Anticipatory Care Series: Moving beyond the crisis – anticipatory care for older people

Adam Gordon is Professor of Care of Older People at the University of Nottingham and President Elect of the British Geriatrics Society. Here he looks forward to the long-anticipated NHS England Ageing Well Programme for Anticipatory Care. He tweets @adamgordon1978. Follow all the tweets via #BGSAnticipatoryCare

Across the UK, our National Health Service is facing huge challenges. There are unprecedented delays for ambulances and waits in emergency departments. Many discharge to assess and rehabilitation services are running at full capacity with exit block due to staff shortages in domiciliary care and care homes. It takes a long time to get into hospital and even longer to get out. In primary care, GPs are struggling with long hours and high demand. 

Older people living with frailty and disability are more likely to come to harm from this situation than other groups. This is partly due to numbers - older people with multiple complex conditions make up the bulk of unscheduled attendances to hospital - but it’s also because physical frailty means that they are more likely to experience persistent disability due to delayed consultation or prolonged hospital stay. 

We find ourselves in this situation because the COVID-19 pandemic was a pressure test for a health and social care sector which was already vulnerable in many ways. Both the NHS and social care went into the pandemic with staff shortages, which have been exacerbated by people leaving (and refusing to join) the workforce following the privations of COVID-19.  Most NHS services were operating at, or close to, full capacity pre-COVID. This made it difficult for them to handle the peaks and troughs in demand that resulted from the lockdowns we experienced during the pandemic.

We are all working hard to keep our services afloat in the face of this. Rarely a day goes past without me receiving a WhatsApp message asking me to drop what I am doing and cover a colleague’s sickness absence on the rota, or to go and see newly admitted patients on outlying wards, or to go to the Medical Admissions Unit or Emergency Department to help support patients there. It could be tempting in this scenario to think that all our focus needs to be on dealing with the day-to-day crisis. Such assertions are almost certainly wrong.

Nigel Edwards, CEO of the Nuffield Trust, in a previous keynote at the BGS annual conference looked at the evidence about what to do when a healthcare system becomes chaotic and turbulent. His conclusion was that the quickest way for turbulence to settle is to add more capacity.

There are two ways to add capacity in the current system. One is to open additional space within units and services. The other is to put in place healthcare interventions that reduce demand. For older people with frailty, we can reduce demand in several ways. One option – the best option – is to put in place interventions that stop people becoming sick in the first place. The second option – also good – is to recognise that older people living with frailty often move around systems looking for the right professionals with the right expertise to address their healthcare needs. If we can get more people seen by the right people, in the right place, first time around, then this will reduce demand and free up resource.

Much of the NHS England Ageing Well programme is designed with these principles in mind. Urgent community response services take the premise that MDT assessment closer to home can identify who can be cared for in the community rather than needing to go to hospital.  There is also the possibility that earlier intervention, without the destabilising effect of an ambulance transfer and ED attendance, may prevent people with acute healthcare crises deteriorating to the point where hospital is the only option. Enhanced Health in Care Homes brings regular MDT consultation, medication review and structured advance care planning into care homes with much the same premise. These two pillars of Ageing Well are already well underway, albeit with variable progress across the country.

Anticipatory care is the third pillar of Ageing Well. While there is useful draft information on the NHS Futures platform, we are yet to see a clear funding commitment and full specification from NHS England. The rationale is that by working with older people with mild to moderate frailty earlier in their healthcare journey, we can avert deterioration and medical crises. The principles here – those of preventative medicine – are sound. The evidence base for how anticipatory care works in practice is much less certain.  Serial randomised controlled trials have failed to show much impact from intervening earlier to prevent progression in frailty. Those that have shown promise – around exercise, diet and reduction of polypharmacy – are as much public health as they are geriatric medicine interventions. 

But the RCT literature has a lot of problems when it comes to this type of work. Often the selection criteria for patient inclusion are poorly defined, the interventions are frequently incompletely described and don’t match what many geriatricians would recognise as Comprehensive Geriatric Assessment. The Cochrane Review on Community Based Comprehensive Geriatric Assessment found no conclusive effect for the intervention, but that the literature was of very mixed, mostly low, quality when judged against objective criteria. We’re in the “absence of evidence” rather than “evidence of absence” zone as we stand.

When, on the other hand, we ask colleagues around the country whether they’ve found anticipatory care to make a difference to their patients and in their systems, the feedback is more positive. We’ll be sharing some of these case studies as part of this blog series over the next few weeks. These case studies are particularly important because implementation of complex interventions is challenging at the best of times – taking account of the human and organisational factors that influence successful implementation is more important now than ever.

If it works, anticipatory care could provide care in a more timely fashion, closer to home, with the potential to generate capacity within the system, to the ultimate advantage of all care recipients. This is the “moonshot” of the Ageing Well programme. We await the next announcement about NHS England’s progress with… well, anticipation!