. They don’t have to continue feeling lonely, as there are so many opportunities to connect with others in communities around the country.

“We can all play our part in helping older people to feel more connected and encouraging them to get involved in enjoyable activities that help promote good health.” (7)

Reframing our approach to ageing

Beyond health and social care reform, reframing society’s attitudes to ageing and tackling age discrimination is vitally important, given the inevitable trajectory of demographic development. The consequences of not creating a more enabling and inclusive environment for all ages of society will mean older people are more at risk of spending their later years with poor mental and physical health, and healthcare systems will continue to crumble under mounting pressures. We can predict population ageing, so there needs to be a step change and policies to support more preventative health and social care globally instead of a reactive approach, which is wholly unsustainable for today’s ever-growing population.

References

1. https://www.who.int/news-room/fact-sheets/detail/ageing-and-health
2. https://www.ageuk.org.uk/latest-press/articles/2023/the-crisis-in-the-nhs-is-largely-a-crisis-in-older-peoples-preventive-care-and-if-were-to-avoid-another-catastrophic-winter-in-nine-months-time-we-need-to-act-now-to-fix-it-warns-age-uk/
3. https://www.skillsforcare.org.uk/Adult-Social-Care-Workforce-Data/Workforce-intelligence/publications/national-information/The-state-of-the-adult-social-care-sector-and-workforce-in-England.aspx
4. https://rcem.ac.uk/wp-content/uploads/2021/11/The_Silver_Book_Quality_Care_for_Older_People_with_Urgent_and_Emergency_Care_Needs.pdf
5. https://www.gov.uk/government/news/patients-to-benefit-from-new-ambulance-hubs-and-discharge-lounges
6. https://enterprise.gov.ie/en/news-and-events/department-news/2022/november/202211302.html
7. https://www.gov.ie/en/press-release/3eff8-ministers-for-health-and-the-chief-medical-officer-encourage-older-people-to-say-hello-again-world-as-they-launch-social-connections-campaign-to-address-loneliness-and-isolation-among-older-people/