Scotland has the worst health inequalities in western and central Europe. It does not have to be this way.

Our previous research on health inequality and the wider societal issues that lead to them shows that change is within reach. Through restructuring our society to be fairer and more equitable, we can take action to reduce, and eventually eliminate, these inequalities with the aim of ultimately eradicating poverty.

In that vein, IPPR Scotland has supported the Royal College of Physicians (Edinburgh) to publish this piece on how to strengthen our care system so that the elderly can live with dignity.

The test of a civilisation is in the way that it cares for its helpless members.

Nobel Prize winner Pearl Buck’s words ring true in Scotland today, 70 years after she uttered them.

In many ways, our ageing population is a huge success story. The changing demography of our country over the last 100 years can be seen as a triumph: the number of people aged 65 and over is projected to grow by nearly one-third by mid-2045, while the number of people over 85 will almost double by 2051. The decline in infant mortality gives generations of people the chance to get old, and advances in medicine also mean that many of us stay physically robust, engaged and active well into our autumnal years.

A key question, however, is: how does society reflect on these changes? Sadly, ageing is seen as a societal burden, not a triumph. Old age is associated with greater dependency, not least because of increasing multi-morbidity (a combination of multiple long-term chronic conditions), and a tendency to forget the value of the elderly as net contributors to society. If we invest in a health and social care system that truly adds years to life and life to years, the elderly can be an asset.

There is absolutely no doubt that both the NHS and social care services in Scotland have a willingness to treat the elderly, many of whom have long-term chronic conditions, within the community. However, in terms of capability and capacity through appropriate systems and structures, the picture in Scotland remains mixed.

The extent of delayed discharge is a key example of not meeting the needs of our older people and depriving them of dignity. In the financial year ending 31 March 2023, people whose discharge was delayed spent 661,705 days in hospital – the highest annual figure reported. Public Health Scotland’s monthly reports indicate that more than 1,500 people, most of them older people, are typically experiencing delayed discharge at each month’s census point.

While delayed discharge is an issue of significant concern for older people, bringing often negative outcomes and extending hospital stays unnecessarily, it also speaks to a much wider issue within our health services – a continued dominance of secondary care over other settings such as primary and community care.

As the Christie Commission identified more than a decade ago, ill-health is often rooted in wider social causes, especially poverty. But despite record levels of funding today, the health system too often still treats the disease rather than the symptoms.

The Scottish government has made positive moves here. In recent years we have seen commitments to increase primary care funding, alongside more recent policy shifts to enhance the role of primary care in supporting community health and wellbeing. Focussing on primary and community care can help address the social, not medical, issues which give rise to our persistent health inequalities. However, it’s not clear that progress is being made quickly enough or yet seeing improved care for people with complex needs.

GPs and other non-secondary forms of care are rooted in their communities. They are the first points of contact for people presenting not just with physical health concerns but also with mental ill-health and personal concerns, which are often related to their health condition.

More importantly, where secondary care will primarily treat the consequences of health inequalities, primary and community care play a frontline role in helping to address the root causes of those health inequalities. However, the additional patient needs faced by practices in more deprived areas means that the inverse care law can often take hold, with political and public debate dominated (often understandably) by what is happening in our hospitals rather than our communities.

This only serves to continue a vicious cycle of health inequalities, leading to acute health problems, adding pressure and funding requirements to an already over stretched secondary system.

Recent analysis by IPPR Scotland estimates that around £2.3 billion of health boards’ budgets are directed at responding to the impacts of poverty, with hundreds of millions more diverted through primary care to address health inequalities driven by financial inequality.

This, of course, puts intense pressure on our entire hospital system – which is then exacerbated by delayed discharge.

Increasing the capacity of social care support and staffing in community and care homes, alongside addressing issues around the legislation covering adults with incapacity, is vital so that older people can return home or access residential nursing or care home services. This can potentially ensure a decline in delayed discharge numbers.

Reablement also plays a critical role here, not least in terms of preventing re-admissions to hospital. The discussion surrounding the elderly with long-term conditions who are admitted to hospital following an acute episode, stabilised through medical intervention and subsequently considered as being medically fit for discharge, often results in discharging patients straight to a care setting. This can be residential or, if more clinical support is required, a nursing/EMI setting (where clinicians are ‘on-site’ over a 24-hour period). What cannot be overlooked is the intermediate opportunity of reablement.

Reablement consists of a specialist team made up of geriatricians, GPs, nurses, therapists such as physiotherapists, speech and language therapists, social workers and care staff. They work collaboratively over a time-specific period with those who are considered medically fit to be discharged from hospital but remain with multi-morbidity. In such cases, they undergo rapid, intensive interventions to get to a point where they can do as many things as they can for themselves. In so doing they can regain their lost abilities, skills and confidence, and learn new ways of doing things to be able to live life as fully and independently as possible, in their own home.

The Scottish government, working in partnership with all the relevant stakeholders, needs to redouble its efforts to tackle delayed discharge across Scotland and to ensure equitable access to reablement services, as part of wider and more fundamental rebalancing of where and how we deliver care. This is essential to prevent older people from facing the indignity of remaining in hospital when they are medically fit to leave. This can consequently improve the patient flow in our acute hospitals that remain under incredible pressure – further exacerbating underlying issues of pressures on secondary care which could be better resolved through primary and community settings.

The Royal College of Physicians of Edinburgh’s Lay Advisory Committee started exploring these issues towards the end of 2023 – involving a broad range of health and social care stakeholders working across many disciplines. The focus has been on how we can tackle some of the long-standing issues around delayed discharge from hospital, something that continues to impact many older patients. This year, the focus is starting a process to identify solutions to that problem, by building on the many positive examples of best practices that do exist.

If Scotland wants to pass the test set by Pearl Buck, then finding a system that seamlessly enables older people to leave hospital without unnecessary and distressing delays and offers them access to reablement would go a long way in ensuring success.

About the authors:

Dr Arun Midha, Royal College of Physicians of Edinburgh, Lay Committee Member and Chair NHS Continuing Healthcare Reviews (NHS Wales)

Douglas Pattullo, Policy Officer, Royal College of Physicians of Edinburgh

Dr Patricia Cantley, Consultant Geriatrician, NHS Borders, Edinburgh