Dr Maggie Keeble, Co-Founder of GeriGPs Group, British Geriatric Society – Written evidence (INQ0100)

 

 

1.       We have heard that one of the challenges to living well in old age is that medical conditions are treated in silos, which means older people with multimorbidities may have to visit multiple specialists. Is this the case in your experience?

 

From the GP point of view: Most long term condition monitoring happens in Primary Care. Only those with complex issues or hard to manage disease need to be reviewed on regular basis by specialists. The management of long term conditions in Primary Care is mostly condition specific particularly in relation to the Quality and Outcomes Framework.[1] This is a framework that concentrates on prevention of complications from long-term conditions (eg Diabetes Mellitus) or secondary prevention as following a heart attack or stroke. GPs and District Nurses may have a particular interest in certain areas such as Asthma or Diabetes, so face to face reviews are usually disease specific done by particular clinicians which means that many patients with multiple conditions will need to see a number of different people within the practice for a certain disease review. Increasingly patients are unable to see the same clinician for interval problems. This lack of continuity results in increased investigations and referrals. Management is based on best practice and tight control to certain targets with little consideration of a patient’s circumstances or wishes and preferences

 

Avoiding or reducing silo care: Whilst there is variation in practice there is generally a lack of coordination between reviews for different conditions meaning several sets of bloods tests and face to face appointments. A more efficient process would be to ensure a single multifaceted review in a person’s birth month with appointments and blood tests arranged ahead of the review. Most of these reviews can be delivered virtually and group sessions can be arranged for education in self-care and self-management.

 

Personalised care for Older People living with Clinical Frailty:

 

The other important area to consider that of Clinical Frailty. This is a condition characterised by increasing vulnerability to sudden decline. It is associated with age, multiple comorbidity and polypharmacy but may be seen in younger people or people without multiple conditions. It is associated with sudden deterioration due to relatively minor insults. It is particularly relevant as the more frail someone is the more likely they are to need hospital treatment, more likely to need long term institutional care and more likely to die. When someone is living with frailty it is really important that their particular conditions are seen in context and that clinicians adopt a Frailty Sensitive Approach to care. This means ensuring that an individual’s wishes and preferences are discussed with them in order to understand their priorities. At the moment all systems are disease orientated, protocol driven and pathway aligned. We need to shift the focus to being person orientated, choice driven and priorities aligned. We are living in a system which is entirely based on clinical algorithms and pathways which does not support a personalised approach to care. Adopting a Frailty Sensitive Approach means departing from guidelines and accepting uncertainty and risk. There needs to be support at the highest level of organisations for people to be enabled to flex from rigid procedures in order to offer what people want. Ironically offering choice is likely to result in lower rates of intervention, investigation and hospitalisation. It is really important however that all these decisions are founded on conversations wishes and preferences and that decisions are not being taken by Health Care professionals purely on the basis of someone’s degree of frailty.

 

Planning for the future: There needs to be an acceptance that over a certain age (83yrs in women and 80yrs in men) that people are living in ‘extra time’ and we should be routinely asking them to consider future planning for emergency situations in later life. Some people wish for all attempts to be made to sustain their lives whilst others take a much more pragmatic approach and prioritise quality of life over length of existence. Unless we promote these conversations, we don’t give people choice and offer a one size fits all service or pathway potentially undertaking unwanted or unhelpful interventions with use of unnecessary resources.

 

We have an NHS that is largely reactive and have not prioritised proactive discussion or forward planning. Clinicians don’t feel they have the time or expertise to have these conversations. Training of all health care professionals and support for conversations needs to be adopted widely and resourced in terms of time and clinical expertise.

 

 

2.       We have also heard in evidence that current medical practice relating to older adults can give rise to polypharmacy, as older people are treated for multiple conditions by different specialists in parallel. What challenges are associated with polypharmacy, particularly for older people?

