The Scottish Government

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5.0 Improving and Maintaining the Health and Wellbeing of Older People in Scotland

The Scottish Executive wishes to see a Scotland which has increased healthy life expectancy. In other words, as life expectancy increases, we want to see an increasing proportion of those extra years lived in health and independence. We also want to see a Scotland where people are enabled to manage long term health conditions, and receive the care and support they need.

It must be stressed that for the great majority of the "younger old", life is likely to be healthy and active, and may be so well into the eighth and ninth decades, with a proportion of even the oldest enjoying good physical and mental health and remaining active in their communities. That is what we would hope for ourselves, and what Scotland as a nation must work towards, while at the same time ensuring that all those in need of health and social care in later life have access to it, at home or as near home as possible.

Improving health in middle age and beyond is an achievable goal, but the clustering of health problems towards the end of life remains a biological fact. Older people are more likely to suffer from non-communicable illnesses - examples being arthritis, diabetes, cardiovascular disease, stroke disease and dementia. Some such long-term conditions can to some extent be deferred or minimised in their impact by healthy lifestyles and good preventive interventions, but caring for people with them will undoubtedly be the main task of Scotland's health and social care systems in the future.

Scotland faces the real challenge of poor diet, obesity, diabetes, alcohol related harm, and mental health problems. We are taking a robust approach to tackling these public health problems, and in the long run we want to see a Scotland which has increased healthy life expectancy, where older people are confident and capable, and where people report good mental health and well-being.

The following key points were identified in responses to the consultation:

The key ingredients for good mental and physical health in later life were seen as physical activity, diet, support from family and friends, mental stimulation and security. For many, the elements of good health are interlinked. Most people recognised that their health and well-being was about far more than the NHS and their access to it, and they acknowledged that healthy lifestyles mattered a great deal.

However, many respondents noted that their behaviour did not reflect such knowledge, and only a few regarded themselves as actively preparing for a healthy old age.

A wide range of services and support were identified as being needed to ensure good physical and mental health.

Some respondents also noted that a holistic approach to life is needed, with healthy diet and physical activity from an early age and not just for older people. Additionally, a preventative approach, encouraging good health throughout an individual's life, is important.

Good health and care services were high on the list of priorities, as was the need for advice and information.

Encouragement for older people to participate in, or make use of, available opportunities was seen as important, with good, accessible amenities to allow them to do so. Opportunities to participate in active leisure and sports should be available and accessible to older people.

Health Care Policy

Significant progress in furthering the interests of older people has been made in the lifetime of the Scottish Parliament. Among its first legislative achievements was the Adults with Incapacity (Scotland) Act 2000, which swept away obscure and ineffective provisions; protected the interests of people with cognitive impairment; facilitated good decision-making about health interventions; and helped their families to ensure their best care.

Building a Health Service Fit for the Future (the Kerr Report), published in May 2005 (Scottish Executive, 2005a), was a thorough review of the future shape of the NHS in Scotland, taking account of demographic pressures, the changing expectations of patients, improvements in healthcare technology, and workforce legislation and pressures. It signals a move towards preventive care and management of long term conditions as the right approach for the 21st century, reflecting the needs of an older population in particular.

Chapter 4 of the report, 'Changing the Balance of Care', is a thoughtful and considered section about the care of older people. It identified three dominant and related issues in the Scottish population's need for health care:

• the growth in the number of older people and in particular the number of relatively frail older people living at home;
• the emergence of chronic disease as the main challenge facing the health service;
• the need to tackle avoidable emergency hospital admissions.

In its response to the Kerr report Delivering for Health (Scottish Executive, 2005c), the Scottish Executive recognized these challenges and set out a new vision for service delivery, based on:

• a fundamental shift in the way the NHS works, from an acute, hospital-driven service to one that is community based;
• a focus on meeting the twin challenges of an ageing population and the rising incidence of long-term conditions;
• a concentration on preventing ill-health and treating people faster and closer to home;
• a determination to develop responses that are proactive, modern, safe and embedded in communities.

These developments are a practical response to radically changing circumstances and their implementation will "future-proof" Scotland's NHS for the benefit of all, not just its older citizens. The maxim is that if we get it right for older people, we will get it right for everyone. Older people will have the necessary access to acute care and high technology interventions when they need them, while far more in the way of support and relatively simple health care interventions will be available to them at or near home.

