Care for Older People- Dream Big and Think Differently

The gap between overall life expectancy and healthy life expectancy forecasts across all UK countries suggests that care for older people will be the biggest challenge facing health and care systems over the coming years. 

The real key to providing care to and for older people, i.e., those over 65, seems to lie in providing effective and sustainable primary care services rather than just more acute care services. In the UK, primary care (general medical, dental, optometry, and pharmacy services) accounts for around 90% of all patient contact. Its whole purpose can reasonably be seen as essentially keeping people living healthily and independently at home for as long as possible, and if they need more acute care, to get them back home again as quickly as safety allows. 

While there are considerable roles for community pharmacy, optometry and dental services within this primary care landscape, the role of general medical services, delivered via GP Practices, is, in my view, key to caring for older people and supporting them, their families, and their communities to care for themselves where they are able. This is because:

1. Almost everyone in the UK is registered with a GP Practice,

2. They still tend to reflect natural communities,

3. They intrinsically understand the health and care needs of their population,

4. They supply continuity for people, families, and communities, and 

5. Reducing acute care demand through increased primary care provision generates a good return on investment (31%: NHS Confederation, 2023). 

In an integrated health and care system, which now exists across all countries in the UK, services not provided by primary care in a community setting will inevitably need to be provided in more acute, hospital-based settings.

Given the higher relative cost of services provided in acute care and the need to ensure that avoidable referrals, admissions, and length of stay, with their attendant impact on patient safety and wider system flow, are minimised, it would seem obvious to have primary care at the front and centre of service planning and delivery. In truth, though, this rarely seems to be the case. The number of full-time equivalents and fully trained general practitioners is falling, while the number of full-time equivalents and fully trained hospital consultants is rising, and, of course, the proportion of NHS spend on primary care is also falling when compared to acute care.

Evidence suggests that older people want to be cared for in their homes or communities as much as possible and that this is more effective and efficient than hospital-based care. However, unless we can break the cycle of rising demand for hospital-based care, resulting in more money being committed to it at the expense of primary care, we will continue to see a growing divergence between evidence and actual practice.

While I acknowledge that decades of effort to redress this balance have been made at policy and strategy levels, the truth is that it has been unsuccessful in changing operational practice consistently and at scale. The gravitational pull of acute care seems too much. This being the case, perhaps a more radical approach to healthcare planning and delivery is required, based not on models from elsewhere around the world, where cultures and circumstances can be quite different but locally derived ones, driven by those who understand the needs of their population best. 

One way of doing this would be to go against the grain and move away from integrated care organisations to integrated health and care planning for discrete populations but with separate primary/community care and acute/tertiary care delivery organisations grounded in value-based health and care principles. This would undoubtedly lead to increased standardisation of practice but should also lead to improved outcomes and efficiencies. In addition, an ability to focus on the needs of older people as part of a more focussed primary/community care offer, which is distinct from that for acute/tertiary care, would allow a more realistic approach to working with primarily independent contractors; a more balanced allocation of resources across the system; and a weakening of the stranglehold that acute/tertiary care currently has on that system.