If ever there was a time to work together to improve services for older patients with frailty, it’s now!

Shelagh O’Riordan is a Consultant Geriatrician, Clinical Director Frailty in East Kent and Chair of the Community Geriatrics Special Interest Group.

Over the past few months, all of us who work with older people living with frailty have completely changed what we do. Covid-19 dominated our discussions and our caseloads. Hospital frailty specialists joined large generic medical rotas to cover the huge influx of extremely sick patients and saw a big drop in the number of people with frailty syndromes who would normally present to every Emergency Department in the country.

GPs and community frailty specialists did everything they could to try to reduce the need for hospital admission for patients without covid-19, in light of the very real fear that they might catch it while there. We also supported many patients dying at home from covid-19. I normally run a community frailty service supporting community hospitals and providing proactive Comprehensive Geriatric Assessments (CGA) for older people living with frailty at home, working with community MDTs. We completely changed what we had previously done, to deliver a ‘hospital at home’ service providing consultant-level support and urgent assessments 7 days a week, which enabled people to be treated in the safety of their own home.

We all recognised the need to know in advance what an older person with frailty would want if they became very sick with covid-19, and we worked hard to enable and to record these conversations. These Anticipatory Care Plans (ACPs) or Treatment Escalation Plans (TEPs) were completed with many older people and their families in care homes across the country and also with older people in their own homes. Many patients dying from covid-19 or other terminal diseases (heart failure, respiratory disease and dementia for example) expressed a wish not to be admitted to hospital, and died at home, including in their care homes. In the past, many of these people may well have been transferred to hospital.

I’m now reflecting, like many of us, on what to do now. I really don’t think covid-19 is going away any time soon and the risk to advantage ratio of an admission to hospital will be more towards staying at home than it was before. There will clearly be times when hospital admission is essential, but there will be more times than previously when we will need to be able to provide care based at home.  How can I continue to provide a non-hospital option for unwell patients with frailty? How can I morph a team which worked 9-5pm Monday to Friday, into a 7-day a week 8am-8pm service? What can we drop from the work we did before which had less value and what should we retain as essential?

I think we must all be asking ourselves these questions but I have a horrible feeling that in many areas frailty specialists will be asking these questions about their own service, rather than looking at the whole pathway on offer for each older person. If ever there was a time for us all to work together, it really must be now! There is a finite resource of specialists in frailty. If we are to provide better care out of hospital or in an ambulatory manner, we need to consider how we can enable this, working seamlessly between community and hospital services. I know from personal experience how hard this can be and I’m absolutely sure my experience in East Kent isn’t unique.

The British Geriatrics Society includes multi-disciplinary professionals working in acute, intermediate, primary and community care. Many are frailty specialists from within acute hospitals or provide frailty services out of hospital. Groups such as the GeriGPs group and Community Geriatrics SIG understand the complexities of services in primary care, and are keen to collaborate with acute care specialists to ensure transitions between care settings for older patients recovering from Covid19 or other diseases are as smooth as they can be. Let’s do this together and let’s do it differently. #nogoingback