Padraig O'Morain reports on a way to look after our older people properly while freeing up much-needed hospital beds.
The National Health Service in England has freed more than one million bed-days per year in its hospitals by introducing a system of "intermediate care" for older people.
The system offers a planned rehabilitation programme in the community for six weeks after a patient leaves hospital. Intermediate care can also be used to prevent people going to hospital "by putting services around the person in their own home," Prof Ian Philp, the national director of older people's services in England told The Irish Times.
The programme is additional to the normal community care services, he says.
"We had a lot of problems with older people being the main users of acute hospital services and often getting stuck in the system," he says. "They had been appropriately admitted but were unable to be discharged."
His office recommended that, instead of building more hospital beds, more money be spent on community services.
"In England we're now putting about £500 million per year extra into the development of community services, most of which are intermediate care services."
Intermediate care is based on what he calls "a rehabilitation philosophy".
"It's essentially bridging the gap between hospital and home. In the language that I think older people in England understand, I call it active convalescence."
The investment in intermediate care has paid off, he says. "There are now in England over 300,000 older people every year benefiting from these services. The reduction in delayed discharge is the equivalent of more than a million hospital bed-days per year and that's taken a lot of the pressure off our acute hospitals."
The result, he says, is better services for older people in the community and shorter hospital waiting lists - this also benefits older people as they are the main users of hospitals. Enabling older people to stay out of hospital or to go home earlier is also helping to reduce waiting times for elective surgery as beds are more available.
The intermediate care package "also helps to reduce the need for long-term institutionalisation because it gives more older people the advantages of having a good rehab programme".
"It's something we're very, very proud of," he says, adding that other countries could benefit from a similar approach. "Many healthcare systems are struggling with what some people term bed-blocking although I find that slightly offensive," he says.
Prof Philp is in charge of promoting the implementation of the National Service Framework for Older People in England.
The framework is made up of initiatives aimed at getting older people a better deal from the NHS.
In drawing up the initiative, Prof Philp and a team of 12 civil servants did an analysis of what was needed and found that there were "three big issues".
"The first was age discrimination which was as prevalent in the health service as it was in the rest of society and it was pretty bad. People were treated in some cases as second-class citizens."
The second was that while the whole health and social care system had "a myriad of services" there were "huge complications" in getting them to work smoothly together.
"The third issue was that in the UK and Northern Ireland we led the world in the development of specialist services for older people's needs and we have some very good services but they were a bit patchy. In particular, we needed to get consistently high standards of care for people with strokes, with falls, with confusion, with incontinence, people who were actually dying."
To deal with some of these issues, he and his small staff have worked with service providers to cut down on the complexity faced by people seeking their help.
So far, 80 per cent of councils in England have agreed to share information with the NHS so that older people can be offered the services they need without having to supply the same information again and again, he says.
Reducing complexity means dealing with practical issues at local level. There is a change, for instance, in how equipment is supplied to older people with acquired disabilities. "In any locality you could have 50 different equipment providers and we have got all that pulled into a single equipment store."
Health services need to realise, he says, that "older people" differ from generation to generation. "The first patients that I worked with when I was 19 as a medical student were men who had survived service in the first World War and the widows of those who didn't survive," he says. They had very low expectations of the health services as they were born and grew up in the pre-welfare state era.
By contrast, when the generation whose formative years were in the 1960s enter old age, "they'll want as responsive a service from the National Health Service as they would expect from their bank or their supermarket."
When he took up the job, "what I most hoped for was that we could tackle age discrimination and we've made some good progress there".
Training for staff is a key factor in removing discrimination, he says. "The research is clear about that. It's ignorance that leads to abuse and knowledge that leads to care so a lot of emphasis is put on acknowledging the skills of staff. The second thing is having leadership: you need the specialists with real knowledge to provide leadership and be exemplars. The third thing is more power for users through better information provision so they are aware of what their choices are."
Prof Philp is also a consultant physician at the Northern General Hospital in Sheffield. His team won the UK Hospital Doctor Care of the Elderly Team of the Year Award in 1998. He is an adviser to the World Health Organisation European Office on care of older people. He did part of his medical training at University Hospital Galway. He describes his stay there as "the best year of my undergraduate life".