David Oliver: Base care on need, not age.

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. But hospital admissions of older people continue to rise, and delays in discharge have worsened alongside fewer beds. One recurring policy idea that defies evidence and experience is that most “high need, high cost” older people can be kept away from hospital through lower tech, lower cost community interventions. 5 But, in describing inappropriate occupancy of acute beds by these pesky old folk who could hypothetically be cared for elsewhere, 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. 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.” His logic? A small percentage of patients account for a high percentage of hospital occupancy and spending. There’s no doubting that. 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. He didn’t propose keeping younger people away from hospitals in their hour of need.