The Scottish Executive has recognized that the main challenge in the health care of an ageing population is that of improving the care of long-term conditions, and strategies for this are being developed and implemented. It is now accepted that the care of frailer older people with continuing health problems should focus on better support for them at home (together with support for carers), early recognition and management at home of new or increasing health problems, and a diminishing use of the "default option" of admission to an acute sector bed; which for the frailest elderly, carries the greatest risks such as acute confusion, hospital acquired infection, loss of function and, in the worst case, loss of home.

The avoidable repeated admissions of older people with longer term conditions require to be addressed, with better care at home (and support for carers) the goal. To achieve this, the Scottish Patients at Risk of Readmission and Admission ( SPARRA) initiative was launched in June 2006 to help identify patients who would benefit most from intensive care management at home as a first step towards providing intensive care management in the community to the most vulnerable across Scotland by the end of 2007.

The Framework for Rehabilitation will set out the vision for delivery of rehabilitation services in Scotland. It will provide clear direction for strategic and local co-ordination of all rehabilitation services to ensure a locally-based, patient-focused, integrated, seamless approach to the delivery of services. A key focus of the Framework will be on how to deliver rehabilitation services to older adults.

Palliative Care

Research shows that most people not only wish to remain at home as long as possible; a majority would, if services were available to support them there, prefer to die at home too. Recent developments in palliative care recognize this, and more and more palliative care is now being delivered away from hospices and hospitals. For example, services in Dumfries and Galloway offer palliative care provided by multi-skilled teams backed up by consultant advice and expertise, and in-patient care if and when required; and succeed in doing so across a far-ranging rural catchment area.

As life expectancy advances, and more and more people live into the eighth, ninth and tenth decades, dying will become increasingly a matter for the old and very old. In this, as in so much else, rising expectations of service provision will be challenging, but good palliative care - with the option of remaining at home for as long as possible - will be an important component of good health care for our ageing population.

Dementia

Unless there are major advances in prevention, the number of people with dementia will double in the next 40 years, and the number of those 85+ with dementia will treble. There are currently 64,000 people with dementia in Scotland, and this is projected to increase to around 82,000 in 2020 and to between 125,000 (Drivers for Change, 2005) and 135,000 by 2040 (Alzheimer Scotland website, October 2006).

Alzheimer Scotland recently launched an awareness-raising leaflet Good for You, Good for Your Brain and the Scottish Executive is working with NHS Quality Improvement Scotland to produce an Integrated Care Pathway and accreditation process for dementia care and other main mental health conditions, which will be available in 2007.

In Delivering for Mental Health, published in December (Scottish Executive, 2006b), we committed to work with the Dementia Services Development Centre at Stirling University and NHS Forth Valley to undertake a pilot programme in improving dementia services, which will be evaluated in 2008. The Dementia Services Development Centre continues to do research and to provide information, publications and literature reviews on all aspects of dementia.

Health and social care services will need to ensure they can adapt to meet the needs of increasing numbers of people with dementia.

Ensuring quality of care for older people

"Care is the key. Enablement is the aspiration. Good health care is about caring for people - with the emphasis on 'people' - to enable them as much as possible. I am heartened to see that this principle is the lynchpin of Delivering Care, Enabling Health."
Olivia Giles, patient, quoted in the foreword to Delivering Care, Enabling Health,
(Scottish Executive, 2006a).

People everywhere are rightly concerned about quality of care, whether for themselves or their loved ones. Individuals, irrespective of age, should be treated with respect and dignity and should receive the same quality of care no matter where they live.

Establishment of the Care Commission as the national independent regulator of care services in Scotland has been a major achievement. The Care Commission inspects the quality of care services against the requirements in the Regulation of Care (Scotland) Act, its associated regulations and the National Care Standards which were developed and published by Scottish Ministers.

The key aim of the Commission is to improve the quality of life of older people, and others, by raising the level of care and support individuals receive. The principles underpinning its work are:

• keeping people safe;
• promoting dignity and choice; and
• supporting independence.

The Care Commission's website provides up to date information about registered care services including inspection reports, complaints and enforcement. A new search facility has been added to the website so that anyone looking for a care service can ask for information on services located within a specified area. This will allow an older person looking for a care home to access information on homes within, for example, 5 miles of their own home or that of their family.

The National Care Standards were developed with people who use services, their families and carers, along with staff, professional associations, regulators from health and social care, local authorities, health boards and independent providers. They are user-focussed and describe what each individual person can expect from the service provider, focussing on the quality of life of the person using the service. The standards are based on the six principles of dignity, privacy, choice, safety, realising potential, equality and diversity. They recognise that services must be accessible and suitable for everyone who needs them, and reflect the strong agreement that the experience of having services is very important and should be positive, and that service users have rights.

