Need Help?

Senedd Health and Social Care Committee: Supporting people with chronic conditions

Older man in a checked talking to someone

Senedd Health and Social Care Committee: Supporting people with chronic conditions

May 2023

Introduction

The Older People’s Commissioner for Wales welcomes the opportunity to respond to the Health and Social Care Committee’s consultation on ‘Supporting people with chronic conditions.

As people grow older, the likelihood of having a longstanding illness or chronic condition increases. In Wales, 71% of those aged 65 or older live with longstanding illness.1 Ensuring that people are supported to manage chronic conditions effectively from an early-stage benefits individuals, the economy and society more broadly.

The Commissioner would like to draw the Committee’s attention to the issues below.

NHS and social care services

 Primary care: Access to GPs

Access to GP surgeries was an issue prior to the pandemic and problems remain. People contacting the Commissioner’s Advice and Assistance service have reported a number of issues including inability to get through to a GP practice by telephone; telephone-only consultations; being required to book appointments and order medication online and not being able to do so; requests to take and send digital photographs, which people were unable to do; and problems arranging follow-up procedures after hospital discharge.

The impact of the pandemic, combined with the public reporting of pressures, has deterred older people from accessing health services. Recent research with older people undertaken on behalf of the Commissioner found that 45% were less likely to try to get a GP appointment. Problems accessing GP services, including becoming reluctant to seek treatment, impact on people with existing chronic conditions.

However, this also impacts on diagnosis and management of those who have developed them, limiting opportunities for early intervention.

Access to GPs was also raised in work the Commissioner is undertaking with older people from Black, Asian, and Minority Ethnic communities. It will be important for the Committee to explore the specific experiences of older people from Black, Asian and Minority Ethnic minority communities in relation to chronic conditions. This should be in addition to how ongoing problems with access to GPs currently impairs management of chronic conditions among older people.

Continuity of care and care at home

A recent Age UK report highlighted continuity of care as a key theme in enabling older people with health problems to stay well at home.2 As health needs become more complex with age, older people can be engaged with a number of different health and care professionals. It is vital that different parts of the health service are joined up to make treatment of chronic conditions more efficient so that older people do not have to repeat the same information to a range of different professionals.

Continuity of care and being able to access the same GP allows people to develop relationships with individual GPs which can be helpful in managing ongoing conditions. This can be especially important where older people’s first language is Welsh or a community language – being able to speak to a GP in an individual’s first language makes it easier to explain symptoms and developments. Older people are also ‘experts by experience’ in terms of day-to-day management of chronic conditions and what works or does not. This expertise needs to be recognised by health professionals in the management and recommendations surrounding ongoing treatment and support.

The right support to manage chronic conditions needs to be available close to home in communities. This means increasing the availability of geriatricians and community nurses to meet the needs of older people. The Royal College of Physicians Cymru Wales (RCPCW) and the British Geriatrics Society (BGS) has called for an expansion of the number of virtual wards and ‘hospital at home’ services that provide specialist medical care in the community across Wales, to reduce hospital admissions, enable people to return home more quickly, and improve the quality of patient care.3 The Commissioner is supportive of the RCPCW and BGS position.

Mental health

Mental health issues range in duration and severity, and can themselves be chronic, life-long conditions. Mental health issues are also associated with chronic physical conditions. The Commissioner has previously responded in detail to the Committee’s inquiry into mental health inequalities.4 In terms of self-management and mental health support, older people are less likely to be offered the full variety of types of mental health services and treatment that would be available to younger people, making self-management harder. This point is explored further below but is important when addressing the link between chronic conditions and deteriorating mental health.

