NHS England and NHS Improvement – Written evidence (INQ0102)

Structure of health services for older people

1. We have heard that one of the challenges to living well in old age is that medical conditions are treated in silos, which means older people with multimorbidities may have to visit multiple specialists. Is this the case in your experience?

Adrian Hayter: National Clinical Director for Older People and Integrated Person-Centred Care:

People with complex care needs often suffer from multiple conditions such as mental health, drug interactions and social vulnerability, which can lead to healthcare services being used inappropriately. As well as complex needs, patients could also have complicated care needs and need specialist support for a particular condition. Specialists are often experts at supporting the decision making or treatment process for this but may not necessarily have the skills to manage multiple conditions. General practice and geriatrician training both include managing complexity as part of core training requirements.

As a guiding principle, clinicians treat and manage ‘people’ and not their conditions. Currently, evidence-based guidelines often focus on a single care pathway, which may not be suitable for people living with multiple, long-term conditions. Personalised care and population health management offer the NHS a more dynamic, person-centred approach to tackling multimorbidities and community based primary healthcare plays a central role in supporting patients with more than one condition. Through its national Community Services and Ageing Well (CSAW) programme, NHS England and NHS Improvement (NHSE/I) has well established programmes to deliver this approach.

The Nuffield Trust report ‘Patient Centred care for older people with complex needs’[1] developed a ‘health 1000 pilot’ to transform the traditional model of care for older people. It highlighted the need for a more proactive approach to caring for people with frailty and multimorbidity. This proactive, approach needs a multidisciplinary team and requires good communication between professionals and with patients. It also requires the right tools to target those who would benefit most. It is therefore essential to take into account wider risks to the population to ensure best use of resources across the healthcare economy.

This is the basis for an Anticipatory Care response which is part of the CSAW programme. In East Berkshire (part of the Frimley Health and Care system) we have been developing this for some years and are currently evaluating a 2-year pilot targeting 4% of patients living with frailty or multimorbidity who are most at need. Through this evaluation we have found that the model can be resource intensive for general practice. In East Berkshire, a practice of 12.500 patients would support 500 patients in this way.

1. What are the main challenges this presents from a clinical perspective, and from a patient perspective?

People are now living far longer, but extra years of life are not always spent in full health. A recent large UK based study[2] found that two-thirds of people aged 65 years or over had multimorbidity, and 47% had three or more conditions. Whereas rates of multimorbidity in older people were largely due to higher rates of physical conditions, in the less affluent multimorbidity due to combinations of physical and mental health conditions was common.

The key challenges for patients and clinicians can be summarised as:

Challenges for Patients:

• To understand their own conditions and manage them
• To have support from a wider community around the social determinants of health
• Considering what really matters to an individual patient[3]

Challenges for Clinicians:

• To be able to deliver person centred care and move towards a more proactive approach targeting those people most at need when they are dealing with reactive care for populations at the same time.

2. Are there any practical ways that this can be avoided or reduced?

The CSAW Programme, set up to support delivery of the NHS Long Term Plan (LTP), has four key priorities to address the challenges posed by multimorbidities: Urgent Community Response; Enhanced Health in Care Homes; Anticipatory Care and; Improvements in how community health services are provided.

To support delivery of these priorities, CSAW has established an Improvement Community. The aim is to generate and test new ideas, share knowledge, good practice and link

professionals around common areas of interest across the country. The improvement community now has over 800 members across the UK.

NHSE/I also contributed to and supports the Healthy Ageing Consensus Statement [4] from Public Health England (PHE) and the Centre for Ageing Better. The statement sets out our shared vision for making England the best place in the world to grow old.

This consensus statement defines the shared commitment of the signatory organisations. It is the first time that such a wide range of organisations have come together to voice their intention to promote healthy ageing. Signatories span the areas of health, employment, housing and communities, and are from academia, local government, the NHS, and the public and voluntary sectors.

Following the launch, PHE and the Centre for Ageing Better have committed to work with signatories and interested organisations to develop and promote good practice, share learning and experience, and inspire others so everyone can look forward to a healthy later life.

2. We have also heard in evidence that current medical practice relating to older adults can give rise to polypharmacy, as older people are treated for multiple conditions by different specialists in parallel. What challenges are associated with polypharmacy, particularly for older people?

Inappropriate/problematic polypharmacy can lead to poorer health outcomes, fails to consider what is important for individual patients and poses a serious medicines safety risk. A person taking ten or more medications is much more likely to be admitted to hospital. Around 6.5% of hospital admissions are for adverse effects of medicines; this rises to rates of over 10% and up to 20% in the over 65 age group.

