Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Base care on need, not age

BMJ 2016; 355 doi: (Published 28 October 2016) Cite this as: BMJ 2016;355:i5788
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}

In 2010 the NHS chief, David Nicholson, proposed a revolution in hospital inpatient care for older (not younger) people, akin to the closure of long stay psychiatric hospitals.1 But hospital admissions of older people continue to rise, and delays in discharge have worsened alongside fewer beds.2

One recurring policy idea that defies evidence and experience is that most “high need, high cost”3 older people can be kept away from hospital through lower tech, lower cost community interventions.4 5 But, in describing inappropriate occupancy of acute beds by these pesky old folk who could hypothetically be cared for elsewhere,6 7 soundbites are not evidence based solutions.

Systematic reviews of evidence for reductions in admissions, bed occupancy, and cost, or for better outcomes resulting from care closer to home, have been far from conclusive.8 9

The most recent promulgator of the idea was the surgeon and former health minister Ara Darzi, who wrote, “We need to keep high cost patients out of hospital.”10 His logic? A small percentage of patients account for a high percentage of hospital occupancy and spending. There’s no doubting that.3 11 12 Darzi described these patients as “typically older, with multiple chronic conditions” and “costing 400% more than the average.”

How dare they? Darzi failed to mention that many also have acute illness or injury and rapid decompensation that complicate their frailty, as well as multiple long term conditions requiring an acute response.13 14 He didn’t propose keeping younger people away from hospitals in their hour of need.

Endemic ageism exists in all health and care settings

The 2010 Equality Act forbids age discrimination in public services.15 Yet the Centre for Policy on Ageing has found endemic ageism in all health and care settings.16

No one doubts that we should do more to keep older people at home—or that hospitals can be harmful, depersonalising environments. As the geriatrician Marion McMurdo said after Nicholson’s announcement, “Few national providers would make such a blatantly ageist inference that its core business was too tricky to manage and propose solving ‘the problem’ by ceasing to attempt to deal with it.”17

The notion that people with the highest acuity and complexity threaten the system and should be kept away is ageist. It runs counter to Darzi’s own commitment to quality in care. Should we cherry pick younger patients with less complexity and lower need, who will be cheaper to help?

The only example in Darzi’s column (although without data on outcomes) was a scheme in which postal workers deliver prescriptions and link elderly people with care services.18 This sounds like a noble idea to help anticipate and prevent problems upstream, but it’s not much use if you’re 85 and have a hip fracture, stroke, hypothermia, or sepsis.



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