As a priority, we will make resources available to ensure that the National Care Standards are well publicised so that people have a clear understanding of what they should expect from Care provision.

In December 2003, the Which? consumer group submitted an informal super-complaint to the Office of Fair Trading ( OFT) on the £8 billion UK Care Home Sector, focusing on care home fees, clarity of contracts and state of information channels. The OFT undertook a market study and published a report - "Care Homes for Older People in the UK" in May 2005. The OFT research highlighted the need for ready access to clear and relevant information to help people make decisions about the right care for them at a particularly difficult and stressful time in their lives. The OFT discovered that information was often difficult to access and there were information gaps and a lack of clarity, and recommended that:

The government should establish a central information source or 'one stop shop' for people to get information about care for older people. This could, for example, be an internet site supplemented by a telephone helpline or a one-stop-shop with information about care for older people.

The Scottish Executive noted that, while much of the information is available, it is held in a number of different places which can make it difficult to access. The Scottish Executive accepted the recommendation and agreed to work with existing providers to develop a central information service. Initial scoping has been undertaken and a feasibility study will commence shortly.

With the care of older people now the main task of the NHS, it is important that clinical research reflects this reality and supports such care by establishing the evidence for best practice. Older people can be disadvantaged because they are excluded from clinical trials on the basis of arbitrary upper age limits, with an estimated 15% of trials excluding them in this way, with obvious consequences for the utility of such research findings in the care of older people (McMurdo, Witham and Gillespie, 2005). The Funders' Forum for Research into Ageing and Older People, which brings together the main Research Councils including the Medical Research Council, is considering this issue. Over time it is expected that this Forum will engage with the research community to improve the quality of ageing research, including the conduct of trials.

In March 2006 the Chief Nursing Officer for Scotland established a new post of Nurse Consultant for Older People in Care Homes in Scotland. The aim is to maximise the quality of life of residents in care homes by enabling, empowering and supporting staff in this sector to deliver high quality, evidence-based care.

The recently established Multi-Agency Inspection of Services for Older People sets out to examine the effectiveness of collaborative working primarily between health, social work and social care services. This work, which was piloted in Tayside in October 2006, has been developed jointly by NHS Quality Improvement Scotland ( QIS), the Social Work Inspection Agency and the Care Commission. Inspections will consider the way in which better outcomes for older people are being jointly achieved, for example through speedier assessments; more effective setting up of complex care packages to support people at home; promoting self-care; and reducing delayed discharges from hospital.

Delivering Care, Enabling Health (Scottish Executive, 2006a), sets out the Nursing, Midwifery and Allied Health Professions' ( NMAPH) contribution to Delivering for Health (Scottish Executive, 2005c). It has an emphasis on the core principles of these professions - caring about people, enabling their self-care skills and protecting their safety and rights. NMAPHs already make a significant contribution to health services and are key elements in determining the quality of patients' experience. This policy direction and associated implementation plan identifies actions that will enable them to continue as key players in taking forward a progressive health care agenda for all, particularly older people, and to harness their contribution to implementing Delivering for Health.

Involving People

Services for older people in Scotland, now and in the future, are likely to perform far better if the views of today's and tomorrow's older people are fully taken into account. In preparing this Strategy, wide consultations with groups and individuals were seen as essential, and proved to be of great value; and, as services evolve over the years to meet the needs of demographic change, the views of users will continue to influence developments.

Patient Focus and Public Involvement ( PFPI) mechanisms are in place across NHS Scotland to ensure services where patients, carers and communities are involved in improving the quality of care and in influencing priorities and in planning services. As part of this approach, the Fair for All-Age initiative has been established to support NHS Scotland, to recognise and respond to the specific healthcare issues affecting older and younger people.

Health Improvement

Everyone wants to be healthy in later life, and longer healthy life expectancy will bring benefits not only for the individual but also in reducing the societal consequences of ill-health and increased dependency in later life. Already there is a broad understanding of what must be done. Respondents to the consultation correctly identified factors such as diet, physical activity, drinking and smoking and the importance of activity and social contact in determining health now and in the future. Many, however, recognized that such lifestyle changes were not always easy to achieve.

