Views from the frontline: an elderly care physician’s prescription for the NHS

1 November 2016

The NHS is 66 years old and struggling with multiple co-morbidities; it is has been prescribed a series of remedies and the number only increases as it consults specialist-after-specialist. As an elderly care physician I often see such patients in clinic. My job is to try a fresh approach and treat the whole patient, not a single medical problem. It is a balancing act between different organ systems, for example, medication that helps the heart can damage the kidneys. It is not always easy but ensuring patient wellbeing is the principal concern, improves outcomes in the elderly. Our 66 year old NHS needs the same approach otherwise we will continue to see changes helping one area but harming another.

Nowhere is this more evident than the interface between primary and secondary care in the management of Ambulatory Care-Sensitive Conditions (ACSC’s). ACSC’s are conditions, such as heart failure or cellulitis that could be managed in the community, but often lead to expensive emergency admission to hospital. The hospital admission rate for ACSC’s has increased by 2 per cent per year since 2002, in 2009-10 the cost of emergency admissions for ACSC’s was £1.42 billion. Previous initiatives to prevent such admissions have put too much strain on primary care services and been ineffective as a result. However this is changing; the generalists are having their turn.

At many hospitals (including my own) ambulatory care clinics are being developed. These allow clinicians to see patients with ACSC’s as outpatients rather than admitting them to hospital. Patients can have investigations, medical review and treatments, such as intravenous antibiotics, within 24 hours of an emergency department attendance or GP contact. They provide the benefit of hospital resources and consultant lead care without the need for hospital admission. Furthermore, they do not place extra burden on community services. The balancing act is achieved.

Avoiding unnecessary hospital admissions in the elderly is one of the best things a doctor can do for them. The elderly are prone to long admissions and these often lead to worse health outcomes and an increase their long-term care needs. Ambulatory care services have the potential to reduce elderly admissions significantly.

The use of an ambulatory care service aids both community services and hospitals. As opposed to fractious conversations about how and where such patients are treated, ambulatory care has been designed around patients to offer specialist treatment in a hospital setting whilst avoiding admission. The ever ageing population with its multiple co-morbidities have forced health professionals to develop novel medical approaches. At long last this is one small step that is helping our ageing NHS is benefit from a similar approach.

Dr Letty Dormandy, Geriatric Registrar, Newham University General Hospital



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