BGS roundtable: Transforming care for older people
This report summarises a roundtable event hosted by the British Geriatrics Society (BGS) on 20 June 2024 to discuss the themes raised in the 2023 report Health in an Ageing Society from the Chief Medical Officer (CMO), and the BGS's blueprint document, Joining the dots: Preventing and managing frailty in older people, also published in 2023. Participants at this roundtable event included senior representatives from NHS England, medical Royal Colleges, professional membership organisations, think tanks and charities with a shared interest in older people's health and care.
1. Introduction
The population of the UK is ageing. This is well documented, as are the challenges presented to the health and social care sector by the changing demographics of the country. There is an opportunity now to change the way health and social care are delivered to ensure that the needs of older people, the largest user group, are met. In doing this, the system will improve for the whole population.
In March 2023, the British Geriatrics Society published Joining the dots: A blueprint for preventing and managing frailty in older people1 which sets out what good quality, age-attuned integrated care looks like for older people. In November 2023, Professor Sir Chris Whitty, Chief Medical Officer for England, published his annual report2 focused on the health and care needs of the ageing population, particularly highlighting the growing population of older people in rural and coastal communities and the mismatch between this population and where specialists in older people’s healthcare tend to be located. The CMO’s report also talks about the need for the medical profession to embrace generalist skills and to move away from a model of single-disease specialties. The report notes the variation in disability-free life expectancy in different parts of the country, something that can largely be attributed to inequalities. Delaying the onset of frailty and multimorbidity will help to ensure that people are able to spend more years without disability.
The CMO’s report sets out the challenge: ‘Maximising the health, and therefore the life chances, of older adults should be seen as a major national priority, and one where we can make very significant progress often with relatively straightforward interventions.’ Both the CMO’s report and the BGS Blueprint show that the problems facing older people’s healthcare are not new. But, encouragingly, the solutions are also well-known. The task now is to ensure implementation of these solutions. A change in government provides an opportunity to make significant strides in reforming older people’s healthcare.
2. About our roundtable
The BGS invited 25 leaders in health and social care to a roundtable event on 20 June 2024 to discuss what needs to happen to meet the challenge set out in the CMO’s report.
Our invitees were from Government, NHS England, Medical Royal Colleges, charities and think tanks. When we initially scheduled the roundtable, the general election had not been called. The subsequent announcement of an election on 4 July meant that our event was held during the pre-election period, with the associated rules constraining what some of our attendees were able to say. We made the decision to go ahead with the roundtable which we held as a private event, and we are grateful to those who did attend for participating and being open and honest.
The CMO’s remit is restricted to England and as a result of this, we made the decision to focus our event on the provision of health and social care in England only. However, BGS members work across the four nations of the UK and many of the lessons and recommendations in this report are applicable across the UK.
3. The discussion
Our event started with a brief presentation from Professor Sir Chris Whitty and Professor Sir Steve Powis (NHS England’s National Medical Director) about the CMO’s report and the challenges and opportunities of an ageing population, with the resulting demands on the health service.
Both highlighted the importance of supporting older people to make positive changes to their own health and wellbeing, as well changing the system to operate more efficiently and provide better experiences and outcomes for patients. It is never too late to prevent ill health and there is an urgent need to empower the general public to take control of their own health to address modifiable risk factors such as obesity, smoking and hypertension. The health service also needs to be reorganised around multiple health conditions rather than by single conditions as it currently is. In 2015, 54% of people aged 65 and over were living with two or more long-term conditions. By 2035, it is predicted that this figure will rise to 68% with 17% of people over 65 living with four or more conditions.3 Reorganising services in this way would be beneficial to patients and would achieve greater efficiency.
A shift to a greater upstream focus on public health and prevention will require changing hearts and minds of the Government, the health profession and the public. Attendees agreed that it is the role of health professionals to have honest conversations with their patients and the public about the implications of shifting the focus of the health service towards prevention. Politicians are more likely to be convinced by their constituents, which in turn may lead to a change in policy.
Attendees discussed the social determinants of health and the impact of other factors such as poverty and housing on health. Unequal circumstances throughout the life course will affect people’s health in older age and their risk of developing frailty or multimorbidity at a younger age compared to their more affluent peers. However, targeted health interventions can still make a difference in delaying ill-health. Multi-agency approaches and joint working between local government, housing, health and welfare services are needed to reduce the damaging effects of such inequalities.
Following the initial discussion attendees were allocated to groups to discuss a specific theme and decide what it was most important to do (and how) to make a step change in the quality, availability and consistency of care for older people across different care settings over the next three to five years.