Changes are easier for some than for others, and health behaviours such as smoking and drinking that can have serious later-life consequences are strongly related to life circumstances. We have in Scotland a widening gap in terms of life and healthy life expectancy between the most and least affluent, with health-related behaviours such as smoking and poor diet much more prevalent in our most deprived communities. We need to tackle life circumstances, health-related behaviours and health care factors too if we are to narrow the increasing health gap between the affluent elderly and the poor elderly.

So if maximum health gains are to be achieved more widely through people looking after themselves better, for many it will be done best not in isolation but in partnership with health care professionals, both in the positive promotion of good health, and in the management of emerging health care issues. And since health and wellbeing are also influenced by the environment, again with the least affluent the most disadvantaged, the public should be able to influence community planning partners to assess any new initiatives in the community for their impact on the health of the population.

Substantial improvements have already been achieved in Scotland's health, with rising life expectancy and, in recent years, a dramatic fall in premature deaths from diseases such as coronary heart disease ( CHD) and stroke. Further improvements are anticipated, and the public health White Paper Towards a Healthier Scotland (The Scottish Office, 1999), set targets to halve the death rates between 1995 and 2010 from CHD and stroke in those aged under 75. Progress has been good, and in 2004 the target for CHD was raised to a 60% improvement.

However, there remains in Scotland a midlife cohort of men and women with high levels of heart disease and other long-term health problems. As a result, the next generation of older Scots may be more dependent and more in need of health care than older people in other parts of the UK, so the task of addressing health promotion and disease prevention in the current 40-60 age band is an urgent one.

The Scottish Executive has identified its priority areas for health improvement focused on physical activity (including falls prevention for older people), smoking, alcohol, diet and mental health and well-being. The Scottish Executive takes the mental health and well-being of older people seriously and recognises the rising expectations of the coming generations of older Scots; both for their own experience, and for the quality and accessibility of the support and services they may require. These priorities are discussed in more detail in Annex B.

There are some grounds for optimism. We know that for many of the commonest and potentially most disabling long-term conditions, early identification and good preventive care can prolong healthy life expectancy, and that such interventions may have most to offer in our most deprived communities. This approach, known as Keep Well, is being piloted in five Community Health Partnerships in 2006, focusing on 45-64 year olds most at risk of cardiovascular disease, and providing them with effective treatment and services, and regular monitoring and follow-up. Lessons learned will have major implications for NHS service redesign and the future shape of primary care services.

Physical activity

Let's Make Scotland More Active: A Strategy for Physical Activity (Scottish Executive, 2003b) devotes a chapter to the importance of physical activity for adults in later life and makes recommendations to secure the provision of support for physical activity in the community and residential care. Remaining physically active is critical to continued good physical and mental health in older life. It is clear from a wide range of evidence and reviews that physical activity in people in later life is effective in dealing with many health problems as well as providing an opportunity to meet new people and remain mentally active. In particular, physical activity develops and maintains strength, develops and maintains good balance and is effective in preventing and treating depression and mood disorders. Even among frail and very old people, trials show positive results for people who become more active.

The Executive is working with the Health in Later Life Team at NHS Health Scotland on the delivery of the physical activity work programme; older adults have been identified as a strategic priority. Our plans to promote physical activity for the 55+ age group include the following:

• The provision of support and development to professionals working with older people based on the learning from a training needs analysis.
• Supporting the introduction of the British Heart Foundation and NHS Health Scotland 'Active for Later Life' guidance with dissemination and training, closely linked with the training needs analysis mentioned above.
• Supporting the Falls Prevention Work through a mapping exercise in partnership with NHS Quality Improvement Scotland.
• Supporting the national roll-out of accredited chair-based exercise programme.
• Working with the Care Commission to extend the remit of community of practice to include physical activity (currently nutrition only); an education programme will be developed around physical activity to increase knowledge and skills amongst community dieticians.
• Disseminate and promote lessons learned from innovative local initiatives such as Braveheart, based in Falkirk, which is providing training for peer volunteer mentors working with cardiac rehabilitation patients. Physical activity forms a significant aspect of the peer support.
• Development and delivery of specific interventions designed to promote walking for those in later life, building on the success of Paths to Health.
• Training staff in residential care and similar settings in how to support residents to benefit from physical activity.
• Support community-based prevention of falls programmes.
• Encourage and support more accredited volunteer trainers running exercise groups targeted at adults in later life.
• Better targeting of resources for the most deprived groups and areas, linking exercise and efforts to improve mental health and well-being.

We are working well with our planning and delivery partners, such as NHS Health Scotland, local authorities, Community Health Partnerships and sportscotland to ensure that all health, social care and public services for people in later life include the promotion of physical activity.