Multiple conditions

Research shows that we are more likely to develop a longstanding health condition as we get older. In Wales, 71% of people aged 65 or older live with longstanding illness.5 Prior to the pandemic, Age UK published a collection of statistics on later life. This showed that an estimated 4 million older adults in the UK (36% of people aged 65-74, and 47% of those aged 75+) have a limiting long-standing illness; equating to 40% of all people aged 65+.6

Likewise, over half (54%) of older people have at least two chronic conditions (also referred to as multi-morbidity). The proportion of people with multi-morbidities among those aged 65-74 is 46% but this proportion increases to 69% among those aged 85+. Multi-morbidity increases the likelihood of hospital admission, length of stay and likelihood of readmission, raises healthcare costs, reduces quality of life, and increases dependency, concurrent use of multiple medications and mortality.7

The British Geriatrics Society Statement on ‘Protecting the rights of older people to health and social care’ published in January 2023 argued that services for older people living with multiple long-term conditions should take a coordinated and person-centred approach, including the involvement of geriatric medical teams as appropriate. This can reduce unnecessary investigations and medicines, and support older people to make informed decisions about their future care, treatment and place of care.8 The impact of managing more than one chronic condition needs to be considered as part of person-centred care, including the overall effect on wellbeing.

This includes offering appropriate mental health support. Older people are less likely to be offered the full range of appropriate options as ageism – treating people differently on account of their age and making assumptions – impacts on what support is made available.

The Royal College of Psychiatrists’ Suffering in Silence report highlights discrimination, infringement of human rights, unmet need and neglect of older people in mental health services in the UK.9 Particularly striking is the reference to a randomised control trial in which 121 doctors were given case studies of two identical patients with depression and asked to assess, diagnose and prescribe treatment for them. The only difference was their age: one was 39 and the other 81.

Diagnoses and treatments given to the younger patient were more appropriate than those for the older patient. The younger patient was more likely to be diagnosed with depression and anxiety, but the older patient was diagnosed with dementia or a physical illness. Therapies prescribed for the younger patient were more likely to be relevant and included psychotherapy, pharmacotherapy, and referral for in-patient or specialist treatment. In contrast, the older patient was prescribed supportive counselling.

It is essential that ageism does not affect the mental health support available to older people with chronic conditions. The Committee might like to explore any differences in how the NHS treats chronic conditions in older people in comparison with other population groups.

Impact of additional factors

The latest data show life expectancy falling: the Wellbeing of Wales report, 2022, shows that life expectancy fell in the most recent period available (2018-20), compared to the previous period (2017-2019), and stood at 82 years for women and 78 years for men for 2018-20. However, over the longer term, the fact that more people are reaching later life in Wales is a success story.10 Yet, this means ensuring that services can meet our needs as we get older, including management of long- term health conditions. The right health and care workforce in the right place is integral to this as indicated above.

The impact of the pandemic, the cost-of-living crisis and reported pressures on the NHS are likely to contribute to exacerbating chronic conditions. This might take the form of the impact of cold homes on the health of older people, inadequate food, or reluctance to seek NHS support.

Many older people living with chronic conditions were deterred from coming forward for health or social care by the Covid-19 pandemic and have experienced deconditioning and deterioration as a result. The impact of long waiting lists makes this an ongoing issue, leaving a number of older people living with chronic pain, anxiety and unmanaged health conditions.

Recent research undertaken on behalf of the Commissioner showed that 89% of older people surveyed are anxious about the state of the NHS. In addition, as referenced earlier, 45% said that they were less likely to try to get a GP appointment due to concerns about pressures on the NHS. With regard to the cost-of-living crisis, 64% of older people had cut back on spending in the previous 12 months. Of those who reported cutting back, 84% had cut back on energy and 83% on food shopping.

These actions will have an effect on public health. As part of its work on the cost-of- living crisis, the Welsh Government should work with Public Health Wales and health boards to establish the impact of the cost-of-living crisis on people with chronic conditions, including older people, and develop a plan to mitigate the effects. This is especially important as we head into what is likely to be another difficult autumn and winter in 2023-24.

