Decisions on whether older people are put forward for surgery must not be based on assumptions of age and fitness, warns a new report from the Royal College of Surgeons (RCS) and Age UK. It says that age should no longer be used as a shortcut to assessing suitability for treatment.
Instead a person’s overall health – or ‘biological age’ – should be the main consideration, says the report. The report identified that even though a patient’s health needs – including conditions that could be treated by surgery – increases with age, elective surgery rates decline steadily for people as they grow older. Therefore, the gap between the increasing health need and access to surgery means that many older people could be missing out on potentially life-saving treatment. The study, Access all Ages: Assessing the impact of age on access to surgical treatment, examines the patterns of surgical treatment in relation to age across eight areas of surgery. The study also warns that the £20 bn NHS efficiency drive heightens the danger of older people being disproportionately impacted, as restrictions may be imposed because of the perceived reduction in the cost effectiveness of providing treatment when relative life expectancy is shorter. It highlights that a new ban on age discrimination in the NHS came into effect at the beginning of this month, providing a legal framework to go alongside moral and professional imperatives to ensure that older patients receive the most appropriate treatment for their individual needs whatever their date of birth. The report does, however, acknowledge that not everyone will benefit from surgery and there are legitimate reasons why older people may decide with their clinician not to go ahead with a procedure. However, it also questions the way the NHS has approached the care of older people, saying it has has failed to keep pace with advances in medical and social care which have resulted in people living longer healthier lives. The report found that:
• The incidence of breast cancer peaks in the 85+ age group, while the surgery rate peaks for patients in their mid-60s and then declines sharply from the age of 70.
• People over the age of 65 make up the majority of recipients of joint replacement surgery. However, the rate of elective knee replacement and hip replacement surgery for patients in their late 70s and over has dropped sharply and consistently over the three years examined.
• Around 10,000 men a year die from prostate cancer and the incidence of the disease increases with age. Overall, half of men who develop the disease will die as a direct result of it. Again, surgical treatment rates for the disease do not match the number of new cases being diagnosed among the older population.
• Emergency surgical procedures are increasing for hernias in older people, while the planned surgery rates plummet once a patient passes the 75-79 bracket.
The report recommends that all those with an interest in improving health outcomes must work together to safely optimise surgery rates for older people. It urges clinicians to inform patients if surgery has been ruled out for a condition where it would normally be considered and provide reasons. The report concludes that there should be no informal ‘cut-offs’ and that older patients and their families must be supported to challenge this where they suspect it is happening.
