Health crisis – what crisis?

A local clinician’s view from the front line 

The call is now out that healthcare in NZ is in crisis. For those on the inside, increasing pressures on our system have been evident for too long. Now however this is apparent to us all – overcrowding in hospitals and EDs, difficult to access GPs and specialists as well as increasing waiting times and thresholds for elective surgeries. 

To complicate further, workload pressure is the major factor behind high rates of burnout now reported within our clinical workforce. Perhaps most worrying however, some commentators foresee the potential collapse of our health systems as a direct result of inadequate resources to care for older people within our community. 

How can this be?

In simplest terms, the very real strain on our health system is the result of a mismatch between clinical demand of our population and resources allocated to meet this demand. Whilst it is relatively easy to focus on increasing resources to match increasing demand, less attention has been paid to the factors influencing demand in the first place. 

And although the current and visible ‘crisis’ relates to large numbers of our population experiencing Covid, flu or other winter viral illnesses, the fundamentals of ‘the human condition’ driving demand for health care have been increasing, essentially unnoticed, in the background over many years.

What has happened?

Modern health care has increased life expectancy within our population by preventing deaths at premature ages, particularly from vascular disease such as heart attacks and strokes. 

In 1980 about one-third of our population died younger than age 65 whereas about 1 in 7 died over 85. By 2016 the rate of deaths at age 65 or younger was almost halved to about one in six, and one in three survived to 85 or beyond. By 2060 it is suggested that only 1 in 25 will die under 65 and seven or eight out of 10 of us will likely live beyond age 85 – now the fastest growing part of our population. 

This enormous change in population demography is occurring within a remarkably short period of time in human history.

The price for living longer – both for the individual and society at large – is yet to be fully appreciated.

With medicine changing deaths from young to old, society is now seeing for the first-time large numbers of elderly people whose health behaviours and demands are not the same as those of a younger population. Nor do they align with expectations of our health system.

Despite advances in medicine, humans remain mortal. When death is delayed to an older age, other, often multiple, illnesses or disabilities are likely to have occurred. Health demand from each of these additional health problems is relatively easy to understand and factor into health planning for an ageing population – for example it is known that admission rates to hospital increase as age increases, people aged 85 or older are admitted at least four times as frequently as people aged 65-69.

Then there is frailty

Frailty is challenging! 

It is estimated that without serious illness the average life expectancy for each of us would be in the order of 85-90 years. Towards the end of this ‘natural’ lifespan there is an inevitable wind-down and ultimate failure of bodily systems, recognisable as the state of frailty. As our population ages towards the limits of our potential lifespan many more of us will become frail towards the end of life. Frailty however can also be accelerated in younger people by factors such as other medical conditions, particularly multimorbidity, or social deprivation. 

Frailty is characterised by vulnerability to illness and complications of treatment, and also dependency – the need for assistance from others for basic activities of daily life. As frailty increases there is a predictable progression of dependency, at first requiring help with activities including housework, shopping and finances, then needing help with dressing, showering and toileting, before finally needing full-time supervision or care for significantly debilitated or bed-bound individuals. 

This care required by increasing numbers of our population can only be provided by human hands. And heavy dependency requires many hands. It is argued that this type of work, in particular at-home and rest home caregiving, is largely undervalued by society, a critical factor in the compromise of community support services currently able to be provided throughout the country. 

Frailty is known to be the most important determinant of health outcomes for older individuals, more so than either age or comorbidity. Frail people are more likely than robust individuals to have poor outcomes after illness or surgery, including increased complications, length of hospital stay and greater likelihood of transfer to residential care or death. Potential to benefit from interventions, such as surgery or medication, is also compromised by degree of frailty. 

Despite these observations, the extent of health demand relating to frailty is not widely appreciated.

Although we are now well advanced in technology and understanding of the ageing process, there is still no straightforward or routine way to characterise frailty for individuals. Assessment tools do exist but vary with differing underlying concepts used to explain frailty or resources needed to assess in the first place. 

This lack of a universal way to describe frailty creates difficulties not only in clinical situations which would be better informed by an awareness of frailty, but also within our health system, which is unable to accurately account for numbers of affected people.

A better way to talk about frailty may be a good start.

Local study

To look at possible effects of frailty on health demand, a local study was 

conducted after the Havelock North campylobacter outbreak of August 2016. Approximately 300 people of average age 82 were recruited, 120 of whom had been affected by campylobacter, the 180 unaffected enrolled as controls. Outcomes over the next three years were determined in relation to the degree of dependency for each individual at the time of the outbreak (this is a simple substitute for frailty). 

