Keeping older people at home.

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❛... older people with frailty and experiencing a crisis manage better if they are properly supported in their home environment.❜ There is consensus that health care needs to be reconfigured by reducing money spent on hospitals so that the money can be moved around the health system to release resources to support people in their own homes. Fewer and shortened hospital admissions will lessen the incidence of hospital-acquired infections and other adverse events, as well as reduce the negative consequences of a hospital admission on an older person, such as loss of independence, depletion in muscle mass, and mental deterioration. However, the realisation of a reconfigured health system is fraught with challenges arising from both healthcare staff and patients. Historically, hospital consultant ‘power’ and ‘prestige’ were related to the number of hospital beds under their control, and university and teaching hospitals cherish their patient activity for research purposes and the kudos it brings; the hospital lobby will need to engage in any reconfiguration. Primary health-care teams also need to reframe their practices so that self-care promotion is central to their endeavours alongside a willingness to support the very frail at home. Importantly, patients and the general population also need to understand that a hospital-centric health service is both unsustainable and undesirable if we are to maximise health-care resources and promote quality of life across the lifespan. Decline in function and general health is an inevitable consequence of growing older, and frailty is a state of health related to the ageing process, reflecting the gradual decline of the body systems. While about 10% of people aged over 65 years have frailty, the numbers rise significantly to 25%–50% in those aged over 85 years and are even higher in the very old (British Geriatric Society (BGS), 2014). The BGS would like all contacts with health and social care staff to include an assessment for the presence of frailty so that functional decline is monitored and reversible conditions treated promptly. The BGS recommends gait speed, the timed-up-and-go test, and the PRISMA questionnaire assessments together with regular medication reviews using the STOPP START criteria. Assessments may also enable effective interprofessional working. Poltawski et al (2011) identified three frailty scales drawn from various conceptual underpinnings that measure things in different ways. They highlighted how regular measurements identify not only the individual’s current status, but also the effectiveness of interprofessional working in the delivery of a proactive personalised care plan designed to avoid hospital usage. There is little evidence relating to the health status of the housebound older population, in part reflecting a historical trend of health research to recruit study participants through hospitals. In addition, until the present time, the lack of evidence relating to the health needs of this population was not recognised as a ‘gap’ because there was no imperative to deliver an effective service. However, this lack of evidence has also been noted in the USA with Qui et al (2010) highlighting the unmet physical and mental health needs of housebound older people. Any reconfigured health system needs to include a reliable and robust community-based response for older people with frailty. The district nursing service will be a crucial component of services. The BGS notes how older people with frailty and experiencing a crisis manage better if they are properly supported in their home environment. Perhaps, this is the opportunity for district nursing to regain its pivotal position within health service provision outside hospitals. BJCN