We are all aware that people are living longer and that numbers of older people are increasing in Ireland. The Central Statistics Office¹ predicts that, over the next 30 years, the number of people in Ireland over the age of 65 will double and the number over 80 will quadruple. From 2016 onwards, Ireland’s proportion of older people will begin to increase. By 2046, there will be 1.4 million in Ireland aged 65 and over, three times more than the older population today. 

This older group will make up 22% of the total population, compared to 11% of the population in 2006. Life expectancy rates have increased and are expected to continue rising significantly. It is expected that by 2046, men will on average live to their mid-80s and women even longer. This will have direct implications for all aspects of our health services including GP practices.

Irelands Age Friendly Cities and Counties Programme

Ireland’s ‘Age Friendly Cities and Counties Programme’ is a national programme co-ordinated by Age Friendly Ireland² and is working to ensure that our counties, cities and towns become more age-friendly and meet the needs of older people. It is informed from the World Health Organization’s Global Age Friendly Cities and Communities Guide,³ which says that; “In practical terms an age-friendly city adapts its structures and services to be accessible to and inclusive of older people with varying needs and capacities”

In each local authority area an Age Friendly Alliance has been established. These alliances are made up of key stakeholders that include senior leaders from key groups such as local authority, HSE, Garda Siochána, service providers, academic institutions and other education providers, business as well as older people representatives from Older People’s Councils. The Older People’s Councils, which are a key component of the Age Friendly Programmes, have been established in response to the National Positive Ageing Strategy 2013.⁴

These alliances oversee the development and implementation of Age Friendly Strategies for the county or city. Together with the National Positive Ageing Strategy, the World Health Organization’s (WHO) Age Friendly Cities Framework provides a blueprint for the required planning that will ensure that our cities and counties become more age friendly. 

The programme embraces the multifaceted challenges and opportunities that ageing presents by providing structure and supports which will enable service providers such as GPs to engage formally with older people through ‘older people’s councils’ that are being set up in all local authority areas. These Councils enable older people to raise issues of importance, identify priority areas of need and inform the decision making process of the city or county age-friendly initiative, based on the WHO eight domains: outdoor spaces and buildings; transportation, housing, civic participation and employment, respect and social inclusion, social participation, communication and information and community support and health services.

What older people have told us about GP services

When an Age Friendly Programme is established, extensive consultation is undertaken with older people throughout the county or city garnering feedback on their experiences of a range of services, as well as capturing their needs from services, such as healthcare-related services. 

It is not surprising that older people see the relationship with their local GP as an important one and in general older people have a lot of praise for and trust in their GP service. Being able to access their GP is important to them; they respect and trust what their GP says and they see their GP practice as a great place to get information. 

Older people frequent users of GP services

Data from the Irish Longitudinal Study on Ageing (TILDA), a nationally representative study of the over 50s in Ireland, shows that nearly 90% of the over 50s had visited their GP at least once in the previous year.⁵ The average number of GP visits among the over 50s is 4.1, with the over 80s visiting their GP on average 5.7 times a year.⁶ Approximately half of the over 50s had received a flu vaccination in the previous year.⁷ Rates of polypharmacy are high among the over 50s, with one-in-five of the over 50s reporting polypharmacy.⁸

To date, Age Friendly City and County programmes have consulted with over 20,000 older people throughout the country when developing strategies such as the Dublin Age Friendly Strategy, 2014-2019.⁹ In addition to this, a number of targeted studies and listening meetings have been undertaken that looked at older people’s experience of healthcare services such as primary care services, GP services and GP out-of-hour services (GPOOH).¹⁰ In the consultation process, older people highlighted a number of areas where they feel improvements are needed. Throughout the country older people have said that:

• GPs see the age and not the patient
• Some GPs do not seem interested in listening to them
• GPs can blame the condition on age – “ah, sure it’s your age”
• GPs can rely primarily or even exclusively on medication and older people may often be prescribed several different drugs by different medical professionals at the same time
• Waiting times to see GPs can be too long (two to three days waiting and sometimes even a week to get an appointment)
• Long waits in GP surgery once you have an appointment and seating is not always suitable for long waiting
• GPs no longer do house visits – “would like to see more house visits” – especially at the weekend. 

