Demedicalising old age: acute social care of older people

Even as we emerge from the traditional months of peak demand for acute medical care and overcrowding of hospitals, there are still calls for people to stay away from critically overstretched emergency departments. It is now recognised that it is not younger people with minor ailments or injuries that cannot be accommodated but older people with ‘multiple co-morbidities’.

We now need to take a closer look at this group of elderly patents to evaluate their needs and make better provision for them. What we discover is not a homogenous population who just happen to be over a certain arbitrarily defined chronological age. Older people with acute medical problems require the same management as younger patients. There is evidence, for example, that outcomes from coronary artery stenting may be better in older patients than in younger ones with more aggressive disease.

For other older people who are admitted to hospital it often becomes apparent that their presenting medical diagnosis is not the reason they have been admitted to hospital. Indeed, the admitting diagnosis often turns out not to be correct but a convenient label to justify admission of patients with complex needs, most of which are social rather than medical.

How often have we heard elderly patients complain that they did not wish to be taken to hospital but the care they needed just could not be accessed in any other way? The care they need is variously described as ‘care in the community’ and ‘social care’. However, the most vocal users of these catchphrases are those whose primary interest is acute or emergency medicine. Those who would provide the alternative (general practitioners, public health nurses and other community-based carers) are less often heard.

One thing is clear – older patients with predominantly social needs are not best managed in emergency departments or in acute hospitals. So a couple of pieces of information are needed to evaluate needs and redirect care: first, review the reasons why older people whose problems are not primarily medical end up in hospital. Next, identify those who are at risk and intervene before hospitalisation becomes necessary.

If, as we are told, the requirement is for social rather than medical care then we need a system of acute social care locally delivered. This would avoid some hospital admissions and, more importantly, deliver necessary social care rather than unnecessary and often harmful medical care. 

What then is acute social care? Nothing complex or mysterious and nothing that does not already exist. The main intervention is the provision of extra care immediately the need arises. It may be as simple as a daily visit from a home care team member to provide support until a more detailed evaluation of support needs can be obtained. Or it may require urgent but temporary admission to a respite facility. The idea is to access local support without the need for emergency department attendance and acute hospital admission and thereby leapfrog an expensive and unnecessary step in the care pathway.