The British Geriatrics Society and the Royal College of Physicians – Written evidence (INQ0049)
Joint response from the Royal College of Physicians and the British Geriatrics Society
When considering the scientific understanding with regards to the biological processes of ageing it is important that consideration is given to the appropriate use of developing evidence bases. Notably, the Department of Health and Social Care are currently investing in the use of genomics which will in time further our understanding and use of genetics.
With specific reference to genomics we recognise that genetic testing can be very beneficial in the diagnosis and treatment and understanding of diseases that are proven to have clear genetic causes and interventions known to improve outcomes, hence genomic sequencing is most effectively targeted towards those people who show symptoms, or have strong family history of, an inherited disease. Caution is urged however as for healthy people, genomic tests will usually only adjust individual risk by modest amounts. Lifestyle factors such as obesity and smoking often make a far larger contribution to overall disease risk than genomic susceptibility.
In addition, it’s important that social determinants of health and health inequalities are considered when understanding ageing. With life expectancy differing by almost 20 years between the richest and most deprived areas in the UK, the government must ensure that reducing health inequalities plays a core part of their strategy for managing an ageing population.
It is increasingly important that public health advice and guidance supports people to live healthier lives. Importantly the government, local authorities and health and care system must recognise the link between poverty and ill-health. Differences in life expectancy differ by almost 20 years between the richest and most deprived areas in the UK which demonstrates the importance of a range of stakeholders working together to co-ordinate public health interventions.
Our members report that one of the largest challenges facing services which deliver public health interventions is the considerable budget reductions that these services have had to work within over the last few years. We note that the current government are increasing the emphasis on ‘social prescribing’ as one approach to supporting people to live healthy lifestyles. We continue to urge the government to increase the resources allocated to develop public health and prevention services via a multi-year funding settlement.
Smoking cessation services are an example of an intervention which supports people to live healthier lifestyles as they age. The RCP report ‘Hiding in plain sight: Treating tobacco dependency in the NHS’ demonstrates that clinicians working in almost all areas of medicine will see their patients’ problems improved by quitting smoking and that systematic intervention is a cost-effective means of both improving health and reducing demand on NHS services. Smoking cessation is not just about prevention. For many diseases, smoking cessation represents effective treatment. We know that smoking cessation interventions are highly effective and cost-effective in treating tobacco dependence in all patient groups. Smoking cessation interventions are also far more cost-effective than many of the treatments and interventions used routinely to treat smoking-related diseases.
Ongoing research will help to establish the role of deprescribing medications to contribute to tackling polypharmacy, especially in older people living with frailty. There is also a growing acceptance of the need to consider frailty and multi-morbidity when writing disease-specific guidelines. There will be an increased implementation of shared decision making to enable patients to make their own choices that are relevant to their own goals. This more personalised approach will help to promote medication adherence, reduce treatment burden and lessen the cost of wasted medications.
Further planned research will establish the impact of side effects due to longer-term use of certain types of medication. For example, observational studies have suggested that drugs with anticholinergic properties increase the risk of developing cognitive impairment and dementia. If confirmed then rationalising the use of some drug classes could have a large impact on population health.
Improved electronic patient records will make it easier for clinicians to understand the history of their patients’ medications better. This will include who prescribed the drug, for what indication and how long ago. This improved access to information will facilitate appropriate medication optimisation, including deprescribing where indicated.
Non-drug approaches will also become better established in clinical practice. This will include improvements in diet, lifestyle and exercise, which can be promoted through government health and social policy and through increased use of social prescribing initiatives. This will tackle polypharmacy, for example, by reducing the need for blood pressure-lowering medications and those used to treat type 2 diabetes. In addition, better implementation of person-centred care can further reduce the prescription of antipsychotic drugs to people living with dementia in both hospital and community settings.
There are various emerging technologies which could be utilised to help older people adhere to treatments. Examples of some of the technologies being developed are:
In addition to technologies role in monitoring patients, technology also presents opportunities for promoting and maintaining exercise and social contact.
There are numerous new and emerging digital solutions entering the market which help older people to live independently. Technology that is currently used regularly by members of the British Geriatrics Society Community Geriatrics Special Interest Group includes:
● Digital fall detectors sound an alarm when a patient falls and are usually triggered by the actual fall. While ‘lifeline’ devices are more commonly used for patients to seek help when they fall, fall detectors are particularly useful for patients who are living with dementia and may forget to press a ‘lifeline’.