GP out-of-hours services (GPOOH)

If using the GP out-of-hours services you can get a different doctor each time – older people usually prefer to see a doctor they are familiar with, to avoid having to repeat histories and symptoms in order to receive service.

GP outgoing call-answering message services need to be more user-friendly, keeping older patients in mind as a target group, with some not allowing older people enough time to take numbers down.

There is a lack of information on GPOOH services, eg. older people are reluctant to bother the GPOOH unless in extreme need. There is a lack of understanding as to when they can and should contact the GPOOH service, and what constitutes an urgent or routine call.  

Accessibility

In some areas, getting to the GP is difficult due to the lack of public transport or concentration of GPs in one primary healthcare centre; this is particularly relevant in rural areas. GPs should take account of accessibility issues when organising appointments to ensure that appointments reflect transport availability.

Health services integration 

Older people say they can get mixed messages from GPs and specialists. Some people reported attending a specialist and being put on medication, and then their GP changed it back. This can leave older people confused and wondering who to believe and why bother being referred to a specialist in the first place.

There is also a need for greater co-ordination between the patient, carers and the community team on patient discharge from hospital, particularly for those who have no families to rely on.

Added to this, there can be longs delays in GPs getting information/results from hospitals/specialists after appointments or stays in hospital.

Changing demographics 

The changing demographics globally and in Ireland present many an opportunity as well as challenges. For GP practices this will mean that your patient list will nearly double in size from 11% today to over 22% by 2046. To this end it is important that GP practices listen to what older people are saying now, and this will in turn prepare GP practices for the change. As GPs, some of the challenges will be:

• How to develop ways to engage with your older patient and listen to how well or not so well you practice meets their needs
• How accessible your practises are physically
• What role can your audit play in age-proofing your practices?
• Is there too much polypharmacy and what role does innovation have in treatment, such as ‘social prescribing’ that promotes prescribing change in lifestyle?
• Older people’s appointments: With an ever-increasing demand on GP time, which will be further challenged with the changing demographics, how can GP care best respond to the older patient who may need more time allocated for their appointments?
• How can communication between GPs and hospitals be enhanced to improve community care of the older patient?

The Age Friendly Cities and Counties Programme can make a difference when all key service providers are engaging in the programme. We invite GPs to actively engage with their local programmes. In doing so we will ensure that the one inevitability that most of us face – ageing – is an experience that is enriched and that we all have the chance to lead healthy and active lives to the fullest. When treating older patients, let’s think of them as yourself, your spouse, your child, your own parents, and keep in mind the words of William Osler: “The good physician treats the disease; the great physician treats the patient who has the disease.” 

References

1. Central Statistics Office. Population and Labour Forve Projections 2016-2046. www.cso.ie
2. Age Friendly Ireland, Website: www.agefriendlyireland.ie
3. WHO Global Age-Friendly Cities: A Guide, 2007
4. National Positive Ageing Strategy, Dept of Helath 2013. www.health.gov.ie
5. Barrett A, Savva G, Timonen V, Kenny R. (2011) Fifty Plus in Ireland 2011. First results from the Irish Longitudinal Study on Ageing (TILDA). Dublin, The Irish Longitudinal Study on Ageing
6. McNamara A, Normand C, Whelan B. (2013) Patterns and Determinants of Healthcare Utilisation in Ireland. Dublin, TILDA
7. Nolan A, O’Regan C, Dooley C, Wallace D, Hever A, Hudson E, Kenny R, (EDS.) (2014) The Over 50s in a Changing Ireland: Economic Circumstances, Health and Well-Being. Dublin, The Irish Longitudinal Study on Ageing (TILDA)
8. Richardson K, Moore P, Peklar J, Galvin R, Bennett K, Kenny R. (2012) Polypharmacy in Adults Over 50 in Ireland: Opportunities for cost saving and improved healthcare. Dublin, TILDA.
9. Dublin City Age Friendly Alliance: Dublin City Age Friendly Strategy, ‘Dublin City a great place to grow old’ 2014-2019
10. Smith S. (2014) Use of PG out-of-hours services: the needs of people aged 65+ in Cavan and Monaghan