Brief Overview
Inadequate operational and structural alignment of teams in the primary healthcare sector, acute hospice trusts, social services, and community trusts compromises the current delivery and financing of social and healthcare services for elderly patients in the United Kingdom. The fact that funding comes from three main sources—the NHS, the Department of Local Social Services, and the insured or personal means—has made this problem worse. The inevitable consequence is the obfuscation of responsibilities. Social care in the UK has long been declared broken and requires fixing by independent and government-commissioned reports, ministers, and academics. A literature review about supervisory challenges in caring for elderly patients in the UK necessitates a critical analysis of numerous facets such as healthcare policies, funding, the quality of care, the workforce, and the overall system of healthcare.
Shifting to Residential care
The focus of long-term care in the UK has shifted from hospital long-stay care as directed by geriatricians to residential homes and community nursing, which are privately operated, in which medical care is offered by general practitioners (Wilson et al., 2022). The vast development of long-term care in most independent homes has entirely been an outcome of the insufficient development of social and health services. Residents in care homes generally suffer from various diseases, including significant mental and physical impairment (Greenberg et al. 2020, p. 68). Their medical care remains entrusted to GPs, most of whom do not have any specialized training and for whom minimal incentives exist under existing remunerations to deliver suitable care patterns. The deteriorating commitment of the NHS to chronic care, specifically for illness, is terminating at the hospital discharge point (Daly, 2020, p. 6). With reduced lengths of hospital stay, individuals are at very profound risk of missing opportunities for rehabilitation and inappropriately entering long-term care, generally on a presumed non-permanent basis, without any management plan.
The key to the management of chronic disease is timely intervention and active surveillance. According to research, senior management and evaluation save money and improve outcomes. Geriatric medicine departments have traditionally caused the management of frail older individuals in hospitals (Murphy et al., 2023). This specialty emanated from the necessity of providing medical care for patients on a long-term stay. With the dissolution of long-term care in the NHS, this specialty has significantly merged with general medicine, with geriatrics constituting the greatest medical sub-specialty within acute adult medication (Wilson et al., 2022). For various general medical specialties, including the inexorable improvement in demands on acute medicine, many geriatricians become firefighters in acute aggravations of chronic disorders. According to Murphy et al. (2023), they cannot lead programs encouraging health maintenance and functioning among elderly individuals. Increased inappropriate acute hospital admissions could be a challenge.
Furthermore, increased hospital admission rates have been associated with better outcomes for the elderly. In contrast, Heydari et al. (2019, p. 16) argue that the outcomes of specific illnesses, such as respiratory infections, could be better managed with a controlled investment in geriatric facilities. Inadequate investment has implied that sub-acute diseases among older adults are significantly managed as cases of full-acute diseases (Heydari et al., 2019, p. 11). A sporadic evolution of contracts for supervisory health care has resulted from the increasing workload that primary care nursing home populations have implemented. Such contracts deviate from old-style secondary or primary structures and, paradoxically, clinical governance.
Aging Population in the UK
The UK population is aging. In the coming 25 years, the number of individuals older than 85 will double and reach 2.6 million (Fusar-Poli et al., 2019). An aging population could lead to the assumption that the need for social and health (medical) services will be high. The reality, however, remains more complex. The percentage of older individuals in need of social care support at different ages has significantly reduced, thus implying that a high percentage of older individuals today can live independent lives. Even though there has been an overall increase in demand, the fall in population among older adults in need of social care has counterbalanced most of the increases brought about by aging citizens (Lewis, 2022, p. 179). The percentage of people beyond 75 years experiencing long-term disorders has, however, significantly increased, and the needs have a high chances of becoming increasingly complex, leading to an increased demand for NHS services (UNECE Policy Brief, 2017). Such findings assert that older individuals are living with many long-term disorders, usually managed through the NHS, without, on average, needing additional support with social care. However, those with social care needs could be managing a significant number of long-term disorders.