● Video-enabled housing allows people living with dementia to be independent but observable. This allows a carer to observe a patient in their own home and check up on them without having to interfere, and perhaps reducing the need to travel to their house. Carers are able to confirm that a patient is safe or identify if they need assistance and thus act accordingly.
● Tracking devices are useful for people who have a tendency to get lost. They can be enabled on a mobile phone or be a standalone device which would either be worn or carried. They can alert carers when a person leaves their house and allow a person with dementia to go outdoors safely. They allow more independence and can be used to assist if the person gets lost.
● Digital solutions in care homes include Skype consultations and kits for taking simple measurements such as oxygen levels and blood pressure. This allows care assistants to take these measurements and monitor over time, reducing the need for GPs, geriatricians and nurses to visit the care home.
There is a growing body of evidence showing that loneliness in older people can have a major negative impact on both mental and physical health. The effect is comparable to the impact of other well-known risk factors such as obesity and cigarette smoking. It is associated with an increased risk of developing coronary heart disease and stroke, an increased risk of blood pressure, and puts individuals at greater risk of cognitive decline. People who are lonely are also more prone to depression.
Research is ongoing regarding the role of both existing and emerging technologies in combatting loneliness among older people. It is important when considering the role of technology in addressing loneliness in older people not to discount those technologies that already exist and may, for some, be considered old-fashioned, in favour of novel technologies. For instance, for many older people, television provides a vital form of companionship, especially if people are unable to leave their homes on a regular basis. Social media, virtual reality and near-field communication have also been used to try to motivate people to take steps to combat loneliness.
Emerging technology also has potential to help to address loneliness. This includes technologies such as socially assistive robots like ‘robotic pets’.
The video-enabled housing described in question 6 is a form of surveillance and therefore the issue of consent and capacity to give consent needs to be considered. An application under the Deprivation of Liberty Safeguards (DoLS) may need to be considered. However, as this allows people to live independently, for which there are significant benefits, barriers to this can be easily overcome.
More broadly we recognise that technology has a role to play in supporting the delivery of health and care, and will become increasingly important in freeing up clinician time to provide high quality patient care. As noted in an RCP report ‘Outpatients: the future – adding value through sustainability’ there are a number of barriers which need to be considered. Notably, the digital literacy and resources of individuals are important considerations. A recent OFCOM survey provides some insight. Smartphone ownership in those aged over 60 years was at 72%, and over 90% for the remainder of the population.
One of the most significant challenges for health and care will be the interoperability of different technologies and platforms to create a single patient-facing self-management toolkit for patients. The diagram below highlights a selection of relevant digital tools which could be combined to create one ‘toolkit’ for individuals if we successfully implement current and developing technologies for the benefits of patients.
Figure 1 Replicated from 'Outpatients: the future – adding value through sustainability'
The Government’s current focus on healthy ageing is to be applauded and much of the work that members of both of our organisations do with older people is focused on this agenda, helping older people to achieve better health outcomes at all stages of the patient pathway. It is important however to remember that much of what is needed to help older people to achieve additional years of health and independence will not be new and emerging technologies but rather getting the basics right. In research published earlier this year, Action on Hearing Loss found that only 54% of CCGs commission an earwax removal service. The other CCGs do not commission this service, do not know if they commission this service or do commission this service but charge people for it. Many older people struggle financially and if they are required to pay for earwax removal, many will not prioritise this. This will obviously have a detrimental effect on their hearing and thus their independence. This is simply one example of ensuring that the basic services are available to help older people to maintain their health and independence.
As the population ages, it’s also key that clinicians feel comfortable and supported to have conversations with patients about the future. We know that at the moment many physicians do not feel confident to initiate these conversations, to handle prognostic uncertainty or to discuss decisions about care and treatment that balance duration and quality of life.
● Economic impacts
● Time spent in work as opposed to in retirement
● Provision of activities and services for active older people
The British Geriatrics Society is the membership body for healthcare professionals working with older people. Membership is multidisciplinary and includes geriatricians, nurses, allied health professionals and GPs. The Royal College of Physicians has a leading role in the delivery of high-quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in the UK and overseas with education, training and support throughout their careers.
As membership organisations representing healthcare professionals, our expertise is very much drawn from the experience of our members. The vast majority of healthcare professionals, including our members, will spend more time caring for older people than any other population group. The NHS workforce is under immense pressure and this pressure will only be relieved when the workforce is adequately resourced and trained in the care of older people. However, in the long term, a healthier older population will improve the quality of life for older people and reduce the time they spend interacting with the health system.
20 September 2019