The POPS journey continues

Dr Mark Johnston is the Perioperative care of Older People undergoing Surgery (POPS) Lead in Liverpool and BGS POPS SIG Co-Chair.

The rate of surgery in older adults has been increasing more rapidly than the rate of ageing¹. Effective elective care for older individuals significantly improves their quality of life, and the benchmark for this care has been clearly established² with a wealth of irrefutable evidence supporting the value of Perioperative Care of Older People Undergoing Surgery (POPS) services.

Despite this, only 27.1% of trusts in England offer Geriatrician reviews for older, complex patients following an Emergency Laparotomy³. This statistic highlights just one aspect of the broader challenge. Remarkably, it has been 24 years since the publication of the NCEPOD Age Old Problem, which initially catalysed efforts to develop POPS nationwide⁴.

Several barriers still persist, including the reluctance to adopt new practices, bureaucratic hurdles in service development, the overarching clinical environment, and competing priorities within the realm of specialist Geriatric Medical care across various health and social care domains. Key factors relating to implementation have been identified, but the importance of a local POPS champion should not be underestimated⁵.

The operational challenges ahead for the NHS make grim reading, with the new Secretary of State for Health describing it as ‘broken’⁶. The current model of care is not sustainable; change is imperative with a key aspect being patient risk identification and appropriate Perioperative interventions.

Perioperative outcomes don’t hinge solely on employing the best surgeons or purchasing expensive devices. Instead, expertise across the entire care pathway plays a pivotal role. For too long, policy makers have fixated on the surgical event itself, overlooking the real complexity and work that occurs over a broader timeframe. The main strength of POPS lies in our ability to assess and interpret complexity and comorbidity. Our expertise in Shared Decision Making (SDM) and advanced communication skills empowers us to make and support significant decisions in the peri-operative setting⁷.

Three distinct patient groups traverse the surgical journey: those where surgical risks outweigh any benefits, those where intervention offers benefit but requires significant mitigation and optimization to achieve, and those where proceeding with prompt intervention is essential. Frailty Syndrome serves as an independent and valuable risk factor, aiding clinicians in determining bespoke care requirements. In some scenarios, addressing Frailty with appropriate interventions can be remedial.

Our mission remains clear: to provide care where older people need it most. Unfortunately, many patients awaiting elective care lack access to Comprehensive Geriatric Assessment (CGA). Even those who receive it often do so reactively. ‘Taking over care’ is neither achievable nor appropriate; Geriatricians play a crucial role in delivering care across all clinical areas supporting upskilling, education, governance, and leadership in the Perioperative environment.

The passion for this field is unmistakably growing, as evidenced by the increasing acceptance of POPS and Perioperative-related positions across the UK. Various teams are at different stages of evolution in developing their services, recognizing that one size does not fit all. However, there exists a wealth of experience and support for all who are interested. No idea or service is too small or insignificant, and everyone embarks on a journey of growth and refinement. The more we welcome and support POPS delivery, the stronger our collective progress becomes.

Lastly, I invite you to this year’s BGS POPS conference hosted at the RCP Spine in Liverpool on 27 September 2024. Take the opportunity to hear from Anaesthetic, Surgical and Medical specialists on Perioperative topics, including the BGS President Elect Professor Dhesi, receive key updates and forge new connections with fellow passionate advocates of Perioperative care.

Let’s continue our quest together, and we hope many more of you will join us on this exciting journey

References:

1. Partridge JSL, Harari D, Dhesi JK. Frailty in the older surgical patient: a review. Age and Ageing 2012;41:142–7.

2. Perioperative Care of People Living with Frailty | Centre for Perioperative Care.

3. Reports - National Emergency Laparotomy Audit.

4. NCEPOD - Elective & Emergency Surgery in the Elderly: An Age Old Problem Report (2010).

5. Lodge ME, Dhesi J, Shipway DJ et al. The implementation of a Perioperative medicine for older people undergoing surgery service: a qualitative case study. BMC Health Serv Res 2024;24:345.

6. 2024-25-priorities-and-operational-planning-guidance.pdf.

7. Bunn F, Goodman C, Russell B et al. Supporting shared decision making for older people with multiple health and social care needs: a realist synthesis. BMC Geriatrics 2018;18:165.