As the government pursues reforming medical care, Raymond et al. (2021) suggest that policymakers must consider the complexities in estimating the future demand instead of merely assuming that the demand for social care will increase relative to an increased prevalence of long-term healthcare conditions. A significant increase in elderly people in the economy implies more spending. Approximately 55% of warfare spending in the UK is now paid to pensioners, with state pensions the most significant aspect of it (Headey, 2021). The expenditure is expected to averagely increase by £2.8 billion annually (Raymond et al., 2021). Growing numbers of elderly individuals also impact the NHS and social care expenditure. The pervasiveness of long-term health disorders increases with age, and based on an estimate in 2010 from the Health Department, these conditions account for about 70% of the total social and medical care spending in England (Fusar-Poli et al., 2019). According to the Department of Health estimates, the average cost of delivering community and hospital health amenities to an 85-year-old is far more than three times that of an individual 65-75.
The Changing Nature of the Social Care System and Care Home Providers for Older People
Following the introduction of early market reform in 1993, care homes in the UK became privately owned (Fusar-Poli et al., 2019, P. 355). Such major changes gave local authorities the power to commission services. This, in turn, implied that care delivery was precisely detached from the National Health Service and from the central government. By 2020, the sector’s regulatory body called the Care Quality Commission (CQC) referred to this unstructured relationship between the government and a sector consisting of various businesses, most of which do not receive public funding (Lewis and West, 2014, p. 13). Individuals pursuing state funding have experienced a test of service eligibility that has progressively been strengthened, resulting in people perceived to be high-risk or in high need being more successful and a means test to judge how much they are expected to contribute to their care.
Funding and Resource Allocation
The context of patient satisfaction and preference in the UK today has become significant. In the barest possible form, such a situation has been explained as a “new consumerism” that has affected the choices in the healthcare sector (Lewis, 2022). Collectivized preferences on healthcare spending can simply be conceptualized as being constitutionally driven and, therefore, ethically respectable for justifying options. There exists profound thinking between respect for patient preference or choice in individual healthcare and honoring the collective choice style in collective choices in priority settings (Abdi et al., 2019, p. 14). Already, various UK healthcare providers are established as social enterprises, meaning there is a sharing of managerial accountability between doctors and lay executives and non-executives under the lay chairs (Henderson et al., 2021, p. 1144). If the commissioners are established similarly, then the voice of the non-professionals gets injected into the process of allocation. In addition, the concepts of transparency deserves to be considered. The issue conflates many others: when the previous system in the UK relied on implicit choices between patients and diseases made in closed rooms, then it was pretty well associated with a high level of trust that those who did were worthy of such trust in doing so (Lewis, 2022, p. 176). When trust in the UK’s GPS is high from a personal point of view, funding dilemmas have increased because patients are denied most healthcare interventions. Trust could not survive a culture of economic constraint when GP motives are unclear and undemocratic. Inputs could help assure the situation.
Thirdly, GP could have been abandoned at the beginning of a new commission, and questions still remain about its workability when the expectation is further on funding from an unpopular priority setting. Of course, it could provide innovations in most integrated care, potentially conferring this opportunity for most GPs to augment their clinical role. Speculation is focused on a GP-oriented commission system, akin to the overall purchasing agreements (Lewis, 2022, p. 200). It is true to say that the NHS must have various experiments based on practical commissioning with a variable influence. If the GP is assigned the role of commissioning on a certain basis, the likelihood appears to be in a federated model, and then patient voice would be worth including despite the complexities.
Even when homes with a preponderance of state-financed residents are at a higher risk of failure, a significant level of attention has focused on the greatest for-profit providers, who would be very hard to replace (Daly, 2020, p. 985). Local authorities were supervising the closure of smaller homes before 2011, but as large-scale providers run a significant number of homes in a certain region, failure would be hard to manage. Big providers having various homes significantly have higher proportions of self-funders compared to providers with one home, even though most of them take state-funded residents (Dambha-Miller et al., 2021, p. 23). There are low reimbursements by the local authorities, even though they do not offer a steady income stream. If they keep falling further under actual terms, many larger-scale providers can choose to serve a greater proportion of self-funding residents. Daly (2020, p. 989) recommends the progress of care homes for most self-funders as a way for future private providers.
