Written evidence submitted by the British Geriatrics Society (DEL0114)
Introduction
The British Geriatrics Society (BGS) thanks the Health and Social Care Select Committee for the opportunity to contribute to this important inquiry into the delivery of core NHS and care services during the COVID-19 pandemic and beyond. The BGS is the membership association for professionals specialising in the healthcare of older people in the UK. Founded in 1947, we now have over 4,000 members, and we are the only society in the UK offering specialist expertise in the wide range of healthcare needs of older people. This submission is informed by the contributions of our Policy Advisory Panel who represent a multi-disciplinary group of our members from across the UK.
Older people are the main users of health and social care services and their high morbidity rates, different patterns of disease presentation, slower responses to treatment and requirements for social support calls for specialist medical skills. Geriatricians, GPs, nurses, old age psychiatrists, allied healthcare professionals and researchers provide high quality care for older people as part of a multidisciplinary team during acute illness, chronic illness, rehabilitation and at the end of life, both in hospital and community settings.
Managing COVID-19 has dominated our health care systems for the last six weeks but as numbers fall within acute hospitals, mechanisms to reset and restart health and care services will need to be considered. For specific services for older patients, there will be a demand for a range of services from primary care, early intervention and preventative care to routine elective surgery (eg, joint replacement) and ongoing management of chronic medical conditions, e.g. Parkinson’s disease, heart failure, osteoporosis, COPD. Protecting older patients from the risk of a second wave of coronavirus exposure will need to remain at the heart of planning for restart of other services and consideration should be given to separating elective from emergency work. Shielding status may not be consistently applied to those older people who would be at higher risk from contracting the virus so risk assessment for all older patients accessing healthcare will be needed. Allowing access to avoid disadvantaging those with significant morbidity whilst maintaining safety and infection control will be a difficult balance.
There is a significant concern among BGS members that during the pandemic, the ‘stay home’ message worked a little too well among older people. Our members tell us that even before the pandemic many older people with frailty did not present to health services until they were in crisis and the pandemic has made this worse. BGS members report that non-COVID services have been quieter than usual during the pandemic, prompting fears that older people are delaying or avoiding seeking help when they need it. There is therefore a need for the NHS and Government to communicate a message that the NHS is ‘open for business’ and that those who need support should not hesitate to seek help.
BGS members report using a multidisciplinary team (MDT) approach for patients to identify those who require additional support to be identified. MDT assessment can take place in a patient’s home and can include medical assessment, diagnosis and management. Some areas have combined specialist frailty teams with community geriatric medicine teams and existing community nursing and therapy teams. Virtual MDT meetings with GPs can help to plan workload and identify patients who would benefit from an MDT approach.
Telephone triage services have been widely used during the pandemic and it may that this continues to be the case for initial contact with services. For patients who need to be seen in person for non-COVID conditions, the risk of infection can be reduced with the use of ‘hot’ and ‘cold’ areas in GP surgeries and hospitals to enable non-COVID patients to avoid any contact with areas and staff treating COVID patients. It will be important to conduct skills and job mapping exercises to ensure that, in particular, those with advanced practice skills are properly utilised, both in the community and hospital setting.
Carrying out comprehensive geriatric assessment (CGA) in a person’s home, as and when the situation presents itself, would be beneficial to patients and would encourage healthcare professional to consider their patients in a more holistic manner rather than focusing on one, potentially small, aspect of their health.
It is important to note that due to the small size of the geriatrics workforce, it will not be feasible to split the workforce into COVID and non-COVID. In addition, the varied presentation of COVID-19 in patients living with frailty means that any patient could potentially be COVID positive. As such, healthcare professionals working with older people with frailty should be prepared to continue to use personal protective equipment (PPE) indefinitely. It will be important to ensure that staff have access to appropriate PPE.
Again, phone triage services will be important to determine clinical priority as services work to catch up. Satellite clinics may be useful to help to reach vulnerable people and reducing infection risk.
