New York Times (free access)
By Megan Specia, December 29, 2023
For 12 years after her husband died, Norma Fitzgerald tried to maintain her independence, living alone in an apartment on the outskirts of Hull, in northern England, despite her mobility worsening as she reached her mid-80s.
Then one day in the spring of 2022, she suddenly grew dizzy. Her legs gave out, and she collapsed on her apartment floor, unable to find the strength to get up.
She lay there for two days.
Eventually, a neighbor realized she hadn’t seen her for some time and called an ambulance.
“They had to force the door open,” Ms. Fitzgerald, who is now 87, recalled. She was severely dehydrated and spent the next five days in a hospital.
As Britain’s population ages, with almost 19 percent of the population over 65, according to the 2021 census, up from 16 percent a decade before, the needs of an increasingly frail older population are weighing on the country’s health care system.
Along with the National Health Service, or N.H.S., many older people also rely on what is known as social care, a mosaic of private and public support that is plagued by chronic staffing shortages, a lack of nursing home beds and slashed local budgets.
The lack of easily accessible social care, which encompasses everything from home health aides who help with washing and dressing to full-time residential care, means that falls or treatable health conditions can lead to extended hospital stays. That is piling pressure on the N.H.S., when earlier intervention or home support would have been more appropriate.
But what happened to Ms. Fitzgerald after she was discharged from the hospital is an example of an approach that could transform the way that older adults living with complex health conditions are cared for, experts say.
In the past, she would likely have been sent home with little continuing care aside from her family doctor. Or she might have had to move into full-time residential care, losing her independence.
Instead, she was referred to the Jean Bishop Integrated Care Center in Hull, a facility that opened five years ago as a one-stop shop for frail older people. The first of its kind in Britain, it brings together doctors, physical therapists, social workers, and other professionals under one roof. In the course of a few hours, a patient can see a number of clinicians and have diagnostic tests if needed, including X-rays and blood tests, and receive a personalized care plan — all free of charge.
On a sunny morning in June, Ms. Fitzgerald sat knitting a red-and-gray blanket in the center’s bright and cheerful waiting room. She had been brought by ambulance — all patients are offered transportation if needed — from her assisted-living apartment, to see a doctor specializing in geriatric care, a pharmacist, an occupational therapist, and a social worker.
Many geriatric health experts believe this kind of “integrated care,” with a multidisciplinary team addressing all the issues that can impact well-being, from loneliness to immobility, is the future for older people with complex health needs in Britain.
Dr. Dan Harman, a geriatrician and one of the center’s clinical leads, sees his job as trying to prevent crisis rather than simply reacting to it, as in Ms. Fitzgerald’s case. The center contributed to a 13.6 percent reduction in emergency room visits and hospital admissions among people over 80 and a 17.6 percent drop in E.R. visits by patients in care homes in the area between 2019 and 2022, according to N.H.S. data.
In the long run that could lead to substantial savings for the health service and local government, while allowing patients more control over their care.
“Older people were sort of lodged in the wrong places in the health and care system, particularly in emergency departments,” Dr. Harman said. “A lot of people are getting stuck there unnecessarily because we weren’t providing the support in the community.”
Integrated services like this are still rare in Britain, where the social care system is under extraordinary strain. After the 2008 financial crisis, the Conservative-led government oversaw a period of prolonged austerity in which local governments cut spending on social care sharply, leading to a rise in hospital admissions of people over 65. The pandemic and recent high inflation intensified the pressure.
Unlike the National Health Service, social care in England, Northern Ireland and Wales is not free for most people and is often hard to navigate (in Scotland it is free for all.) Anyone in England with assets over £23,250, or about $29,000, must pay for social care themselves or rely on help from family or charities. Many older people say they worry about steep out-of-pocket costs.
The crisis in the sector is not new. In 2011, a government-commissioned independent review, led by the economist Andrew Dilnot, declared the system was “not fit for purpose” and urgently in need an overhaul. More than a decade on, the report’s recommendations have gone unheeded, Mr. Dilnot said in a recent interview with The New York Times.
“The pressures that the strain in social care is creating within the rest of the health service have definitely gotten worse,” he said, adding that without adequate provision, the number of people staying in a hospital when another setting would be better, “can rise incredibly quickly.”
His report recommended a spending cap to limit the amount any individual would have to pay in their lifetime toward social care and protect people from potentially astronomic bills. But the government has delayed introducing a cap until October 2025.