The Quality of Care
The manner in which health care services are structured is not reflective of the fact that elderly people are the major users. Care provision for individuals with long-term conditions, and particularly multiple long-term conditions (called multi-morbidity), is generally recognized as a comparative weakness in the delivery of care. The health disease is generally treated in isolation instead of in the context of an individual living with other disorders in addition to a variety of environmental, psychological, and social needs. Early interventions necessary to deter an individual’s health from worsening, such as helping with diabetes management or respiratory health, would imply that individuals are prioritized after being seen in need of emergency and urgent services. The number of older individuals with unmet support and care needs is significantly increasing because of the problems facing the informal and formal sectors in the contemporary UK. Addressing such unmet needs has become one of the most urgent public health concerns. In order to come up with an effective solution for addressing some needs, Abdi et al. (2019, p. 14) conducted a scoping review by using Arksey and O’Malley’s enhanced and original frameworks to understand the support and care needs of older individuals and focused on the individuals living at home with chronic conditions in the United Kingdom. The study conducted the search using five electronic databases, reference list checks, and gray literature. The results of this study showed that older individuals living with chronic conditions have unmet needs for care associated with their psychological and physical health, environment, and social life. Where they stay and interact. This review finding also highlights the significance of initiating care models as well as support services on the basis of older people’s needs.
Similarly, Heydari et al. (2019, p. 17) explored the most challenging issue experienced by ICU staff, particularly nurses, while providing care to their elderly patients in a typical adult ICU. The study used a qualitative research design by following the Standards for Reporting Qualitative Research (SRQR). Based on theoretical sampling, the study conducted 34 in-depth, semi-structured interviews with various medically elderly ICUS. The findings showed that there are challenges and obstacles to care provision for the elderly in a general ICUS unit. The study found that the care provided to elderly patients remains unfair and inappropriate. Numerous obstacles should be addressed to improve the care of such patients and achieve the desired quality of care. Furthermore, Raymond et al. (2021, p. 9) argue that older patients are disproportionately likely to stay in poor-quality housing and houses that need to be restructured or well repaired, particularly when they live in socially underprivileged places. Poor heating, unsafe stairs, a lack of insulation, or reduced levels of both natural and artificial lights can adversely affect the elderly patient’s mental health status. The GOV.UK (n.d., p. 5) posits that the greatest risk is usually from cold and damp homes, which is a more significant factor leading to the UK losing 40,000 more fatalities during the winter than would be anticipated based on their rates of mortality throughout the remaining part of the year and putting them at a higher risk of physical harm from ineffectively designed and maintained housing that can amplify an older individual’s risk of loneliness.
Workforce Challenges
Increased difficulty and turnover during recruiting new workers exacerbates risks related to care quality and generates legal, operational, and reputational challenges. Due to structural aspects such as a high percentage of part-time employees, challenging working conditions, and an aging workforce, the health and social sector necessitates strategies and measures to address such challenges. A qualitative study by Henderson et al. (2021, p. 1145) analyzes if and how organizations in three countries—Germany, the UK, and Finland—report the same challenges and how they sustain longer employment professions in their Health and Social Care sector (HSC). The study conducted numerous case studies in care organizations, carried out 54 semi-structured interviews with workers and management representatives, and analyzed them thematically. The results of the study showed that organizations in the HSC mainly focus on recruiting younger employees and migrant workers to address the existing gap in skilled workers. This notion of explicitly focusing on elderly workers and the idea of age management as a potential solution appears to lack popularity and awareness among various organizations within the sector (Merkel et al., 2019, p. 8). In contrast, Anderson et al. (2021, p. 91) argue that an estimated 13% of the entire workforce works in the healthcare sector. The study posits that there is an increase in multi-morbidity. The demand for healthcare will increase not only due to the fact that there is an aging population but also due to the fact that people live longer with various long-term disorders. The UK population with complex multi-morbidity (that is, more than four conditions or diseases) is set to double by 2035. This might pose a management problem since elderly patients with multiple morbidities are more probable to have unplanned or unpreventable hospital admissions, with a higher risk of clinical errors being highly likely in such a situation. A more significant balance between generalists with skills capable of managing multiple chronic disorders in the same patient and specialists is required, rather than a continuing and developing trend towards specialization among various healthcare professionals.