The four groups were asked to consider the following themes and questions:
- Supporting older adults to live well with disease (frailty and long-term conditions)
How can services be reorganised to better join up care for older people, ensuring that all their health issues are addressed in a holistic way without them having to see multiple healthcare professionals?
- Enabling older adults to live free from disease for longer (prevention)
How can people be supported to remain healthy and independent for longer, delaying disease until the very end of life (or preventing it entirely)?
- Ensuring consistency and quality of services across England (regional variation)
How can unequal access be addressed so that the health needs of older people across England are met, enabling them to live independently in their communities for as long as possible?
- Care closer to home (community care)
How can we speed up the provision of care closer to home, minimising avoidable hospital admission and expediting discharge from hospital without compromising patient safety, quality of care and support for recovery?
Across the four topics, attendees were in agreement that there is an opportunity now to change the way older people are cared for and supported in later life. The NHS Long Term Plan set out some key initiatives, and these developments should now be built upon, taking a strategic approach. We need to go further and faster to realise the ambition of better healthcare for older people and, as a consequence, a health and social care system that works better for everyone.
Older people with frailty and multimorbidity use healthcare services more than any other population group and it is they who bear the brunt of the pressures on the NHS and social care. It is older people with frailty and multimorbidity who wait in ambulances at hospital entrances, who spend hours on trolleys in emergency departments and who get stuck in hospital for weeks on end while they wait for social care. There are known solutions to the challenges faced by older people in the health system. Early intervention through proactive care and providing more care at or closer to home help to avoid older people being admitted to hospital. Services such as front door frailty and same day emergency care identify older people when they present to hospital, with the aim of discharging them on the same day. For those who are admitted to hospital, discharge planning and adequate social care help to ensure that they are able to leave hospital as soon as they are well enough to do so. Implementing these solutions not only improves outcomes for older people but also frees up capacity in the whole system.
The NHS currently has record waiting lists with estimates suggesting that nearly 10 million people are currently waiting for an appointment or treatment.4 This will be one of the many challenges waiting for the new Government as they take office. Our attendees firmly believe that one way to make a dent in the waiting list will be to improve services for the NHS’s largest patient group – older people.
4. Emerging themes
Key themes that emerged from the group discussions are set out below:
a. A skilled workforce
Nearly all of the groups discussed workforce shortages and the importance of education and training. These discussions included making changes to the shape of training to address the current mismatch between services available and the needs of the population. There is particular concern that rural and coastal areas are projected to see a significant increase in the numbers of older residents in the coming years yet do not have the healthcare workforce with the required skills to care for this population. This needs to be addressed with particular effort made to understand why newly qualified healthcare professionals are not moving to these areas and what can be done to attract them.
Participants also identified the importance of the multidisciplinary team in older people’s healthcare and the need to ensure that generalist skills are promoted and recognised. There was an acknowledgement that there will never be enough geriatricians to meet the BGS’s proposed benchmark of one geriatrician per 500 people over the age of 85.5 There is therefore a need to use the multidisciplinary team as effectively as possible and to ensure that all healthcare professionals have the generalist skills needed to care for an ageing population with complex needs. Currently there is a lack of publicly available data about non-doctor healthcare professionals working with older people. Availability of such data would help organisations such as BGS to identify areas of the country that are particularly badly served. This information could then be used to better plan the workforce on a local level to meet the needs of the population it serves.
Attendees highlighted the importance of shared decision-making and better integration in order to reduce duplication. This would have benefits to patients who would feel more involved in their care and not be required to repeat themselves to numerous healthcare professionals, as well as making systems operate more efficiently.
b. Better use of data and technology
The NHS collects a lot of data about individual patients and the whole population and it is acknowledged that this data is not currently used in the best way to optimise care. Better use of population data can support interventions such as proactive care to ensure that the right people are being targeted with the right interventions. In the case of older people, this can help to prevent deterioration which has obvious benefits for the individual, who is able to stay well and independent for longer, as well as benefits for the system through hospital admission being avoided.
There was acknowledgment that use of patient data and particularly sharing patient information across services has improved but there is still some way to go to ensure optimal use of data. Too many patients still report having to repeat their information to different health and care professionals or needing to log into numerous online portals to access data.
The attendees also acknowledged the gaps in the evidence regarding older people’s healthcare. There is a particularly urgent need for more studies to include older people to ensure that research reflects the experiences of the largest likely patient group. Real world data, including evidence from ‘what matters to you’ conversations, should also be central to decision-making in older people’s healthcare.
