When you hear of an injury or an incident described as “major trauma” (NHS speak for injuries that have the potential to cause prolonged disability or death) what scene do you picture?
Many of us might conjure up pictures of ‘24 Hours in A&E’ with victims of road traffic accidents, work based accidents or a serious assault being rushed into hospital. It would probably involve a young person, most likely male, and more often than not located outside – major roads, bridges, building sites or city streets.
But it turns out that imaginary picture can be far from the reality of many trauma cases. And so, unfortunately, is the NHS care that goes with it.
A ten year study by the Trauma Audit and Research Network revealed that the leading cause of major trauma is, in fact, falls from a standing height by older people, most of which happen at home. The one place most of us like to feel safe.
Falls, of course, are a common occurrence for older people, and the vast majority do not result in major trauma injuries. But each year more than 5,000 people aged over 60 suffer a fall from standing height that results in major trauma.
What are the reasons behind these significant numbers? Part of it is simply down to an increasingly elderly population – more people are living longer and very old age often goes hand-in-hand with increased frailty, susceptibility to falls and trauma from the impact of those falls. More people are living with conditions such as Parkinson’s and dementia or are taking combinations of medication that can make falls more likely. A high number of falls may also be indicative of the unmet everyday needs of older people – support carrying out day-to-day tasks, lack of adaptations in the home environment – as well as much bigger issues such as the suitability of current housing design to the older population. Some may be exacerbated by the isolation of the older person, living on their own without assistance, which can turn a minor incident into a more urgent crisis.
Whatever the reason behind the increase, the real impact of the report is the revelation that this is news not just to lay people but to the NHS itself. Protocols used for identifying major trauma are primarily designed for much younger patient populations and focus on identifying high impact injuries – which are usually obvious from the accident scene. But older people can sustain serious injuries from a relatively low impact – i.e. a standing-height fall. And if major trauma isn’t identified at the scene then the patient won’t be fast-tracked through the NHS’ excellent major trauma pathways. Older people are disadvantaged by a service set up to serve younger people, yet we now know that older people are the people who need the service the most.
The failure to reflect the needs of older people don’t stop at the point of identification. Even when major trauma is recognised for an older person (whether this is caused by a fall or for another reason), their care experience is significantly different to that of a younger person. The report tells us that older people are less likely to be operated on and their operation is more likely to be carried out by a junior doctor rather than a consultant. Over 65s wait, on average, 1.5 hours longer for surgery than their younger cohort, and older people suffering a brain injury are less likely to be transferred to a specialist centre for treatment.
If this situation sounds all too familiar it’s because it is. Major trauma is a particularly stark example of (unintentional) system ageism within the NHS but it is by no means the only one. People aged over 65 are less likely to be referred to psychological therapies for depression despite evidence showing they are more likely to benefit from the therapy than other age groups. And in 2015 Macmillan found that older people are less likely to receive life-saving cancer treatments and dispelled the myth that it’s because they choose not have treatment.
The case of major trauma is a particularly worrying example because so much work has been done in the last ten years to improve care, including the development of highly-acclaimed regional trauma networks across England. Some hospitals are recognising that older people need something different. Hospitals like Leicester have set up a ‘frailty front door’ and many others have established multi-disciplinary hubs more suited to supporting multiple long term conditions, - the pharmacy, Occupational Therapy, dentistry, eye clinics, physiotherapy, GPs and community nurses to handle these admissions, support treatment and effect rapid discharge. These developments in Urgent and Emergency care are hugely welcome – the demand isn’t going to get any lighter.
However, there is still more to be done in ensuring people can access the right care pathway, alongside admissions avoidance, falls prevention, coordinating GPs, community services, social care and involving the third sector. Because the best solution to demand is to ensure the maximum number of older people avoid trauma and entering hospital at all.