The NHS is working hard to address the challenge of polypharmacy through key initiatives like medicines optimisation, which aims to help patients:

• improve their outcomes;
• take their medicines correctly;
• avoid taking unnecessary medicines;
• reduce wastage of medicines;
• and improve medicines safety.

1. Is there enough clinical pharmacology expertise within the health system, to provide advice and guidance on appropriate combinations and dosages of drugs, and where does this expertise tend to sit (e.g. hospitals, GPs, pharmacists)?
2. How common is it for recommended dosages to be too high for older people, and does this worsen the issues of polypharmacy?

Although Clinical Pharmacologists may have a role to play, it is usually Clinical Pharmacists who lead medicine management expertise within local systems.

Clinical Pharmacology is a specialised area mainly carried out in hospitals. Most prescribing support in general practice is carried out by Pharmacists in medicines optimisation teams. These teams often work as part of a Clinical Commissioning Group and are allocated practices to work with.

They often support educational sessions, carry out annual visits and set performance measures, individualised to each practice or group of GPs.

New roles have also recently been developed in General practice and these include Clinical Pharmacists who are employed by Primary Care Networks (PCNs) (groups of GP practices with 30-50k populations).

There are also regional and national prescribing networks which support national policy around medicines management and implementation. Most GP clinical systems manage prescribing through the British National Formulary (BNF). Prescribing software tools such as Scriptswitch can also support clinical decision making around medicines management.

Expanding the primary care workforce is a key commitment of the LTP. One of the main vehicles to achieve this is the Additional Roles Reimbursement Scheme, which provides funding for 26,000 extra staff over the period to 23/24.

The Scheme was established in 2019 with the advent of PCNs. By signing up to the Network Contract DES, general practice (as part of PCNs) can access a flexible pot of funding to recruit to defined roles, including clinical pharmacists.

PCNs have been able to recruit clinical pharmacists through the Scheme since its inception, and they are critical to the delivery of activity that PCNs are required to undertake through the DES – particularly Structured Medication Reviews in general practice and in Care Homes. National reporting on the primary care workforce indicates that over 1,500 clinical pharmacists were in general practice as of 30 June.

In addition to this, hospitals have their own pharmacy departments led by pharmacists who support hospital clinicians. These services may work together and agree a formulary approach across hospitals and general practice. For example, East Berkshire has the Frimley Health Area Prescribing Committee which brings together 3 local CCGs with Frimley Health Foundation Trust.

The NHS Business Service Authority (NHS BSA) has also developed a set of Polypharmacy Prescribing Comparators to help Clinical Commissioning Groups (CCGs) and general practices identify patients most likely to be exposed to the risks associated with taking multiple medicines or certain combinations of medicines. The comparators include identification of patients by the number of medications they take but also key areas of focus to reduce inappropriate polypharmacy.

3. Are GPs given the training and tools to provide holistic care for someone with multimorbidities? What are the challenges of treating older people with multimorbidities in a primary care setting?

1. How could GPs be better supported to provide holistic care for older people?

The LTP and increased funding for Primary Care provide the framework and resources to achieve the following initiatives to support holistic care for older people:

• Greater population health intelligence – understanding the population and being able to use accurate risk stratification tools to target those who can be supported best by a proactive intense model of care. Using existing tools, such as the Electronic Frailty index and local tools to identify people living with frailty or those with multimorbidity.
• Using these risk stratification tools to enable proactive support and an anticipatory care planning approach. This approach engages the clinician and patient in a conversation around the care plan with the individualised wishes of the patient within the context of their conditions. This is supported through a shared care record, which enables those wishes to be managed in the most appropriate setting for that patient.
• Multidisciplinary teams across health and care who are involved in decision making and support. As part of this, recognising that social determinants of health can be as important as medical issues and that these can often be unmet needs. Local social care services can support through integrated care teams with the support of local authority services to tackle important issues like, housing, food nutrition, and heating.
• Link workers in general practice help signpost to local authority support care and reablement as well as local community resources
• Care Coordinators who support older people to navigate across health and care settings.
• Regular medicine management support from clinical pharmacists

The RCGP has championed new ways of working in their document RCGP 2022 [5]. This sets out how GPs can maximise efficient care for patients with several co-morbidities to benefit individuals and also to support primary care to manage the changing prevalence, demands and pharmacological complexities of non-communicable diseases.

2. Is there enough coordination between primary and secondary care regarding the care of older people?

NHSE/I has been introducing improvements in coordination and collaboration across primary and secondary care, especially to support implementation of the Long Tern Plan. These include:

New GP contract: To deliver on the LTP there is a commitment to boost ‘out-of-hospital’ care. The updated GP contract paves the way for thousands of pharmacists and pharmacy technicians to join other professionals to create new multidisciplinary teams across primary care in England over the next four years, offering better care to the public.

