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1 Introduction

The care of the older frail patient in community settings is complex and comes within the responsibility of many different clinical professionals including General Practitioners and their teams, community nurses, physiotherapists and occupational therapists, secondary care clinicians including geriatricians, psycho-geriatricians.

Frail older people are vulnerable to poor quality services, to some extent reflecting ageism within the delivery of services. Pitt stated “ Most developed societies do little to enhance the image of the "senior citizen," who is liable to be patronised, marginalised, or simply ignored and is seen as a problem for an overburdened welfare state” 1. Frail older people benefit from “Comprehensive Geriatric Assessment”, which requires an assessment of activities of daily living, mental well-being and the need for social care as well as a thorough medical assessment. Poor quality services may neglect this medical assessment: for example, non-specific problems (such as falls, immobility) may be managed poorly because of the lack of an adequate medical diagnosis. Poor quality services are therefore likely to be ineffective. Poor quality services may also neglect physical and mental abuse by relatives and ‘caring’ institutions, abuse that commonly is not recognised.

The General Practitioner is central to the coordination of this care. For most frail older people, he or she is the ultimate case manager orchestrating the medical care of the individual on a daily basis and seeking the advice of others with specialist knowledge and skills when needed. This may be through referral to the professions allied to medicine or to other clinical colleagues – such as General Practitioners with Special Interest or Consultants - either in intermediate or secondary care. In the “New NHS” – discussed in detail later – there are more players in this area, and this potentially causes confusion. In these circumstances, the clarity of a joint and team approach cannot be underestimated. A particular potential area of confusion is the part played by different medical practitioners – particularly the respective roles of General Practitioners, General Practitioners with Special Interest and secondary care clinicians. This paper seeks to address the team working between these groups to the maximum advantage of the frail older person.

The best approach to this vulnerable section of our society has been considered in this statement by the British Geriatrics Society and the Royal College of General Practitioners. The production of this document was initiated by a conference in June 2006 between the British Geriatrics Society and the Royal College of General Practitioners to which other professionals were invited and who contributed widely to the discussions. These included community and practice nurses. It is recognised that the sign-up of other organisations such as nursing, physical therapies and pharmacy is required. But this first attempt at a document throws down the challenge for us all to collaborate to produce further guidance on joint working to optimise the care of frail older people. Therefore, this document is not the end of the process but the start of a joint programme of work between the British Geriatrics Society, Royal College of General Practitioners and others to optimise the care of one of the most vulnerable sections of our society.

2 The New NHS and specific purpose of this document

The National Service Framework for Older People set out a plan for the optimal health and social care for the start of the 21 st century and, although introduced for the NHS in England , it includes many central elements that are held to be true in any country and at any time. This document was written in a period during which health policy in England was moving towards a model where care is delivered in community settings as opposed to hospitals - on the basis that this might be more cost effective or preferable to users. And so, the National Service Framework for Older People stimulated the growth of intermediate care services, and subsequent policy initiatives have continued this process by introducing community matrons to case-manage certain frail older people in the community.

The National Service Framework recognised some of the complexity of the task. It required that services deliver p erson-centred care. This meant that NHS and social care services should treat older people as individuals and enable them to make choices about their own care. The National Service Framework stated that this should be achieved through the single assessment process, integrated commissioning arrangements and integrated provision of services, including community equipment and continence services. Regarding intermediate care, the NSF stated that older people should have access to a new range of intermediate services at home or in designated care settings, to promote their independence by providing enhanced services from the NHS and councils to prevent unnecessary hospital admission and effective rehabilitation services to enable early discharge from hospital and to prevent premature or unnecessary admission to long-term residential care.

The development of intermediate care and the introduction of community matrons has significantly changed the health and social care landscape towards greater community provision of health care: part of the “new NHS” referred to in the title to this document. The good news is that there is a real opportunity for the care of frail older people in the community to improve. But difficulties remain. For example, Intermediate Care services are often fragmented, some with questionable standards of clinical governance. Lessons from good practice need to become routine practice.

One of the many necessary conditions for effective services for frail older people is adequate medical input. This may appear self evident, because the health problems in older people arise from acute illnesses occurring in the presence of chronic illnesses. It follows that it is vital that these conditions are diagnosed, their prognosis established and their treatment given. However, there are no accepted standards for the medical requirements in services for frail older people in the community.