Furthermore, in the UK today, there is a gap in unpaid care providers’ supply. There are about 9.1 million unpaid care providers in the UK, who are generally friends or family members. Many unpaid care providers perform an extensive range of tasks, such as emotional and practical support, personal care, and monitoring medications. Unpaid care providers make significant contributions to the care and health sectors. The estimates of the monetary value of their contribution in the United Kingdom vary from £57 billion to £132 billion (Anderson et al., 2021, p. 56).
Integrating social care and health care
Closer social and healthcare integration has been a fundamental policy goal of successive governments in the UK for more than 40 years. However, the advancement of the agenda has not been accomplished at the pace needed to satisfy the demands of an increasingly aging population with increased multi-morbidity levels. Recent estimates of care dependency profiles show that 80% of the aging populations, which include individuals aged 65 and above, according to the UK National Health Service, shall necessitate high or medium dependency care because of the multi-morbidity. In that context, Wilson et al. (2022, p. 56) suggest that it would be fundamental that the primary caregiver be capable of closely working with social amenities and broader community care providers in harnessing the collective capacity that can address a broad range of physical, social, and behavioral health care needs in the aging population. This necessitates a more cautious consideration of the funding, organizational structure, and systems across providers in an attempt to detect certain opportunities for quick integration. Dambha-Miller et al. (2021, p. 12) conducted a scoping review to associate healthcare systems with other human service systems to improve clinical satisfaction and efficiency. The results from different themes showed that most of the studies that looked at specific areas focused on improving processes rather than finding better ways to use resources or improve outcomes. There was also little evidence of progress in providing and integrating services across multiple sectors and levels for older adults with multiple illnesses (Dambha-Miller et al., 2021, p. 19). It might take time to initiate it and may necessitate local input.
Since a part of the most significant policy reform started in 2010, England has introduced a wave of initiatives that would encourage more integrated care between social and healthcare. They were established on earlier attempts to accomplish the same objectives with a focus on the most effective partnership working. In contrast, Murphy et al. (2023, p. 243) offer a synopsis and a critical commentary on the UK’s integrated care policy between 2010 and 2020 using reviews from the national audit offices, parliamentary committees, and regulators. According to the overview policy, integrated care was a priority through the work of the Future Forum, which members of leading stakeholders established because of concerns about higher competition in community healthcare. This caused public statements of mutual commitments to integrated care through social care and national health. Early mechanisms involved a common fund to accomplish nationally set objectives, the creation of partnership boards led by local authorities, and high-profile programs for innovation. Notwithstanding the progress in some local areas and a reduction in stuck discharge from healthcare facilities, the general picture based on the national reviews was that expected developments were not realized. Emergency hospital admissions kept on growing, and patients in primary care settings reported minimal engagement in care, leading to the worsening of health inequalities. The UK experience suggests that higher progress should be made when the major focus of integrated care is a tangible issue, and if there exists a clear understanding of it, it would be successfully measured. Even with a vast investment, intentional progress must be anticipated to remain slow and difficult. The positioning of various policy initiatives offers some confusion and distracts from the significant work relationship building. Integrated care, therefore, may not, on its own, address the most significant inadequacies in structural inequalities and underlying resources.
Rural vs. Urban Disparities
Low service provision levels, difficulty assessing services, and potential high costs explain why rural elders have a lower likelihood of receiving formal care compared to their urban counterparts. According to data from the Generations and Gender Survey (GGS), the proportion of older individuals receiving regular assistance with personal care from only non-professionals is higher in rural regions (76%) compared to urban zones, where it is 65% (UNECE Policy Brief, 2017, p. 11). Such an urban-rural disparity in formal service use can also be partly associated with cultural differences. The GGS data set shows that in most nations, rural populations tend to more generally highlight the significance of family responsibilities in the provision of care for the elderly. Older people in rural regions of the UK, for instance, generally choose to initially depend on support from the community and their families before seeking any formal assistance. Individuals’ hesitance to seek formal assistance reflects specific rural and generational values and norms that prevent most elderly people from voicing their needs and using the services they should be entitled to. According to the UNECE Policy Brief (2017, p. 12), rural people in most nations have a high sense of self-reliance and independence and have a high suspicion towards assistance from outsiders. They could be reluctant to burden other people attempting to manage theirs and anticipate initially depending on formal help.
