Silver Book

Executive summary: Despite the majority of urgent care being delivered in the primary care setting, an increasing number of older people are attending emergency departments and accessing urgent health and social care services. This is partly related to the demographic shift that has resulted in a rapid increase in the number of older people, but may also be due to lower thresholds for accessing urgent care. Over the next 20 years, the number of people aged 85 and over is set to increase by two-thirds, compared with a 10 per cent growth in the overall population. Recent national reports including from Patient UK, Care Quality Commission, NCEPOD and the Health Service Ombudsman highlighted major deficiencies in the care of older people in acute hospitals ranging from issues around privacy and dignity to peri-operative care. Older people are admitted to hospital more frequently, have longer length of stay and occupy more bed days in acute hospitals compared to other patient groups. There is a pressing need to change how we care for older people with urgent care needs, to improve quality, outcomes and efficiency. Emergency departments need to be supported to deliver the right care for these patients, as no one component of the health and social care systems can manage this challenge in isolation; implementation of improved care for older people requires a whole system approach. Important factors in primary care that impact on the use of urgent care services include a timely primary care response and ready access to general practitioners. More community based services with a rapid response time may reduce the need to access secondary care. There needs to be better communication between ‘in-hours’ and out of hours services. The ambulance service has a key role to play and can be an important contributor in doing things differently – for example, referring non-conveyed patients directly to urgent care, community and primary care services, including falls services. Attendance at the Emergency Department is associated with a high risk of admission for older people, so the nature of the service and the environment in which it is provided needs to change to reflect the changing nature of health care in the 21st century, the bulk of which relates to older people, and increasingly frail older people. Dedicated teams delivering comprehensive geriatric assessment can support this, but in themselves are not sufficient to realise whole system change. Services in all settings including health and social care need to improve their communication and handover, and greater use of the voluntary sector is to be encouraged. In acute medical units, greater use of geriatric liaison services should increase the proportion of older people able to be managed in the community setting. In all settings, staff need to develop their understanding and confidence in managing common frailty syndromes, such as confusion, falls and polypharmacy as well as issues such as safeguarding in older people. These syndromes are commonly overlooked, but attention to these has the potential to greatly improve outcomes. There needs to be greater working across disciplines, both between professions and within professions. Finally, commissioning evidence based integrated health and social care systems that address care across the continuum will help deliver safe, efficient, effective and a high quality holistic care for frail older people in the years to come.