The core care of the frail older patient in the community remains the responsibility of the General Practice team. Because of this, the requirements for good General Practice in this area have been included in the General Practice curriculum statement 2. At the same time greater sub-specialisation of primary care doctors has led to the development of General Practitioners with special interests in older people and General Practitioners with “extended knowledge”. The Royal College of General Practitioners website gives information and advice for those wishing to pursue an interest in General Practice with Special Interest 3.

However, the “new NHS” represents a transfer of provision from secondary to primary care doctors, and this has stimulated growth in the development of community geriatric medicine 4. Historically, General Practitioners and community geriatricians would interface either through referral to out-patient clinics, or through requesting domiciliary visits. But now opportunities exist for secondary care doctors as well as General Practitioners with Special interest or extended knowledge to support the work of matrons, provide services to care homes, and to provide input to intermediate care settings.

We are currently witnessing the development of community geriatrics services in this area. Many different models have developed, largely dependent upon the views and experiences of the enthusiasts who have taken leadership roles for project development and the resources available to them. Some have deliberately chosen to develop demonstration projects so as to illustrate what high quality care can achieve, aiming to model good practice to encourage improvements in other neighbouring services and leading by example. Others, particularly those arising in primary care, have taken a population based approach based upon the needs and resources of a PCT (a unit of primary care health organisation) or primary care practice.

The purpose of this document is to give guidance upon good ways of primary and secondary care doctors and their teams working together.

3 Challenges faced in the provision of specialist community services for frail older people

3.1 Problem-based as opposed to diagnosis based services

Many new community services for frail older people led by staff other than doctors have developed using a “problem-based” model of care, with the risk that underlying diagnoses are not sought or treated. Such models have many advantages in stable patients with medically untreatable conditions where person-centred problem-based interventions are likely to be highly acceptable to users. Such models are potentially dangerous when medically treatable conditions are the principal cause of the problems (e.g. congestive cardiac failure or anaemia) and if they fail to facilitate secondary prevention (e.g. aspirin or statins).

3.2 Tensions related to professionalism

General Practitioners, General Practitioners with extended knowledge, General Practitioners with Special Interest, community geriatricians and community matrons may all wish to claim this area as their professional territory.

3.3 Ambiguity regarding responsibility

If no-one takes clear responsibility, management can be inefficient or ineffective. Governance may be weak and safety may be compromised. Elder abuse may flourish.

3.4 Communication failures

This includes the adequacy, sharing, and using of particularly medical information, such as a diagnosis. Its absence leads to anxiety in patients, their families and their caregivers, and uncertainties in the professionals who are treating them.

4 Responses to these challenges

4.1 Teamwork

Of prime importance is proper teamwork focused on the clinical care of frail older people in the community. The primary health care team is always involved in this role but there are increasing instances when the primary care team may request additional input from an extended team. Examples include patients in receipt of intermediate care, those case managed by community matrons, those in care homes, or those seen by specialist falls prevention teams.

Teams are needed that can:

• Respond rapidly
• Make diagnoses
• Make comprehensive assessments
• Deliver comprehensive care
• And can do this at home, in care homes, and in assessment units.

Features of good teams are that they:

• Meet regularly
• Understand each other’s competences
• Are clear about responsibility and its delegation (in those who delegate it and to whom it is delegated)
• Take pains to communicate effectively
• Plan together
• Contribute to teaching and training each other

These elements of teamwork clearly apply in those instances where General Practitioners, General Practitioners with Special Interest and geriatricians are to provide shared care. Since the patient’s own General Practitioner retains the ultimate responsibility for his or her medical care, it is crucial that delegation of the responsibility to others is explicitly agreed, and that communication at all times between all parties is of the highest order.

4.2 Time

One of the features of the geriatrician, the General Practitioner with Special Interest or the community matron is that he or she can provide the time to assess complex patients - time that is not ordinarily available in primary care. The need for adequate medical time to assess, determine the need for investigation, and monitor progress is important to achieve the best outcomes, efficient use of resources. This, combined with rigorous admission procedures, is of particular importance in residential intermediate care – whether in community hospitals or care homes.