 

As people age, they are more likely to suffer adverse effects from medication prescribed for a number of conditions. The causes of this are multiple: older people may have liver and kidney problems meaning drugs are not excreted as efficiently causing a build-up in the system. They may lose weight over time meaning that the amount of drug available to the body increases. Older people are more prone to falling for many reasons and this tendency is exacerbated by medication often used in older age eg medication to treat blood pressure, incontinence and pain. Other side effects such as delirium (acute confusion) are more common in older people. Medicines are tested under very controlled situations usually on younger people with single diseases. It is rarely tested in older people and in multiple conditions hence there is a lack of evidence of interaction and of the efficacy of the medication on older people in general.

 

Clinical Pharmacists are becoming more common in the system being employed by a variety of agencies – GP practices, Primary Care Networks, Community Dispensing Pharmacists, Acute Trust and Community Trusts for inpatient units eg community hospitals and mental health wards. Some are acquiring advanced practitioner training and are working in specific areas eg Clinical Frailty Hospital at Home services and Care Homes. There is a range in expertise with some colleagues being very aware of older people’s needs and others being less well in formed – in particular those working in Community Dispensing Pharmacies ( as opposed to Pharmacists working in Community based teams). Unfortunately there tends to be insufficient interaction coordination or communication of pharmacy colleagues in primary care and across the interfaces of care resulting in too many errors with medication, changes not be recognised and systems being too inflexible to enable timely alteration in drugs eg Dosette boxes. Community pharmacists have all been issued with nhs.net email addresses but some are slow to adopt this method of communication and in my experience there is no direct communication between community pharmacists who dispense most of the medications for older people and other pharmacist dealing with the same patients

 

I am unclear as to the level of knowledge and training in older people’s medicine received by community dispensing pharmacists who often challenge dosing or adverse interactions but never ( in my experience) become involved in discussions about deprescribing or assessing compliance – they would not appear to have the capacity to do this. GP based pharmacists however are fully involved in clinical assessment and prescribing and are a very welcome addition to the team.

 

 

Older people are more likely to have multiple comorbidity, polypharmacy and conditions such as renal and kidney disease which means that they are more likely to be subject to drug interactions and increased drug levels in their blood to the reduced excretion. As a result older people are more vulnerable to side effects of drugs and more likely to suffer adverse effects such as renal impairment falls confusion haemorrhages and constipation. [2]

 

There needs to be a Structured Medication Review on a yearly basis to flag excess drug doses and to consider discontinuation of medication. At the moment the duty to do this falls on Primary care and their pharmacists. This is a very time intensive intervention as it takes time to discuss with patients and to develop an individual agreement and care plan. This then needs to be communicated to other professionals so that mediation which has just been stopped after decision with a clinician isn’t restarted by another health professional in another health care setting eg anticoagulants statins and antihypertensive mediation. This could be done with more patient involvement and informed choice with remote consenting providing a way to do this – but any clinician undertaking this intervention needs to be able to take clinical responsibility for decisions to deprescribe otherwise a GP would not be keen to comply with this decision without discussion with patient resulting in repeat consultations and no time saved.

 

 

3.       Are GPs given the training and tools to provide holistic care for someone with multimorbidities? What are the challenges of treating older people with multimorbidities in a primary care setting?

 

In my experience few GPs have adequate training to provide holistic care for people living with multiple comorbidities. Clinical Frailty is increasingly being recognised and its implications for the individual and their carers both formal and informal but systems are still set up to recognise and response to individual conditions. The paradigm of Comprehensive Geriatric assessment and Care and Support Planning the domain of Geriatrician’s has to date but unknown to Primary Care and whilst this is now incorporated into the Enhanced Health in Care Homes Directed Enhanced Service many GPs lack the knowledge, time or skills to do this well. They are not used to working as part of a Multidisciplinary team which takes a whole different set of skills and brings its own complexities. Similarly the nursing colleagues who will also be part of the MDT are training to recognise single conditions and manage accordingly.

