First published April 2007, updated December 2021

Key points:

  • Older people are the largest group to use hospital wards.
  • The NSF for Older People was designed to improve care standards in hospitals.
  • Forty national pilot sites were established.
  • Progress was limited because engagement of senior management was difficult to achieve.

One riposte that can be an all-too-familiar greeting to a member of an elderly care team visiting a surgical ward is: ‘This (older) patient shouldn’t be here!’ It represents a rather desperate cry from hard pressed ward staff as they struggle to care for an older person having complex needs, often with a confusional state. The subtext is always clear — ‘Please move this patient, and quickly!’

However, the real issue is not ‘this patient shouldn’t be here’ — but that there is a skills gap present. The ward team does not have the appropriate knowledge, training and skills to deliver the care required by sick older people with complex needs. This was an important deficiency to be addressed by Standard 4 (The General Hospital Standard) of the National Service Framework (NSF) for Older People published in March 2001. Standard 4 specifies three areas for action: improved access to multidisciplinary teams, a nursing structure that identifies nursing leaders for older people and a review of the skills, education and training for staff. However, informal visits by a team from the Department of Health to 16 general hospitals in 2003 indicated there was considerably more work to be done1 . This is not to say that progress was not being made — it was. But it was uneven: some trusts had embraced the standard and were making major changes in their care for older people; others had barely begun. Moreover, much of the work was too limited in scale, or too fragmented, to make a distinctive difference to the care experience for older people.

Table 1. Older people and hospital care

  • Admission rates for people over 65 years are three times higher than for those aged 16–64 years
  • Lengths of stay for people aged over 65 years are significantly higher than for the under 65s — twice as long for elective admissions, three times as long for non-elective admissions
  • Older people occupy around two-thirds of general hospital beds
  • Rising admission rates are mostly attributable to older people
  • Most medical outliers (medically ill people occupying non-medical beds) are older people
  • Hospital stays for outliers tend to be longer
  • Around 80 per cent of delayed transfers of care are people aged over 75 years
  • The national beds enquiry found that 20 per cent of bed days for people over 65 years were unnecessary, provided alternatives were in place

More than a decade of steady, continuing emphasis on day surgery, new technologies, outpatient treatments and rapid response clinics have insidiously changed the orientation of general hospitals to one in which the needs of older people have become dominant. Our health service, however, has been slow to recognise the consequences of these changes — that the modern general hospital is increasingly an older person’s facility. For example, over two-thirds of the beds are occupied by people over 65 years. A recent census study identified 69 per cent of patients in one hospital as having complex needs (multiple conditions) requiring multidisciplinary team care2 . Although on one level these issues are widely recognised (see Table 1), we have not yet made the cognitive step to create a fundamentally different type of general hospital. Systems of care can be poorly developed and not adequately aligned to the needs of this vulnerable group. The result is that older people too frequently become ‘stuck’ in care systems designed for different sets of patients. The problem is not unique to the UK.

Writing from a North American perspective, leading Canadian geriatrician Professor Kenneth Rockwood summarised the problem succinctly: ‘We have largely designed a system to care for people who have only one thing wrong at once, but which is chiefly subscribed by people who have many things wrong3 .’ One consequence is a steady stream of adverse reports concerning hospital care and older people — most recently that some older people are receiving insufficient care at meal times.

How can we do better? Standard 4 of the NSF lists 16 core topics such as nutrition, continence management and pressure sore prevention that require careful attention if care standards for older people in hospital are to be improved and/or maintained. However, common sense suggests that tackling adequately all 16 topics as separate initiatives or projects will be a demanding task, possibly leading to an overly fragmented approach such that the whole hospital care experience — that is, the perspective of older people themselves — is not necessarily transformed. Some general hospitals have taken a more strategic approach. This approach acknowledges that older people, particularly those with complex needs, are the major users of hospital inpatient care. Thus, instead of regarding Standard 4 as a set of separate activity areas, the improvement work is integrated and embedded into all key hospital development and reconfiguration projects. For example, when re-designing an accident and emergency service, the needs of older people are acknowledged as central — older people are the main group accounting for a ‘four-hour breach’. Similarly, tackling delayed discharges becomes easier if a hospital-wide approach is taken to improving the assessment and management of older people with complex needs.

To promote this more whole systems integrated view of Standard 4, it was considered important to more fully engage trust boards. In part, the thinking was that trusts would be more likely to fulfil their financial and other performance targets if routine care systems inherently supportive of older people with complex needs were put in place. That is, improving care for older people should be regarded as a major route to a trust’s financial and clinical success. With this in mind, the Department of Health produced an easy to use, self-assessment checklist to help trust boards review the hospital care they were providing to older people ( 04/06/91/18/04069118.pdf).

Standard 4 pilot projects In 2004, to further stimulate improvements in general hospital care for older people, the Department of Health commissioned via a competitive application process 40 NSF Standard 4 national pilot projects. Each project was funded for two years and the aim was to achieve significant changes to the experience of older people in general hospital care. The idea was to encourage the participating hospitals to develop and share practical long-term solutions to improving care and better understand the opportunities and barriers to progress. Each project was distinctive with various topics, clinical focus and methods (see Table 2).

Table 2. General approaches used by the 40 NSF Standard 4 pilot studies



Mental health focus


A&E focus




Educational initiatives

a)       Classroom based

b)      Ward based




Skills gap audit/analysis


Care pathway improvements


Whole hospital approach


Many of the projects included some aspect of training. The main barrier to training delivery was not lack of interest or unwillingness to change, but the busyness of hard-pressed front-line staff that precluded attendance at traditionally delivered training sessions. However, many successful practical methods to overcome this difficulty were discovered by the project teams including ward-based training, short sharp teaching sessions and modifying existing training programmes (including induction courses) to encompass issues related to the care of older people. There were also gratifying examples of engagement of non-clinical staff — for example, the introduction of standards that improved hospital porter contacts with older people. Most of the work involved ‘bottom-up’ projects. However, as advisors we still hoped, and encouraged the teams to promote their work with the senior hospital management. The extent to which this was achieved was limited and patchy, and there appears to be substantial internal cultural barriers in hospital trusts that militate against a whole hospital approach to systems design for older people.

Through these 40 national projects, and the associated contact we had with these hospitals over two years, we believe there remains considerable scope to improve the care of older people in our general hospitals. The NSF has undoubtedly raised awareness of the special needs of older people but we have not as yet translated this raised awareness into a step change in the care experience of older people. There continues to be a major missed opportunity to focus on the organisation and delivery of care for the main general hospital user group. Interestingly, this is not an issue of money. Our work has suggested it is primarily an issue of organisational culture change, of education and appropriate skilling of front-line staff. Further, relatively simple training strategies (for example, modifications to existing training programmes) will go a long way towards the improvements we are seeking. What is missing, at present, is strong leadership within hospital trusts to recognise these opportunities and enact change.

Conflict of interest: none declared.

Acknowledgements Professor Young and Ms Sturdy are grateful to Heather Stevens and Lois Willis from Innove who co-ordinated this work, and to the enthusiasm and commitment of the project managers and their team in the participating hospital.


  1. Young J, Sturdy D. Senior Moments. HSJ June 10th, 2004
  2. Hubbard RE, O’Mahony MS, Cross E et al. The ageing of the population: implications for multi-disciplinary care in hospital. Age Ageing 2004; 33: 479-482
  3. Rockwood K. Frailty and the geriatrician. Age and Ageing 2004; 33: 429-430