Prevention and Lifestyle

Age-Friendly Communities

Age friendly communities can play an important role in managing chronic conditions by creating environments that enable people to stay connected, take part in social activities and access local services and facilities. The World Health Organisation (WHO) describes Age-Friendly communities as being places in which older people, communities, policies, services, settings, and structures work together in partnership to support and enable us all to age well. The WHO identify eight essential features of Age-Friendly communities, known as the ‘eight domains’:

  • Outdoor spaces and buildings
  • Transport
  • Housing
  • Social participation
  • Respect and social inclusion
  • Civic participation and employment
  • Communication and information
  • Community support and health

More broadly, the United Nations has proclaimed 2021–2030 the Decade of Healthy Ageing, with WHO leading international action to improve the lives of older people, their families, and communities. The Decade brings together a variety of stakeholders to promote concerted action to:

  • change how we think, feel and act towards age and ageing;
  • develop communities in ways that foster the abilities of older people;
  • deliver person-centred, integrated care and primary health services that are responsive to older people; and
  • provide older people access to long-term care when they need 11

Providing support for older people with chronic conditions is an important aspect of delivering on both Age Friendly Communities and the Decade of Healthy Ageing, with a focus on responsive care but also the holistic community connections which help people stay well. The role of Age Friendly Communities in supporting older people with chronic conditions should be further explored, including the connections across the eight domains above. Support for chronic conditions should not be seen as a stand-alone health issue but part of a wider environment where transport and social participation, for example, are also part of effective management.

The Commissioner is recognised as an Affiliate of the World Health Organisation’s Global Network of Age-Friendly Cities and Communities and works to promote age- friendly progress at the local, regional, national, and international levels. The Commissioner’s Office advocates for the work of the Global Network in Wales, seeking to advance knowledge and action on age-friendly environments. The Commissioner’s Office also works as a catalyst at the national and regional level by promoting the age-friendly approach as well as providing guidance and support to local authority-led partnerships who wish to become members of the Global Network.

The Welsh Government continues to be supportive of Age Friendly Communities, citing the wish for Wales to be part of the global movement towards age friendly communities as part of the Age Friendly Wales strategy.12 On 9 May 2023, the Deputy Minister for Social Services, Julie Morgan MS, announced that investment in Age Friendly Communities would continue in 2023-24.13 This funding supports the work of local authorities to become more age friendly, building towards membership of the Global Network.

The Age Friendly Communities approach can support people in the management of chronic conditions by creating supportive, connected, and accessible environments.

Employment

Chronic conditions have an impact on employment: ill health, including poor mental health, has influenced a number of older people’s decision to leave paid employment or not return following the pandemic.14 The backlog in NHS treatment as a result of

the pandemic has also impacted older workers’ ability to stay in paid work. ONS research undertaken across Great Britain found that around 1 in 5 workers aged over 50 who had left employment since the start of the pandemic said they were currently on an NHS waiting list for medical treatment.15

Among older people who want to work but are not employed, 39% of 65–74-year- olds say a long-term illness or condition, or a disability is the reason why they are unable to work.16 ONS research also shows that between 2019 and 2022, there was a 16% increase in economic inactivity because of long-term sickness among people aged 50-64.17

The right support to manage chronic conditions plays an important role in ensuring we can continue to work as we grow older. Flexible working is vital to enable older people to manage chronic conditions and the Welsh Government should examine what more it can do to actively promote flexible working beyond its immediate employed staff. This includes measures to encourage businesses in receipt of Welsh Government support to offer flexible working options to all staff.

The Welsh Government should continue to focus on reducing the numbers of older people waiting for NHS treatment, including those needing to manage chronic conditions, setting out the steps being taken.