There was some discussion among attendees about how to better use technology to improve care, particularly with respect to care in the community. The group felt that technology could be better used to free up people to provide care rather than deployed to replace the workforce. Examples of this included monitoring devices to pick up early signs of illness. However, ethical issues and digital exclusion were both identified as potential barriers to more use of technology in older people’s care. It was also identified that some of the existing technology, such as the electronic patient record, could be used more effectively in care.
c. Social care and housing
The group identified that there is a false divide between health and social care. The public do not understand how social care works. A sustainable long-term solution to the issues in social care remains elusive, despite numerous government promises. There is a lack of integration between health and social care, causing duplication and confusion. Possible options for a sustainable social care system have been set out in detail and government action to resolve this issue is overdue.
The group also discussed the importance of housing in supporting people to stay well and at home for as long as possible. The group acknowledged the work of the Older People’s Housing Taskforce which aimed to set out options for housing in later life.
d. Prevention and healthy lifestyles
While there was a specific group discussing prevention, healthy lifestyles came up in the discussions on all four tables, as well as in the plenary discussion at the end of the day. There was acknowledgment that there is a need to focus on what works, including targeting modifiable risk factors for disease including smoking, obesity and high blood pressure. Interventions in this area may include exercise classes, smoking cessation or social activities provided locally by voluntary or leisure organisations. There was agreement that it is never too late to prevent illness but that healthy lifestyles are about more than just being free from disease. General wellbeing and being part of a community are also important factors. More social prescribing is needed to support older people to find the interventions locally that could help them.
There is a significant role in prevention for healthcare professionals working in primary care, provided this is adequately resourced. People aged 75 and over consult their GP around four times more than those aged 5-14 and around twice as often as those aged 25-64.6 These healthcare professionals have an opportunity to help their older patients to avoid ill health and unnecessary hospitalisation by providing lifestyle advice and support and early identification of frailty. Primary care leaders can help to reduce demand for care across the system by prioritising prevention in older age to support patients to lead healthier lives.
e. Integration of services
It is important to note that older people’s care works best when it is a multi-agency, integrated endeavour. There will always be a limit to what can be achieved by working in siloes. Integration across primary, secondary and social care is crucial, as well as involvement of the voluntary sector, leisure and housing sectors and unpaid carers. Joined-up support is likely to be more effective for the individual concerned as well as more cost-effective in the long run than the fragmented approaches that currently exist across many areas. Systematic reform of healthcare for older people must start from a premise of being person-centred if it is to be sustainable, realistic and lasting in its impact.
Integrated care systems have a key role to play in ensuring that services are joined up across the NHS and social care and that health and care services meet the needs of the local population. They are however immature in much of the country and progress towards integration is patchy.
5. Recommendations
As a result of the discussions at the roundtable, we make the following ten recommendations of organisations and individuals across the health and social care sector.
We have aimed for these to be specific and measurable and we will be following up with the organisations concerned.
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1. NHS England should set targets for training the wider health and social care workforce in frailty. |
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2. NHS England should make public the numbers of nurses and allied health professionals working in older people’s healthcare across England. This data is currently held in the Workforce Intelligence Portal but is not publicly available. |
| 3. Integrated Care Boards should be required to have a named individual responsible and accountable for older people’s healthcare in their area. |
| 4. The Medical Royal Colleges should encourage their members to develop their generalist skills in acknowledgement of the high proportion of patients they see who are older people with multiple long term conditions. |
| 5. The new Government should take urgent steps towards a long-term, sustainable social care solution. |
| 6. The new Government should publish the report of the Older People’s Housing Taskforce which was presented to the Departments of Levelling Up, Housing and Communities and Health and Social Care in May 2024.7 |
| 7. Research funders such as the National Institute for Health and Care Research (NIHR) should commit to ensuring that no publicly funded research excludes participants on the basis of age alone. |
| 8. The Chief Medical Officer for England should continue to monitor progress on the recommendations made in his 2023 report. |
| 9. The Chief Medical Officer for England should use his influence in Government to ensure that the Department of Health and Social Care prioritises early intervention approaches. |
| 10. Voluntary sector agencies should engage with ICBs to help build multi-agency strategies for person-centred older people’s care across all parts of the country. |
6. Next steps
This event brought together a unique group of leaders in health and social care. We convened senior clinicians with civil service roles, third sector leaders, those from think tanks and Presidents of Medical Royal Colleges.
We are grateful to Professor Sir Chris Whitty and Professor Sir Steve Powis for laying out so clearly the scale of the challenge and the progress made already. This may have been the first time that this particular group of leaders had found themselves in a room together. The BGS has a unique role in bringing together thinkers, doers, decisions-makers and clinicians to discuss the issues central to older people’s healthcare. We embrace this convening function and have committed to bringing this group together again in six months, and into the future as needed.