Similarly, the exploratory study by Cohen et al. (2021) examines the potential relationships between alterations to caregiver burden following the COVID-19 pandemic and the rural urban context, using 761 informal caregivers as the nationally representative sample. The study used statistics on two rural-urban migration measures: population density and rural-urban commuting areas (RUCAs). The study showed that disparities in informal caregiving go beyond individual demographic and social-economic factors. Individuals living in remote areas have a high chance of being informal caregivers. Research also suggests that rural informal caregivers have increased CB and caregiver strain and have reduced social support compared to their counterparts in urban areas. Compounding such an issue is the absence of a unified measure of rural-urban status within population health research. Thus, Cohen et al. (2021, p. 11) suggest that the protection of the wellbeing and health of every informal caregiver, despite their place of residence, is fundamental to achieving effective healthcare provision.
Patient and Family Involvement
Elderly adults are normally accompanied by repetitive health visits. A study by Manias et al. (2019) on family involvement in handling medications of older patients across care transitions shows that when families actively engage with elderly patients in strategies to ensure safe medication management, communication on medical care plans tends to become disorganized and haphazard across various transitions, and there is no mutual decision-making between health professionals and families. Similarly, in managing the complexity of medication across care transitions, Manias et al. (2019, p. 9) argue that family members perceived the absence of medication plans tailored to the needs of the patients and trusted that they had to portray perseverance to have their views heard by healthcare professionals. In another study by Ozavci et al. (2021), participants identified significant challenges to family involvement in patient visits to older primary care. The study identified some challenges as difficulties in navigating patient independence and caregiver inspirations for involvement, adjusting family-patient disagreements, and reducing disruptive behaviors by the family. Clinicians described three major approaches to the management of family-patient interactions. Collaboration involved a three-way discussion. Division involved personal consultation with the caregiver, while focus entailed selective dialogue with a single member of the patient care team. Clinicians approaches changed from patient-related to care-giver-oriented due to a decline in patient cognition. However, other studies report that family involvement in caregiving for aging patients positively improves care quality among older patients (Raymond et al., 2021; Abdi et al., 2019; and Manias et al., 2029).
Conclusion and Recommendations
The UK nursing homes are currently configured to deliver long-term care but are significantly being applied for different forms of sub-acute and intermediate care. These forms of care should be developed to allow homes to cope with elderly patients whose health needs remain unmet but who need convalescence or general rehabilitation. Pooling medical finances would generate incentives to lower hospital costs through improving primary healthcare while leaving the existing schism between social and medical goals. Social goals are compensatory given that successful care is being considered, which satisfies clients’ needs while avoiding various negative events. The idea of pooling together medical and social funds to support frail elderly individuals could generate worries about discounting social concerns. The risks associated with disregarding potentially correctable issues, such as iatrogenic, remain factual to neglect. The primary goal is to align and integrate services, encouraging various investors to do what should be done to satisfy the care needs of every individual. With these recommendations in place, the challenges of managing the elderly will be addressed to achieve informed care.
References
Abdi, S., Spann, A., Borilovic, J., de Witte, L. and Hawley, M., 2019. Understanding the care and support needs of older people: a scoping review and categorisation using the WHO international classification of functioning, disability and health framework (ICF). BMC geriatrics, 19(1), pp.1-15.
Anderson, M., O’Neill, C., Clark, J.M., Street, A., Woods, M., Johnston-Webber, C., Charlesworth, A., Whyte, M., Foster, M., Majeed, A. and Pitchforth, E., 2021. Securing a sustainable and fit-for-purpose UK health and care workforce. The Lancet, 397(10288), pp.1992-2011.