Shared decision making (SDM): This is a key component of universal personalised care. SDM ensures that individuals are supported to make decisions that are right for them. It is a collaborative process through which a clinician supports a patient to reach a decision about their treatment.

English Deprescribing Network (EDeN): EDeN was launched at the Clinical Pharmacy Congress in June 2019. The network has been established to promote appropriate prescribing to avoid severe and avoidable harm from medicines.

The EDeN network aims to:

• bring together a wide range of healthcare professionals, researchers and policy makers with an interest in promoting appropriate prescribing and shared decision-making.
• support knowledge transfer and encourage the sharing of tools, resources and good practice to support deprescribing.

4. We have heard that the Comprehensive Geriatric Assessment potentially offers one route to provide a holistic assessment of the needs of the older patient (including a review of their medication, their social and environmental circumstances and their functional status). In your experience is the CGA used in primary care, and if so, how widely? If it is not used, why not?
1. If used correctly could CGAs help to extend healthy lifespan and reduce the impacts of multimorbidities?
2. Do CGAs involve social care services as well?

The Comprehensive Geriatric assessment is a process which leads to a plan to address the issues which are of concern to the older person, their families, and carers.

As a tool, CGA can be used during the assessment of frailty as a holistic assessment, supports a healthier life and has been validated for use in older people as recommended by NICE[6]. It is an interdisciplinary diagnostic process to determine the medical, psychological and functional capability of someone who is frail and old. The aim is to develop a coordinated, integrated plan for treatment and long-term support and reduce impact and extend healthy life.

The CGA should be completed in a multi-disciplinary way and historically has been focused on the expertise often found in acute hospitals. The challenge is to ensure that: all relevant people that will benefit from a CGA has that undertaken; the information is shared by all relevant NHS and social care professionals; and proactive care plans are written to support the older person to flourish and be safe.

The CGA takes into account a social assessment and is used within an integrated care context to support a holistic care planning approach. As part of the multidisciplinary approach to supporting patients, social care teams should be involved in supporting meeting some of those social care needs.

5. Are geriatricians the best placed specialists to oversee a system involving more holistic care for older people, or should these clinicians work more closely with other specialists (e.g. cardiologists, rheumatologists)? Or, are clinicians with broader "cross-specialisms" needed?

1. If geriatricians are best placed, do we have enough of them?
2. If changes to the system of specialisms is required, at what point in medical training would changes be needed?

Eileen Burns and David Oliver published a paper[7] in 2016 on geriatric medicine in the UK and what the future might hold for the profession. This set out the important role of geriatricians as clinical champions and in the idea of ‘hospitals without walls’, as highlighted in the Royal College of Physicians Future Hospital programme[8].

Geriatricians should be a part of the local population health team. The role of oversight should be that of the local system. Clinical leadership within local healthcare systems should come from primary care community and secondary clinicians working together with local partners to lead any service changes that are necessary.

Primary care[9] can also play a strong role in leading the way and in improving the health outcomes of local populations by ensuring care is commissioned to maximise the best use of resources. Similarly, geriatricians have an important role in in the population health approach, in understanding and supporting local communities to support policy changes and influence local Integrated Care Systems.

6. Does the NHS Long Term Plan adequately address the changes required to provide better care and support for older people, particularly those with multimorbidities?

Mental Health

The LTP commits the NHS to improving the provision of mental health support for older people with a range of needs and diagnoses, including common mental health problems and severe mental illnesses.

This applies across all mental and physical health services and settings, including IAPT, community care, crisis and liaison mental health as well as community-based ‘Ageing Well’ models of integrated care for older people living with frailty and also those with complex needs.

As part of this, Older People’s Mental Health teams will also be expected to work closely with ‘physical health’ and other older people/Ageing Well teams, through multidisciplinary teams (MDTs) within Primary Care Networks; supporting GPs, primary care and community services with identifying, assessing and treating mental health problems in older people with multimorbidity, frailty and social care needs.

Delivering universal personalised care

The LTP also commits to personalised care becoming ‘business as usual’ across the health and care system. Universal personalised care: Implementing the Comprehensive Model sets out how we will do this by 2023/24. It is an action plan for rolling out personalised care across England and follows a decade of evidence-based research working with patients and community groups.

This plan lists 21 actions, to be delivered with partners from across national and local government, and organisations from across health, care, voluntary and community-based sectors.

The NHS has already made strong progress in rolling out the Comprehensive Model. In the last year there has been a significant expansion of the number of people benefitting from personalised care, including:

• Delivering 88,953 personal health budgets (PHBs) by February 2020, exceeding mandate target two years early. This is more than double the amount since last year.
• A new legal right to have a personal health budget was launched in December 2019. Estimates are that this has the potential to benefit up to a further 100,000 people by 2023/24.

