Effectiveness of care for older people: a review.

Older people that is, those aged 65 and over are the largest single group of people using health care services in Great Britain. In 1986-7 in England 48% of all NHS expenditure was accounted for by those aged 65 and over, 17% by those aged 65-74, 22-7% by those aged 75-84, and 8-6% by those aged 85 and over. Average annual NHS expenditure per head was estimated at £414 for those aged 65-74, £926 for those aged 75-84, and £1452 for those aged 85 and over.' Demographic forecasts for England and Wales predict an increase between 1991 and 2031 of 43% in those aged from 60-64 (pensionable age) to 74 (from 5-8 million to 8-3 million) and of 237% in those aged 85 and over (from 0-8 million to 19 million).2 The 1991 census enumerated 11 6 million people in Great Britain aged 60 or over, with roughly 800000 being aged 85 or older.2 These demographic trends imply that considerable pressure will be placed on the NHS. Against this background of potentially substantially increasing demand it is important that older people (and indeed other client groups) receive the most effective forms of care and treatment. In this paper we bring together evidence about the evaluation of health care for this important client group. We can approach a review of the effectiveness of services for older people in two ways. We could review current knowledge about the types of health problems faced by older people such as stroke or dementia, or we could consider what is known about the different types of services used by older people such as continuing care or rehabilitation. From a public health purchasing perspective we considered that the second approach was appropriate because contracts are currently placed for specific services rather than conditions. This paper is part of a needs assessment for older people undertaken for a review of services provided for older people in an inner London health district. We reviewed work published about the effectiveness of the care of older people in seven main areas: (a) health promotion and primary prevention; (b) secondary and tertiary prevention; (c) hospital discharge; (d) rehabilitation; (e) home care; (/) continuing care; and (g) palliative care. We recognise that this is not a comprehensive review. It does, however, include the main service areas concerned with the care and treatment of older people. In reviewing the evidence for the effectiveness of specific interventions we have concentrated on randomised controlled trials or comparative studies when available, but we have also had to consider evidence derived from descriptive and observational studies.