Anderson, M., O’Neill, C., Clark, J.M., Street, A., Woods, M., Johnston-Webber, C., Charlesworth, A., Whyte, M., Foster, M., Majeed, A. and Pitchforth, E., 2021. Securing a sustainable and fit-for-purpose UK health and care workforce. The Lancet, 397(10288), pp.1992-2011.
Cohen, S.A., Kunicki, Z.J., Nash, C.C., Drohan, M.M. and Greaney, M.L., 2021. Rural-urban differences in caregiver burden due to the COVID-19 pandemic among a national sample of informal caregivers. Gerontology and geriatric medicine, 7, p.23337214211025124.
Daly, M., 2020. COVID‐19 and care homes in England: What happened and why?. Social Policy & Administration, 54(7), pp.985-998.
Dambha-Miller, H., Simpson, G., Hobson, L., Roderick, P., Little, P., Everitt, H. and Santer, M., 2021. Integrated primary care and social services for older adults with multimorbidity in England: a scoping review. BMC geriatrics, 21(1), pp.1-24.
GOV.UK. (n.d.). Future of an Ageing Population. P.1-128.
Greenberg, N., Docherty, M., Gnanapragasam, S. and Wessely, S., 2020. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. bmj, 368.
Headey, B., 2021. Housing policy in the developed economy: The United Kingdom, Sweden and the United States. Routledge.
Henderson, L., Bain, H., Allan, E. and Kennedy, C., 2021. Integrated health and social care in the community: A critical integrative review of the experiences and well‐being needs of service users and their families. Health & social care in the community, 29(4), pp.1145- 1168.
Heydari, A., Sharifi, M. and Moghaddam, A.B., 2019. Challenges and barriers to providing care to older adult patients in the intensive care unit: a qualitative research. Open Access Macedonian Journal of Medical Sciences, 7(21), p.3682.
Lewis, J. and West, A., 2014. Re-shaping social care services for older people in England: policy development and the problem of achieving ‘good care’. Journal of social policy, 43(1), pp.1-18.
Lewis, J., 2022. The problems of social care in English nursing and residential homes for older people and the role of state regulation. Journal of Social Welfare and Family Law, 44(2), pp.185-204.
Manias, E., Bucknall, T., Hughes, C., Jorm, C. and Woodward-Kron, R., 2019. Family involvement in managing medications of older patients across transitions of care: a systematic review. BMC geriatrics, 19(1), pp.1-21.
Fusar-Poli, P., 2019. Integrated mental health services for the developmental period (0 to 25 years): a critical review of the evidence. Frontiers in Psychiatry, 10, p.355.
Merkel, S., Ruokolainen, M. and Holman, D., 2019. Challenges and practices in promoting (ageing) employees working career in the health care sector–case studies from Germany, Finland and the UK. BMC health services research, 19(1), pp.1-12.
Murphy, P., Lakoma, K., Eckersley, P., Dom, B.K. and Jones, M., 2023. Public goods, public value and public audit: The Redmond review and English local government. Public Money & Management, 43(3), pp.242-250.
Ozavci, G., Bucknall, T., Woodward-Kron, R., Hughes, C., Jorm, C., Joseph, K. and Manias, E., 2021. Knowledge and power relations in older patients’ communication about medications across transitions of care. Qualitative Health Research, 31(14), pp.2678- 2691.
Raymond, A., Bazeer, N., Barclay, C., Krelle, H., Idriss, O., Tallack, C., & Kelly, E. 2021. Our ageing population: how ageing affects health and care need in England.
United Nations Economic Conditions for Europe (UNECE Policy Brief, 2017). Older persons in rural and remote areas.
Wilson, N., Beasley, M.J., Pope, C., Dulake, D., Moir, L.J., Hollick, R.J. and Macfarlane, G.J., 2022. UK healthcare services for people with fibromyalgia: results from two web-based national surveys (the PACFiND study). BMC Health Services Research, 22(1), p.989.
write