4.3 Available specialist expertise with older people

Practitioners in these new settings (matrons, and other advanced practitioners) indicate that they sometimes need specialist advice, and they need it almost immediately. Both General Practitioners and geriatricians need to be easily available to the teams they support, for example by mobile phone or email.

By virtue of their dedicated training (defined by the training curriculum for trainees in geriatric medicine) and secondary care workload, geriatricians have deeper and more up to date knowledge than most General Practitioners giving them the ability to manage more complex situations outside the District General Hospital, Geriatricians can also best identify those who would benefit from further investigation or treatment. Geriatricians have the training and authority to martial the resources of secondary care, whereas the General Practitioner can martial the primary care resources. This illustrates the importance of shared care.

Describing the roles of the various medical practitioners is not straightforward. This is partly because their roles adapt as the roles of those they work with change. More can be delegated to highly trained community staff than to less trained staff.

4.4 Accepting responsibility

As General Practitioners and geriatricians and new clinical colleagues interact, some of the etiquette and practice of the past bears re-examination. In the past General Practitioners were ultimately responsible for patients at home and consultants were responsible in hospital. General Practitioners requested consultants to “consult”. In the new interfaces there are other responsible people, and the consultant might be asked to consult by someone other than the General Practitioner. This can lead to problems about who is responsible for taking actions. These issues can be over come by the following:

• Prior agreement between General Practitioner, Consultant and matron / advanced practitioner of referral practices, to ensure that General Practitioners remain central to the decisions that affect what happens to patients for whom they have the prime responsibility
• Meticulous attention to communication between all members of such arrangements, not just between any two people
• Full acceptance of the responsibility of the referral process if delegated to non-medical personnel

5 Establishing a community specialist elderly care service

5.1 Elements of the service

A community specialist team for frail older people is required to respond rapidly, and to provide the range of help needed. This should break down the separation between primary and secondary care. The development of community care is suitable for commissioning by the emerging practice-based, or practice cluster, commissioning groups. Its delivery requires a combination of primary and secondary care.

It makes sense to identify (and establish if absent) the elements of specialist services for frail older people in each locality:

• Community geriatrician sessions
• Primary Care specialist practitioners
• General Practitioners with Special Interest in the care of older people (when available)
• General Practitioners with specialist training in the care of older people care (to be encouraged where there is no General Practitioners with Special Interest)
• Community Matrons
• Other community specialists (e.g. falls specialists)
• A social work team
• Intermediate Care and therapy services
• Old Age Psychiatry services
• Voluntary sector

We recommend that these elements are developed into an integrated service. This service should adhere to the principles outlined in the previous section by concentrating upon teamwork, ensuring that staff have adequate time, ensuring access to appropriate specialist input, and understanding and accepting of responsibilities. Shared information systems may be useful, but at the very least ensuring good flow of communication between practitioners is vital.

In parts of the UK there has been investment to develop an integrated community specialist elderly care service along these lines, but at present this remains the exception. In some parts of the country the necessary elements do not exist. Some areas do not have community geriatricians, and others do not have General Practitioners identified with special interest or extended knowledge. Both are ideally required, but the exact ratio of one to another, and which of them should take on the leadership role may vary according to local preference.

5.2 Organisation and roles of services

The community service for frail older people should be organised and commissioned by the Primary Care Trust and the new practice-based commissioning model. It is likely to operate at two levels, although these might be merged.

5.2.1 Practice-based, or practice-cluster level

This team should meet weekly, to discuss new cases and review problems. It may comprise a:

• District nurse working as case managers
• Community matron
• General Practitioner taking special responsibility for managing vulnerable older people
• Social worker
• Representative from a local neighbour support group or other arm of the voluntary sector
• Community psychiatric nurse
• Link to the locality-based team, for example through the community matron

5.2.2 Locality-based team

This team has three principal responsibilities:

• Supporting frontline staff in delivering community services for older people at the request of the practice-based team
• Running Intermediate Care services within its locality – community hospital services, residential and domiciliary intermediate care
• Supporting local care homes

The locality team is likely to run specialist assessment services, ideally as integrated “one-stop” services. The locality-based team will facilitate clinical governance within elderly care community services. It will also meet with commissioners in forming strategy, reviewing effectiveness and identifying service gaps.

