Every winter has its spring

Dr Rowan Wallace is a Consultant Geriatrician and Clinical Director for Older People’s services in NHS Ayrshire and Arran on the west coast of Scotland. She is the current Specialty Advisor for Geriatric Medicine to the Chief Medical Officer in Scotland and a past Chair of BGS Scotland Council. She tweets @rowan_wallace

I have to admit that I am fearful of pressures mounting even higher in the upcoming winter months. It feels like there is little left to give of ourselves, and not much in the way of flexibility within our systems. Having said that, we will strive to improve where we can.

We start with a recognition that short term crisis interventions especially during the winter do little to maintain the sustainability and consistency all year round that our patients value. We also appreciate the reality that winter pressures affect every part of a person’s health journey through health and social care. We tend to focus on hospitals and acute care in our efforts to offer alternatives to admission, but this in turn increases the burden on primary and social care. Feedback from representative organisations to Scotland’s Winter Resilience Overview 2022-2023 was wide-ranging in content and highlighted these issues. The Scottish Government have recently published this year's plan with announcements on a number of areas which may help us and our citizens through winter 2023-2024 and beyond. I’m going to highlight a couple of these national initiatives and show how we are implementing the work in our locality.

Foremost is the boosting of Hospital at Home services. Scottish Government released a funding package in June to enable this expansion in all health boards, and this is backed up with an established community of practice through Healthcare Improvement Scotland and the iHub to support us in delivering this for patients. We have used this resource within Ayrshire and Arran to boost our Hospital at Home team staff, increase our daily capacity, and also move to safely take direct referrals for people living within local care homes, as well as continuing to add to our evidence base. The feedback from the people for whom we have been able to provide assessment and care has been reassuringly positive. We are very fortunate to be approaching this winter with the added bonus of a GP trainee based within our team, and also to have employed a GP with extended role. This provides us with vital direct links and experience into primary care. These links are becoming increasingly crucial. There is still room for us all to consider how we create enhanced and direct connections with primary care colleagues. Long wait lists for specialty advice along with long waits for elective care means that many people are living in our communities with significant and unresolved health issues. Our GP colleagues are currently managing the associated risk without extra resource. In our area we have the added benefit of specialty input into our pre-op assessment service targeting those people expecting elective procedures and living with frailty. We chose to use our very limited available consultant resource to set this up with our pre-assessment colleagues, recognising that the waits have been long for many people and that we need to manage the risks with them. We presented on our journey so far at the BGS Scotland Autumn meeting in Glasgow on 6 October. If you missed out, there is still the opportunity to register to view the content for the next 12 months.

‘Focus on Frailty’ is a change package from Healthcare Improvement Scotland for the frailty improvement and implementation programme fully launched in May 2023. The aims are whole system, wide-ranging and person-centred. These include the aim that people living with frailty, along with their families and carers, report positive experiences of health and social care, and that health and social care teams report on improved integrated working. Locally for this winter and beyond, we are choosing to focus on enhancing front door frailty services for older people, including in the emergency departments. This allows early building of comprehensive geriatric assessment and delivering on the actions identified. We have two acute hospitals within our health board and in common with other areas, our main challenge is specialty workforce. We have been pleased to see funding secured for additional front door AHP resource – without this it’s impossible to provide the high-quality MDT-driven comprehensive geriatric assessment that we know has the most value for our patients living with frailty.

As ever we face critical gaps in social care. This is a whole UK issue and underpins the struggles we continue to have in ensuring that the entire healthcare journey for people living with frailty runs smoothly. We know that older people are more likely to end up displaced as a result of systems running at over-capacity. The negative impact on their health, well-being and quality of life is significant, and these are often people who are already on the steepest downturn of their life curve. Whole-system interventions aim to reduce the number of people stuck because of discharge delays. Some of the Focus on Frailty projects across Scotland are choosing to improve community based options and boosting the MDT.

So, yes ‘Winter is coming’. To fully embrace the Game of Thrones theme, I would add, ‘Chaos isn’t a pit, Chaos is a ladder’. Out of crises we can learn, and hopefully grow stronger.