The ultimate goal here is to deliver a step change in the delivery of older people’s healthcare across the country. Older people should be able to live healthy, independent lives for longer. When they do experience ill health, they should be able to access the care they need at a time and place that is appropriate to their needs and wishes. Hospital stays should be as short as possible and, when required, social care should be arranged quickly. And when they approach the end of their lives, older people should be able to die peacefully, in a place of their choosing.
These ambitions are not new or controversial. The attendees at our roundtable agreed a collective responsibility to work towards a shift in the way healthcare for older people is delivered and to hold those responsible for change to account. As a group, we acknowledged the strength of working as a coalition and agreed to continue to do so until we have transformed older people’s healthcare.
Since this event was held, the Labour Party have been elected to Government with a sizeable majority. On taking office, the new Secretary of State for Health and Social Care set out three shifts in health that are highly relevant to older people’s healthcare: moving care into the community, a shift from analogue to digital including better use of data, and a focus on public health and prevention. These issues all resonate with our roundtable discussion and we are heartened to hear the Secretary of State prioritising these so early. We stand ready to support the new Government as they work to implement these shifts and to transform care for older people.
References
- British Geriatrics Society, 2023. Joining the dots: A blueprint for preventing and managing frailty in older people. Available at: https://www.bgs.org.uk/blueprint
- Whitty, C. 2023. Chief Medical Officer’s Annual Report 2023: Health in an Ageing Society. Available at: https://assets.publishing.service.gov.uk/media/6674096b64e554df3bd0dbc6/...
- National Institute for Health and Care Research, 2018. Multi-morbidity predicted to increase in the UK over the next 20 years. Available at: https://evidence.nihr.ac.uk/alert/multi-morbidity-predicted-to-increase-...
- Thomas, Tobi, 2024. ‘Almost 10 million people in England could be on NHS waiting list.’ The Guardian. Available at: https://theguardian.com/society/2024/apr/03/almost-10-million-people-in-...
- British Geriatrics Society, 2023. The case for more geriatricians: Strengthening the workforce to care for an ageing population. Available at: https://www.bgs.org.uk/MoreGeriatricians
- Bostock, Nick, 2023. ‘How an ageing population is piling pressure on general practice.’ GP. Available at: https://www.gponline.com/ageing-population-piling-pressure-general-pract...
- Gov.UK, 2024. Older People’s Housing Taskforce. Available at: https://www.gov.uk/government/groups/older-peoples-housing-taskforce
Full list of attendees
- Caroline Abrahams CBE, Charity Director, Age UK
- Simon Bottery, Senior Fellow Social Care, The King’s Fund
- Dr Adrian Boyle, President, Royal College of Emergency Medicine
- Dr Esther Clift, Chair, Nurse and AHP Council, British Geriatrics Society
- Professor Jugdeep Dhesi, President Elect, British Geriatrics Society
- Dr Tom Downes, National Clinical Director for Older People and Integrated Personalised Care, NHS England
- Carole Easton, Chief Executive, Centre for Ageing Better
- Professor Andrew Elder, President, Royal College of Physicians of Edinburgh
- Dr Deb Gompertz, Deputy Honorary Secretary, British Geriatrics Society
- Professor Adam Gordon MBE, President, British Geriatrics Society
- Professor Martin Green OBE, Chief Executive, Care England
- Beverley Harden MBE, National AHP Lead, NHS England
- Dr Adrian Hayter, Medical Director for Clinical Policy, Royal College of General Practitioners
- Professor Anne Hendry, Past Honorary Secretary, British Geriatrics Society
- Dr Ruth Law, Honorary Secretary, British Geriatrics Society
- Dr Sarah Mitchell, National Clinical Director for Palliative and End of Life Care, NHS England
- Dr Crystal Oldman CBE, Chief Executive, The Queen’s Nursing Institute
- Professor David Oliver, Trustee, Nuffield Trust
- Professor Sir Steve Powis, National Medical Director, NHS England
- Professor Vic Rayner OBE, Chief Executive Officer, National Care Forum
- Professor Julian Redhead, National Clinical Director for Integrated Urgent and Emergency Care, NHS England
- Dr Andrew Rochford, Improvement Clinical Director, Royal College of Physicians
- Sam Sherrington, Deputy Director Strategy and Transformation, NHS England Northwest Region
- David Sinclair, Chief Executive, International Longevity Centre UK
- Dr Jane Townson OBE, Chief Executive, Homecare Association
- Paul Vaughan, National Deputy Director for Community Nursing and Primary Care Nursing, NHS England
- Professor Sir Chris Whitty, Chief Medical Officer for England, Department of Health and Social Care
- Sarah Mistry, Chief Executive
- Sally Greenbrook, Policy Manager
- Lucy Aldridge, Policy Co-ordinator