1. What other changes within the health system would you recommend?

Care is often segmented into Primary, Community, Secondary, Tertiary and Social Care services. When they are ill, most people don’t recognise which organisation or healthcare professional looks after them, they just want seamless care and for the quality and experience to be of a high standard.

As was set out in the Long Term Plan, we need to be better at organising and delivering that care in a seamless way. As outlined above that involves professionals working much more collaboratively. Collaborative effort needs leadership at all levels and a focus on the specific goals and ambitions of the individuals we provide services for.

Clinicians and Specialists can often spend a career in one setting. With a more integrated approach there are opportunities for clinicians to be able to work in a variety of settings. This can give clinicians an appreciation of what’s important for the individual patient beyond the organisation they work for.

Clinicians who are given opportunities to work as part of multi-professional teams in a variety of care settings can also have the opportunity to rotate between different provider organisations and potentially facilitate integrated care by recognising the contribution of each team member, regardless of their place of work.

7. Is the Government's target of five more years of healthy and independent life by 2035 achievable? What are the main barriers to achieving the target with regards to the healthcare system?

The government’s target of five more years of healthy and independent life by 2035 is dependent on tackling wider determinants of health. This involves working with a wide range of partners and should be coordinated by the government. The NHS can play a key role but the contribution it makes will not determine whether the target has been achieved or not.

1. The Grand Challenge also aims to reduce inequalities in healthy ageing. Is the current structure of the healthcare system a contributor to these inequalities?

The recognition of multimorbidity associated with socioeconomic deprivation is particularly important to help tackle health inequalities.

ICSs are taking partnership working to the next level, by using a growing share of funding for primary and community services to help build and develop Primary Care Networks. This should lead to better understanding of data and other intelligence about the health and wellbeing of all people in their area, so that they can improve day-to-day physical and mental health and reduce health inequalities between different groups.

Over the next four years the NHS will do more to proactively identify and treat people at risk of CVD, particularly those with the greatest health inequalities. Clinical pharmacists working alongside GPs in Primary Care Networks will work to find and treat an additional 1.4 million people a year through case finding models for high risk conditions like AF, BP and cholesterol preventing 40,000 stroke, heart attack and dementia cases.

8. What are your observations regarding older people’s health and healthcare, in relation to the COVID-19 pandemic and future impacts?

The COVID-19 pandemic has had a disproportionate effect on older people. It has affected them in all care settings and has had both a direct and indirect effect on them in terms of mortality and morbidity. However, we have also seen how communities have been resourceful in their support for the most vulnerable.

The spirit of volunteering, some coordinated nationally through the Good Sam initiative, but often through a local community response has been very encouraging. In many areas, volunteers have been checking on older people collecting and delivering medication and shopping providing regular contact. This has mitigated some of the social effects from COVID-19.

Older people might have often felt isolated and alone for longer periods of time with less opportunity to exercise, potentially impacting on an individual’ strength and balance and increasing the risk of falls and fractures in time.

We are also currently investigating potential impact of the pandemic on older people’s mental health. The recent publication ‘Implementing phase 3 of the NHS response to the COVID-19 pandemic’[10] outlines the NHS approach within the restoration of adult and older people’s community health services as well as other areas.

1. In what ways have multimorbidities (or other issues) complicated the treatment of older people with COVID-19, and would you recommend any changes to the configuration of healthcare services for older people ahead of future stages of this pandemic (or different pandemics)?
2. Do healthcare services have the capacity and coordination to treat the longer-term health implications for older people who have survived COVID-19?
3. Has the pandemic changed (or reinforced) any of your views about the approaches to healthcare for older people?

We are starting to understand the longer-term health implications for all people who have developed COVID-19. We have been creating resources and care pathways to treat and support those who have been admitted to hospital. We cannot however fully anticipate the effect that COVID-19 will have on those who survived but did not access hospital care.

There is possibly a larger population of people for whom the understanding of the impact may not be as well-known and the interaction with other conditions and effect on people living with frailty may not be known for some time.

The pandemic has reinforced the urgency to join up health and care at a local level to develop local ICS at pace and meet the objectives of the LTP through the NHSE/I Ageing Well and Community Services Programme.

This however may need even more support if we have to reduce the inequalities to care that older people require. We urgently need more resources directed specifically to Older People through social care and real clarity around this through a social care settlement.

As people grow old they want to be able to ensure their health needs are met but this needs to be delivered in a person centred way that ensures they are cared for in their own home with carers who know them well and take their individual needs into account, that they can visit friends and family and be connected to their local community and remain as independent as they can for as long as they are able.

2 October 2020