Mr. Dilnot said that while integrated care programs like the Jean Bishop Center were beneficial and could improve older people’s experience through earlier interventions, they wouldn’t prevent the huge financial costs that older people faced if they needed long-term care.
“Fundamentally, they won’t do a great deal unless we address what happens if you end up facing catastrophe,” he said.
For now, charities like Age UK, a British organization for older adults which has local affiliates across the country, often step in to fill the gaps. The charity offers services from advice phone lines to home cleaning to community meet-ups. It also has a befriending service that matches older people with volunteers who visit them weekly.
Alan Walker, 96, was referred to the befriending program to combat the loneliness he experienced while caring for his wife, who suffered from dementia and could no longer speak.
“It’s very hard going sometimes,” he said.
Through the program, Lucy Henn, 28, came every Friday afternoon to spend time with Mr. Walker. It was a simple thing, but it significantly increased his quality of life, he said.
On a summer afternoon, she stopped over to make a cup of tea, which she sat next to Mr. Walker in the living room where he spent most of his days. “We talk about all sorts of things, don’t we?” Ms. Henn said with a laugh.
The cost of care workers, who visited four times a day to help, was steep, Mr. Walker said, but he and Jean had done a great deal of financial planning to ensure their savings would last.
“You think to say to people, ‘Look, you see what’s happening to me. It could happen to you,’” he said.
A few weeks later, he was moved into residential care as his needs grew. His wife, Jean, died in late August, and Mr. Walker died in October.
The expectation that people would be able to save excessive amounts of money to cover the cost of long-term care, including residential care, was unfeasible, said Mr. Dilnot, the economist.
“Most people couldn’t possibly have savings that will be enough if they and their spouse ended up needing 10 years of residential social care,” he said. “It’s not a savings problem, it’s a risk pooling problem,” he added, referring to the concept of spreading the cost of care across the population so no individual faces the risk of unaffordable bills alone.
In October, the lawmaker responsible for social care, Helen Whately, praised the Jean Bishop Center and said that the N.H.S. and Age U.K. were looking at ways to roll out its integrated care model more broadly.
“The future of health care is as much about what happens out of the hospital, as what happens in it,” Ms. Whately said.
For many seeking care, and for their loved ones, like Emma Gawthorpe, 46, the priority is the present. Her father, Alan Gawthorpe, 72, was diagnosed with Alzheimer’s two years ago. As they waited for his appointments at the Jean Bishop center, she told The Times that the service had made a significant difference after they had struggled to get help in the early months after his diagnosis.
“It was a lot of jumping through a lot of hoops, and you need to be really firm sometimes,” Ms. Gawthorpe said. “And unless it’s happening to you, you don’t know anything about it.”
Selected online comments:
- “Gracie”: This new way is an old way and it works. We need more integrated approaches to many things—the siloing of health care, of education, of community resources and services, etc. does not serve people well. Caregivers need to be talking to each other; specialists need to coordinate their care; and community members need more accessible services—-not a la carte, which is expensive, incomplete, and often only serves the people with the most resources well because they know what to seek out and have the money to pay for it.
- “Thomas Wolfe”: Integrated medical care, integrated education and perhaps most of all (it’s also known as the “sharing community”) an integrated community, where people work/play together to solve challenges within their own neighborhoods, villages, etc. No reason why this can’t be done in a small town with 1000 or so people and in a small neighborhood in a city like New York. Think of the implications for climate change, and so much more – people sharing, getting together, developing integrated approaches to childcare, meaningful jobs, etc.
- “CG”: My wife has multiple chronic conditions and was hospitalized several times this year, each time for a different one. Her doctors NEVER talk to each other. I’ve spent enormous amounts of time and energy collecting records and relaying them and medical and prescription information. It’s nothing short of criminal. It’s also obviously inefficient, can lead to critical inaccuracies, and costs everybody money when things have to be corrected or duplicated.
- “Theresas”: Elder care is a significant problem here too in the USA. I’m 78 and watching friends decline and struggle to get assistance. It’s unbelievable that we’ve spent so much money on preK programs but almost nothing on Senior care. Our doctors have no training in geriatric issues so their answer to everything is Tests and more Tests. The only thing they will find out is the person is old. They haven’t a clue about checking B12 levels or ferritin or adding magnesium to lessen aches and pains. They Pooh-pooh Vitamin D levels which might also offer relief. They barely listen as they sit with laptops typing instead of giving the elderly time to speak. Nursing home prices are outrageous, drug costs way too high, home health care workers not getting paid enough. There’s a bursting point here as well as in the UK. This Hull facility sounds like a good first step. Keep up these articles.