 

GPs and MDT colleagues need easy and free access to appropriate training to enhance their knowledge of the Core Competencies of Frailty and how to adopt a Person Centred Approach – there needs to be rapid investment in online sharing platforms to enable compilation of the comprehensive assessment contributed to be patient and carers as well as all member of the MDT with a portal directly accessible to patients themselves.

 

There remains very poor coordination between Primary and Secondary Care with very limited sharing of information – Acute Trusts have been permitted previously to develop their own computerised Electronic Patient Records without any consideration of how information can be shared with community colleagues. IT solutions are being sought by STP Digital leads across the country but progress is painfully slow. The Summary Care Record with Additional information already in place would transform this communication but there has been no widespread publicity to encourage people to give their consent to sharing and there has been no incentive or even advice to Acute Trusts to use the Smart Card Access required by their clinicians that would completely transform their ability to understand more about their patient. A nationwide system has been created to share a subset of coded information but for some reason this has not been promoted.

 

 

4.       We have heard that the Comprehensive Geriatric Assessment potentially offers one route to provide a holistic assessment of the needs of the older patient (including a review of their medication, their social and environmental circumstances and their functional status). In your experience is the CGA used in primary care, and if so, how widely? If it is not used, why not?

 

Until very recently the CGA has been the domain of Geriatricians. GPs were not and many are still not aware of or use it. Traditionally Primary Care has focused on single issues with a reactive mind-set. Short appointments and home visiting only when requested by the patient or carer as a result of a deterioration doesn’t allow for the time required to undertake a lengthy intervention in a planned proactive manner. Training of medical students and for GPs doesn’t to my knowledge include training on the use of CGA nor how to go about completing a Care and Support plan for someone with complex comorbidity and clinical frailty taking into account their wishes and preferences in a frailty sensitive manner. Another barrier to completion of a CGA is a lack of integrated computer systems enabling the compilation of information already held by different professionals working in different parts of the system. Primary Secondary Community and social care usually work of different systems which differ again from Emergency and Out of Hours services.

 

Awareness of CGA is increasing gradually in primary care. It features in the Enhanced Health in Care Homes framework as the standard assessment process. CGA incorporates physical issues and past medical history, mental health and memory issues, medication review, a functional assessment and social and economic factors. Future planning should also be incorporated as an additional sixth element to ensure peoples wishes and preferences about future care are known when they are no longer able to express a preference. There is good evidence in hospital settings that adopting this framework of assessment reduces length of stay in hospital, reduces transfers to long term care and reduces mortality rate. There is no evidence in community settings to suggest that CGA extends health lifespans as CGA in primary care has not been the subject of extensive research. This should not be a barrier to implementation as person centred high quality safe and holistic care of people living with Clinical Frailty and complex comorbidity is impossible without a full awareness of issues in all six domains of the CGA and it has been shown to improve patients sense of being involved in their own care.

 

The elements of the CGA can be compiled by a single individual but it is more efficient and likely to be more detailed if contributed to by all members of a multidisciplinary team including social workers. In my experience however social workers are rarely standard members of the team especially in the community where adult social care works in a very silo’d manner and social workers rarely communicate proactively about individuals for whom care is also being provided by GPs. This is hugely frustrating because in my experience when you do get to speak to Social Workers they have a wealth of information at their fingertips, family and home and environmental circumstances and safeguarding information in particular, which can be very useful and sometimes essential when supporting someone with planning current or future care.

 

 

5.       Are geriatricians the best placed specialists to oversee a system involving more holistic care for older people, or should these clinicians work more closely with other specialists (e.g. cardiologists, rheumatologists)? Or, are clinicians with broader "cross-specialisms" needed?

 

As a GP I would say that the main requirement of clinicians overseeing a system involving holistic care is that they are generalists able to see a person in the context of their lives not in the context of an acute hospital. Only people working in the community – whether as GPs ACPs or Community Geriatricians really understand the situation faced by older people within their home environment where they spend the vast majority of their time. They need a good understanding of the workings of community services, the voluntary care sector, the domiciliary care and care home market, community pharmacy, housing and transport services and well as the developing market in telecare and assistive technology. We need to significantly increase the numbers of geriatricians in particular community geriatricians and increase the recognition of GPs with an interest in Older Peoples medicine of which there is an increasing number self declaring.