Looking at dependency for control individuals (not affected by campylobacter), the risk of death within three years and health demand, as measured by total days in hospital over one year, were greatest for dependent people – risk of death at three years was one in three for people receiving daily home help compared to one in six for independent people. And people receiving daily home care spent three times longer in hospital over one year than independent people. 

Strikingly, the study showed that mortality and hospitalisation for dependent individuals increased further in the year after they were affected by campylobacter. Dependent individuals with campylobacter then stayed, on average, eight times longer in acute hospital care over the following year than non-affected independent individuals of similar age and comorbidity.

This extreme compounding of health demand after dependent individuals experienced an additional health insult is an unexpected but important finding, and one not previously described in the medical literature. Implications however are profound for our health system.

Scale of frailty problem

Frailty has always existed but now it’s a problem of scale. Since about 2008 people over the age of 80 have occupied more acute adult hospital beds than for all other ages combined – and numbers of older and frailer people in hospital beds continue to grow with population ageing. 

For unwell, frail, older people, admission to hospital is often urgent and unavoidable, as much due to dependency – immediately needing someone (often multiple staff members) to provide basics of care when confined to bed – as to the underlying medical or surgical problem itself.

Recently in HB up to 180 people have occupied acute medical beds at any one time, despite planned capacity for acute medicine of 120 beds. Overflow and overcrowding have understandable and detrimental effects on the rest of the hospital, including deferral of scheduled elective surgery for many people.

Dependency which persists after acute illness is one of the biggest challenges facing our health system. Frail individuals requiring ongoing care at discharge now occupy large numbers of acute hospital beds, the result of inadequate caregiving resources in the community, whether this is home-based or within residential care. 

Although it is argued dependency is only one aspect of frailty and too crude for precise assessment, it is simple to understand and count. Health agencies providing formal care at home have accurate information about individuals under their care, but are unable to account for large numbers of the elderly for whom care is informally provided by family or others. 

In 2019 Hawke’s Bay District Health Board funded home care for 2,500 individuals, approximately one-third of whom were receiving daily care.

However, overseas data – using dependency – indicates that approximately 35 percent of people over the age of 65 need care or support less frequently than daily, whereas about eight percent need daily help at home. For Hawke’s Bay this suggests up to 10,000 individuals currently require less than daily help and 2,500 individuals need daily help. 

These numbers suggest a significant shortfall in current publicly funded home care and indicate that most support in the community is either provided informally by family, whanau and others – or is not adequately in place, precariously exposing individual vulnerability.

The health system must provide for us all, not just the elderly.

Modern medicine is for everyone. But it is important to understand that presentations to hospital are the ‘tip of the iceberg’ of healthcare demand. The increasing dominance of the elderly within the Emergency Department and acute hospital beds reflects a much larger pool of similar individuals remaining in the community who, in view of accumulated conditions and frailty, generate markedly disproportionate workload for other health providers at the same time. 

Although seemingly simple, the lack of a relatively straightforward way to account for severity and scale of frailty within society is a major problem for healthcare. Unanticipated health care demand is already exhausting – and has potential to overwhelm – the capacity of many clinical services. 

The bottom line? 

Population ageing is climate change for healthcare. 

More than 40 years ago the prospect of ‘compression of morbidity’ was first raised, speculating that modern medicine had the potential to minimise the burden of chronic disease and disability within our older population. This initial optimism has transformed to an expectation, both within healthcare and society, that health problems of older age can be treated as effectively as for young people. Vigorous efforts are made along these lines in a constant attempt to control and minimise demand.

Reality however is different. With increasing life expectancy, the burden of multimorbidity and frailty in our population has markedly increased. As frailty progresses, health outcomes are determined more by ageing biology than underlying disease or illness, and for which medical or technological intervention is increasingly ineffective.

Healthcare’s struggle is now a numbers game. Without adequate workforce and basic support for our most vulnerable population, hospitals will predictably fill if the rest of of our health system is stretched beyond capacity.

So, is healthcare in crisis?

The definition of crisis includes a state of instability, a possible turning point with potential for decisive change. There can be no doubt about the current instability of healthcare. But whether our new health structure is able to recognise this as a turning point and correctly anticipate and adequately plan for our future remains to be seen. 

Timothy Frendin, MB BS FRACP, is a practicing physician and geriatrician working full time, until earlier this year, for more than 30 years in Hawke’s Bay Hospital. His clinical and research interests include the health challenges of older people and their effect on the sustainability of our Health System. He has served as Clinical Director of Services for Older People within HBDHB and on the National Executive of Association of Salaried Medical Specialists.