Age must not close the door to surgery.

Decisions on whether older people are put forward for surgery must not be based on out-dated assumptions of age and fitness, warns a new report launched today. 

As people are living longer and healthier lives, using someone's age as a shortcut to assessing their suitability for treatment should now be redundant. Instead a person's overall health - or "biological age" must be the main consideration, says a report released today by the Royal College of Surgeons and Age UK. 

It shows that whilst a  patient's health needs - including conditions that could be treated by surgery - increases with age, planned (elective) surgery rates decline steadily for people as they grow older. Thus the gap between the increasing health need and access to surgery means many older people are missing out on potentially life-saving treatment. 

The comprehensive new study, ‘Access all Ages: Assessing the impact of age on access to surgical treatment', published by Age UK, The Royal College of Surgeons and MHP Health Mandate, examines the patterns of surgical treatment in relation to age across eight areas of surgery. 

‘Access all Ages' looks at  the potential causes of these trends and makes recommendations as to how the NHS can ensure that all patients can access the best possible surgical treatment, irrespective of their age. It highlights that communication with patients to discuss risks and benefits, and the effective working of multi-disciplinary teams to bring together several specialists, including geriatricians, is essential in a joint decision-making process. 

The study also warns that the £20bn 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. 

‘Access all ages also raises concerns that the way the NHS has approached the care of older people has failed to keep up with the major advances in medical and social care which have resulted in people living longer healthier lives. 

Among the findings in the report are:

• 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.
• Ten thousand 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 amongst 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 study is an important step towards understanding the variations in surgical care that exist according to age, as well as the explanations for them. 

Professor Norman Williams, President of the Royal College of Surgeons, said: 'This isn't about surgeons slamming the theatre door on older people. In fact it is alarming to think that the treatment a patient receives may be influenced by their age. There are multiple factors that affect treatment decisions and often valid explanations as to why older people either opt out of surgery - or are recommended non-surgical treatment alternatives. The key is that it is a decision based on the patient rather than how old they are that matters.' 

The report outlines 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. 

There can also be barriers before someone is even in front of their surgeon. For example, some symptoms can be dismissed as an inevitable part of ageing rather than a potential sign of ill health. This can mean that a disease is at a more advanced stage by the time they are diagnosed; ruling out surgical treatment. Equally, a comprehensive assessment of a person's health may reveal that the risks of surgery outweigh the benefits. 

Michelle Mitchell of Age UK said 'When it comes to peoples' health, their date of birth actually tells you very little. A healthy living 80 year old could literally run rings round someone many years younger who does not share the same good health. Yet in the past, too many medical decisions we believe have been made on age alone with informal "cut-offs" imposed so that people over a certain age were denied treatment.

'This report shows the large gap between the number of people living with a condition or health need and the surgery rates to treat older people. We would like surgeons and other health professionals to read this report carefully and examine what they can do to ensure that age discrimination is eradicated from the NHS, as legislation now demands.' 

‘Access all Ages' 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.