 

Changes need to be made early in the medical curriculum to encourage awareness of the importance of medicine for older people (only two specialties do not feel the impact of the increasing numbers of older people – Obstetrics and Paediatrics) but also to raise awareness of the need to modify pathways to allow a frailty sensitive approach to be adopted when appropriate.

 

 

6.       Does the NHS Long Term Plan adequately address the changes required to provide better care and support for older people, particularly those with multimorbidities?

 

The Long Term Plan is laudable in its aims to improve primary and community services with a focus on community based care with anticipatory care and personalised care and support planning at its heart. There does however need to be an appropriate allocation of funds in community services to support this (yet to be seen). The additional funding to Primary Care Networks is welcomed but this predominantly will see employment of allied professions and not the core professionals also required – Advanced clinical practitioners of all backgrounds as well as nurses and therapists

 

There is a lack of focus or provision for healthy ageing activities with no widespread public communication about how to prevent decline in later life and that deterioration and the onset of frailty is not predetermined and can be either prevented, reversed or reduced if appropriate measures are taken. This message needs to be promoted at all ages. If awareness were raised at school this would an impact on parents and grandparents if their young are promulgating the messages about high protein low fat diets and resistance exercises focusing on core muscles and improving strength and balance. The LifeCurve model[3] or similar can be used to demonstrate the ability to avoid, delay or reduce dependency in later life. Recognising the first marker of decline (ie not being able to cut your own toenails) is a very useful way of demonstrating to people how age related functional decline can creep up insidiously but information about how simple it is to prevent or reverse using simple resistant exercise techniques combined with an appropriate diet and maintaining social interaction gives a really positive message about ageing. The other strong message that needs to be given by Government is that people will end up spending far less on their health and social care needs if they adopt an age positive life style. These messages are as important as the stopping smoking messages of previous decades and investment in communication will pay dividends in reducing costs to Health and Social care in the future.

 

 

7.       Is the Government's target of five more years of healthy and independent life by 2035 achievable? What are the main barriers to achieving the target with regards to the healthcare system?

 

I firmly believe that the Government’s target of five more years of healthy and independent life within the next 15 years is achievable through promoting the impact of age positive life styles including diet and resistance exercises which show sustainable improvement if relatively moderate change is adopted. Currently our health services are predominantly focussed on firefighting once decline is well embedded and there is not capacity or incentive in the system to adequately promote Public Health measures. The separation of Health, Public Health and Health Promotion Services has undermined the ability to influence life style measures consistently across the board with organisations working in silos with little awareness of each other’s work or priorities. Bringing these organisations closer together through a single public body would go a considerable way to enabling a coordinated approach. There needs to be a widespread and consistent public message about the benefits for the individual and society and there needs to be legislation to reduce costs of healthy options (including foods and activities) and increase costs of unhealthy ones. Anti-Smoking legislation based on harm to others was the tipping point for the Stop Smoking Campaigners. There needs to be similar legislation focussed on Age Positive lifestyles with suitable support (subsidising weight reduction and exercise classes) for those people who genuinely want to make changes but haven’t the funds to invest in themselves. Mainstream media campaigns and free access to broadcast exercise classes suitable for all ages and levels of ability, a true commitment to making cycling easy and safe and a focus on healthy built environments. Encouragement to remain engaged socially and incentives to volunteer or to return to paid work for those that want it would show a true commitment to older people and demonstrate their worth in our society.

 

8 September 2020

[1] https://en.wikipedia.org/wiki/Quality_and_Outcomes_Framework

[2] Adverse Drug Reactions in Special Populations – The Elderly E A Davies M S O’Mahoney 24 January 2015 https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1111/bcp.12596

[3] https://www.adlsmartcare.com/Home/LifeCurve