Food and Health

The importance of a healthy diet was recognised in the consultation as an important feature of maintaining health and well-being in older years. We want everyone in Scotland to be aware of the health benefits associated with healthy eating. We want to make it easier for people, especially those in low-income areas, to have choice in accessing healthier options for food cooked in the home and meals enjoyed in public places. Older people have particular needs associated with food and diet and we will include a specific section addressing this as part of our developing food and health delivery plan. The plan will look at:

• Preventing poor dietary habits and malnutrition developing through changing life circumstances, such as becoming single and losing structured family meal times;
• New food provision patterns, for example, in supported and sheltered accommodation and in the community, as well as in hospitals and residential care - where we are already developing nutrition and catering standards and best practice guidelines;
• Encouraging the preparation and eating of meals as part of well-being

Future Challenges for health improvement and health care services

Scotland aspires to a situation where the population enjoys an enhanced quality of life and where older people can continue to actively contribute to society for as long as they wish. A healthy population is not only good for the individuals who benefit, it is essential for the economy of the country. We need to continue to take steps to reduce health inequalities and maximize good health. Scotland has had a poor track record in health but is now actively driving forward a multi-sectoral integrated health improvement programme that is beginning to pay off. Smoking is being phased out of our culture through both the legislation preventing smoking in enclosed public places and expanded support for smoking cessation services. Nutrition standards are being set and developed across the public sector and the significance of physical activity in maintaining and improving physical and mental health in people of all ages is increasingly acknowledged. Recent improvements in audiology services are hugely important to older people whose lives can be seriously restricted by hearing problems. Innovative work in anticipatory care is helping us to tackle problems of health inequalities before they become entrenched.

Initiatives such as the new free eye test will also impact particularly on older people. The new NHS eye examination was introduced in Scotland on 1 April 2006. This examination is free to all UK residents and those overseas visitors exempt from NHS charges who receive an NHS eye examination in Scotland. The new examination has been redesigned to be tailored to meet the symptoms and needs of the patient, taking into account their history and symptoms. The new eye examination includes certain set procedures as well as patient specific procedures depending on the patient's age or condition. It may be that not every test or procedure required by a patient can be carried out at the one visit. Under the new service, repeat examinations are also provided free of charge to the patient. The new eye examination allows for the management of a wide range of common conditions in the community and will also significantly reduce inappropriate referrals to secondary care.

Health improvement will need to be the responsibility of all sectors and of everyone in Scotland. We can all help to develop Scotland as a health promoting environment where everyone has access to the information, skills and learning they need to enjoy a healthy, vital life and to reach their older years in good health. Adequate support will be needed for those with poor health or disability to help them live life to their maximum potential. Specialised healthcare services will have to adapt still further. They will need to focus not only on increasing care and support for older people, but also on developing innovative approaches to service provision for smaller numbers of younger people, who have the same right to the best skills and care.

We can expect that these measures, and the changes we will be making now, will continue to improve healthy life expectancy now and in the future. But it will be the response of us all as communities, families and individuals that will ultimately determine whether future generations of Scots will reap the full benefits of these changes.

Challenges for providers of health improvement and health care

• Educating and encouraging individuals to take more responsibility for their own health
• Understanding, communicating and co-ordinating the necessary contribution of all sectors and settings in improving health
• Making an impact on upstream or disease prevention actions
• Adapting universal health care service provision to anticipate needs and to adjust to the changing demographic

Conclusion

Much is happening to benefit the health and well-being of older people in Scotland. Already there have been major gains in life expectancy, and as our population ages there is much more to do. The older people of tomorrow may well take more interest in maintaining healthy lifestyles, with some needing more encouragement and support than others. Developments in leisure and sport that encourage greater participation by older people will pay dividends by promoting activity and hence health. The emphasis in health care will change, with better management of long-term conditions the major goal.

For frailer older people, a major shift in the balance of care, away from sometimes unnecessary acute admission and towards far more supportive care at home, will challenge service providers, but has the potential to meet the aspirations of older people to maintain their independence by staying at home as long as possible. However, the care of older patients will increasingly emerge as the central task of acute health services, in future more centralised but backed up by the wider provision of less specialised services at or nearer home.

Achieving such radical changes in the way services are provided, while at the same time delivering the quality of service expected by a new generation of all the people whose expectations are higher than ever before, will be a considerable challenge to the Scottish Executive and to all our health and social care services. However, considerable progress has been made already and robust policy developments and quality assurance mechanisms point the way ahead.

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