Summary

Given the likelihood of developing a longstanding health condition increases with age, as part of this inquiry, the Commissioner would like the Committee to:

  • Explore how problems accessing GPs impact on older people in terms of managing or being diagnosed with a chronic This includes the specific experiences of people from Black, Asian and Minority Ethnic communities.
  • Consider how the Welsh Government and public bodies can implement better continuity of care for older people, through ensuring that the different health professionals involved in care work in a more coordinated way and by being able to see the same GP.
  • Examine ways to make services to manage chronic conditions more community based, by increasing the number of community nurses and community access to geriatricians.
  • Investigate any differences in how the NHS treats chronic conditions in older people, with a special focus on the types of mental health support offered, and whether this is impacted by ageism.
  • Consider the role of Public Health Wales in preventing chronic conditions, what more can be done, and how they can work with the Welsh Government and health boards to assess and mitigate the impact of the cost-of-living crisis on older people with long-term illness, developing a specific plan.
  • Assess the contribution that Age Friendly Communities can make to supporting older people with chronic conditions in managing ill health as well as possible, including the connections across the eight domains referenced
  • Explore solutions for how best to reduce the numbers of older people waiting for NHS treatment, including those needing to manage chronic conditions, and specifically consider what the Welsh Government can do to help older people stay in employment.

 

 

Notes

1 StatsWales (2020) General health and illness by age and gender, 2016-17 to 2019-20. Available at: General health and illness by age and gender, 2016-17 to 2019-20 (gov.wales)

2 Age UK (2023) Fixing the foundations: Why it’s time to rethink how we support older people with health problems to stay well at home. Available at:FTF-feb-2023.pdf (ageuk.org.uk)

3 Royal College of Physicians Wales (2022) No place like home: using virtual wards and ‘hospital at home’ services to tackle the pressures on urgent and emergency care. Available at: No place like home: using virtual wards and ‘hospital at home’ services to tackle the pressures on urgent and emergency care | RCP London

4 Older People’s Commissioner for Wales (2023) Mental Health Inequalities. Available at: Mental_Health_Inequalities_-_response_from_Older_People_s_Commissioner_for_Wales.pdf (olderpeople.wales)

5 StatsWales (2020) General health and illness by age and gender, 2016-17 to 2019-20. Available at: General health and illness by age and gender, 2016-17 to 2019-20 (gov.wales)

6 Age UK (2019) Later Life in the United Kingdom. Available at: Microsoft Word – FINAL MAY LLFS.docx (ageuk.org.uk), p.8.

7 Ibid., p.8.

8 British Geriatrics Society (2023) Protecting the rights of older people to health and social care Available at: Protecting the rights of older people to health and social care | British Geriatrics Society (bgs.org.uk)

9 Royal College Psychiatrists (2018) Suffering in silence: age inequality in older people’s mental health care. Available at:college-report-cr221.pdf (rcpsych.ac.uk).

10 Welsh Government (2022) Wellbeing of Wales, 2022. Available at: https://www.gov.wales/wellbeing-wales-2022-healthier-wales-html#103947

11 World Health Organization (2021) Decade of Healthy Ageing (2021 – 2030). Available at: Decade of Healthy Ageing 2021 – 2030 (who.int)

12 Welsh Government (2021) Age friendly Wales: our strategy for an ageing society. Available at: Age friendly Wales: our strategy for an ageing society [HTML] | GOV.WALES

13 Welsh Government (2023) Oral Statement: Update on the Delivery Plan for Age Friendly Wales: Our Strategy for an Ageing Society. Available at: Oral Statement: Update on the Delivery Plan for Age Friendly Wales: Our Strategy for an Ageing Society (9 May 2023) | GOV.WALES

14 Office for National Statistics (2022) Reasons for workers aged over 50 years leaving employment since the start of the coronavirus pandemic: wave 2. Available at: Reasons for workers aged over 50 years leaving employment since the start of the coronavirus pandemic – Office for National Statistics

15 This rose to 35% for those who left their previous job for a health-related condition. See Ibid.

16 Older People’s Commissioner for Wales (2022) Understanding Wales’ ageing population: key statistics. Available at: 230307-Understanding-Wales-ageing-population-24-November.pdf (olderpeople.wales), p. 9.

17 Office for National Statistics (2022) Half a million more people are out of the labour force because of long-term sickness. Available at: Half a million more people are out of the labour force because of long-term sickness – Office for National Statistics (ons.gov.uk)

 

Need to talk to someone? Email us or message us