A typical community hospital service with 20-24 beds should be provided with 5 sessions of medical time, split between Consultant and other trained staff. This is effective, evidence-based 5, and cost-effective 6. It is reasonable to apply this recommendation to residential Intermediate Care units, where the case mix and medical needs are similar. These units can also provide rapid out-patient clinics and comprehensive multidisciplinary assessment, which can also often prevent hospital admission.

High quality health care is required in care homes as in the rest of the community. Applying principles of palliative care and optimising managing of late-stage long-term conditions improves quality of life and avoids unnecessary hospital admission. The support necessary to provide such care in these settings needs to embrace training as well as delivery of care. In a typical locality of 100,000, with 1,000 older people in care, at least one specialist nurse, 0.5 community pharmacist, and 0.5 WTE of specialist medical time (either a General Practitioner for the care of older people or a community geriatrician) is recommended. A comprehensive collaborative statement issued by the Royal College of Physicians in 2000 on this subject remains apposite 7.

5.3 – Communication: between teams and with patients, their families and caregivers

As the primary / secondary care divide has given way to new interfaces between services and increasing responsibilities being held by a wider range of professionals, the requirement for effective communication has increased. Examples include the transfer of appropriate information (such as diagnoses and drugs) to intermediate and secondary care by primary care teams. It includes details of care packages to the primary care team either on discharge from hospital or consequent upon the proceedings of community team meetings.

The divide between health and social care is an administrative one, but one which threatens the communication of relevant information between health and social services personnel. For example, medical diagnoses and hence prognoses clearly affect the way future care packages need to be assembled. Similarly, a change in social care needs for a patient should prompt a medical review to seek the diagnoses responsible for it. Health and social service personnel need to be part of these teams and communicate as such.

In proposing practice–based or locality-based teams to meet the needs of frail older people in the community, it is important to do so while maintaining person-centredness. Services should be sensitive to the wishes of frail elderly people, respect their confidentiality (a potential risk when personal information about them is shared by a wide number of people), and should ensure that they are as involved and informed as possible in all decisions affecting them.

6 Summary of recommendations

The emergence of these teams at practice and locality levels would provide a structure which can be built into routine practice, reducing fragmentation, encouraging integration and easily understood lines of communication and would augment the usual care of older people by the primary healthcare team. This is already happening in many parts of the country, but has not yet become standard practice.

We recommend:

6.1 Planning of integrated community specialist services for frail older people by the PCT and by practice-based commissioning, but in a manner involving acute Trusts if they employ community geriatricians and other staff working in the community

6.2 Investment in specialist medical care for older people in the community, responsible for supporting frontline clinicians in their day-today work, providing the medical care within intermediate care services, supporting care homes, and running local training and clinical governance structures.

6.3 Identification within each locality the services that can be delivered through a practice-based service, and those which will be delivered by a team at locality level

6.4 Development of practice based and locality based community teams for frail older people

7 Conclusion

This document is merely the start of an iterative process by which the British Geriatrics Society and the Royal College of General Practitioners and other interested and involved organisations can champion the optimal care of frail vulnerable older people people.

8 Authorship

This document was prepared by Professor John Gladman, Dr Ian Donald , Dr Graham Archard & Dr Jackie Morris on behalf of the writing group formed after the June 5 th meeting between the British Geriatrics Society (Special Interest Group in Primary and Continuing Care) and the Royal College of General Practitioners.

9 References

1 Pitt B. Loss in late life. BMJ 1998;316:1452-1454.

2 Royal College of General Practitioners. GP curriculum website. http://www.rcgp.org.uk/education/education_home/curriculum.aspx

3 Royal College of General Practitioners. General Practitioners with Special Interests. http://www.rcgp.org.uk/education/education_home/gpwsi.aspx

4 British Geriatrics Society. The specialist health needs of older people outside an acute hospital setting. http://www.bgs.org.uk/Publications/Compendium/compend_4-3.htm

5 J Green, J Young, A Forster et al Effects of locality based community hospital care on independence in older people needing rehabilitation: randomised controlled trial. BMJ 2005;331:317-22.

6 J O’Reilly, K Lowson, J Young et al A cost effectiveness analysis within a randomised controlled trial of post-acute care of older people in a community hospital. BMJ 2006;333:228.

7 Health and Care for Older people in Care Homes. Report of a joint working party of the Royal College of Physicians, the Royal College of Nursing and the British Geriatrics Society. July 2000.