There is a concern among BGS members that there will be many patients in the community who have had severe COVID-19 but will not access the rehabilitation services they require. This could be for a variety of reasons including not realising that rehabilitation is available, not ever having sought medical assistance for COVID and therefore not being on the radar of GP and acute services, feeling they can’t access rehabilitation because of the risk of infection and seeing deficits or fatigue as just part of the illness and assuming it will go away. Community rehabilitation needs to be promoted so that patients who have had COVID are aware that it is available and that they can be referred if necessary. It is important that those patients who require rehabilitation are able to access it, not only for their own long term health but also to avoid placing a greater burden on the health and social care system if they do not access the support that they need.
It will also be important to prioritise the needs of healthcare professionals as we come out of the pandemic. Health and social care staff have put in extraordinary effort to deal with the coronavirus pandemic and will need to start considering taking time off for annual leave and restarting supporting professional activities such as appraisal, teaching and quality improvement.
For older adults a focus on mental health may require a complete re-design of services to deal with the effect of the pandemic and lockdown on emotional wellbeing and affective disorders such as anxiety and depression. Mental health services for older adults often focus on the challenge of cognitive impairment and dementia. However, we may face a situation after the pandemic when we need to consider more services for affective disorders in older adults.
It is important to recognise that this issue is not confined to times when there is a pandemic – BGS members are accustomed to meeting the needs of patients discharged from hospital who have complex needs. For older people, the use of comprehensive geriatric assessment (CGA) is vital as well as ensuring that CGAs are shared between healthcare professionals, possibly in the form of a CGA ‘passport’ that is created in the community or in hospital and remains with the patient. This is necessary as communication between professionals is often poor for this specific patient group and discharge summaries often lack the depth of information needed.
This is another example of where telephone triage and satellite clinics can work well to protect vulnerable people. However, these people will sometimes need to be seen face-to-face. When they are required to attend clinics, they should have protected appointment times so that they do not need to sit in waiting rooms.
Through utilising the skills of healthcare professionals with advanced clinical skills, hospitals could provide outreach services in patients’ homes whilst vulnerable groups are still shielding. Falls assessments, medicines reviews and CGA can all happen in patients’ own homes via outreach services.
It will be important also not to neglect the mental and physical health and wellbeing of those who are shielding. While they may be protected from COVID-19 during shielding, this should not be at the expense of other aspects of health. There is a concern that many of these people will emerge from the pandemic untouched by COVID-19 but having developed frailty. We must ensure that people who are shielding are supported to stay mentally and physically active during the pandemic.
Public health teams will have a major role in advising on population level health interventions such as testing and vaccination. Research tells us that older patients benefit hugely from a population-based vaccination policy. As individuals, they may have a limited response to vaccine but have benefited hugely by a population gaining immunity and reducing viral spread. Evidence is particularly strong in supporting patients in both health and social care settings (hospitals and care homes) and staff working in these settings should be prioritised for vaccination as this will not only support the health care systems but protect vulnerable patients.
The key to this will be good leadership, starting with service evaluation by managers. During the pandemic, many clinical areas have been running on ‘skeleton’ staff as clinicians have been redeployed and services have been scaled back. Service evaluation is now needed to identify those areas that have been impacted and which may have run better. Feedback from staff and patients during the pandemic is crucial to identify how workload and care have been affected during the crisis.
There has been an increased focus during the pandemic on advance care plans for vulnerable people and older people with frailty. This has not always been communicated appropriately, with debates often taking place through the mainstream media. However, we should not lose the importance of advance care planning as this allows healthcare professionals to consider the views of patients or their close advocates to prevent harms of escalating to inappropriate or unwanted treatments or care locations.
The health and care service have had a very clear single purpose responding to the COVID pandemic. This has motivated individuals to work collaboratively. We need to ensure that the impact the illness has had particularly on the frail and vulnerable population in care homes is used as a stepping off point for ensuring they are an integral part of our health care system. Enhanced health in care homes has been a key element of this pandemic with examples of support for best supportive care and excellent palliative care being delivered. We need to ensure that relationships meet the needs for the patient and not the organisation.
Thank you for the opportunity to contribute to this inquiry. If you have any questions about our submission or wish to invite one of our members to give oral evidence to the committee, please contact our Policy Manager.
May 2020