Dr Tan Boon Hian is a Consultant Geriatrician based in Singapore and a member of an eleven-person, multi-hospital cluster team consisting of Doctors, Nurses, Physiotherapists, Occupational Therapists and Pharmacists. The team recently completed a six-week observership with the Perioperative Medicine for Older People undergoing Surgery (POPS) service at Guy’s and St Thomas’ NHS Foundation Trust (GSTT), supervised by Professor Jugdeep Dhesi. Here, Dr Tan shares his personal reflections on the experience.
Proactive, data-driven, evidence-based and patient-centred care
I was impressed by the POPS team’s ability to proactively screen and intervene to support inpatients with frailty, multimorbidities and cognitive impairment on their wards, regardless of their surgical status. Many geriatric syndromes, such as delirium and functional decline, are best managed proactively and pre-emptively. The service provides a practical example of how this approach can be implemented and sustained. Interventions were evidence-based and guideline-driven, drawing, for example, on guidance from the Centre for Perioperative Care1.
In the outpatient clinics, patients were assessed using similar criteria. I was particularly impressed by the patient-centred approach to consultations, which revolved around shared decision-making (SDM)2. The team used the BRAN framework — benefits, risks, alternatives and nothing3 — to support these discussions. Patients left the clinic with greater clarity about their health and treatment options and appeared satisfied with the consultations.
In Singapore, our geriatric-specific perioperative services are mainly inpatient-based, and referrals to Geriatric Medicine must generally be initiated by the surgical team. Some pathways exist, such as those for emergency laparotomies4, but these are typically condition- or age-based rather than vulnerability-led, focusing on factors such as frailty, multimorbidity and cognitive impairment, as emphasised in SNAP-35. Nevertheless, some proactive geriatric services have emerged in recent years, including initiatives targeting cognitive impairment6.
Singapore has introduced shared decision-making in limited areas, such as organ transplantation, termination of pregnancy and research involving human subjects7. However, challenges remain, including the health literacy of older adults and the complexities of our medicolegal environment, particularly when third parties, such as family members, are involved8,9.
Empowerment, collaboration and integration of the healthcare team
Advanced practice is embedded within the POPS service10, reflecting the NHS approach to developing advanced clinical roles. One notable example is the role of Clinical Nurse Specialists (CNSs), who anchor various perioperative services with appropriate supervision.
Empowering these professionals supports the sustainability, continuity and expansion of geriatric services, particularly in the context of global consultant workforce shortages and the high cost of specialist medical staffing. In rehabilitation units, such as the Amputee Rehabilitation Unit, advanced practice therapists and nurses have successfully run the service for years, providing much-needed geriatric and rehabilitative care for patients with complex medical needs.
The integration of POPS into surgical teams is another important lesson. Through a consistent presence, persistence, clinical ownership, excellence and a willingness to help, the POPS team has established itself as a trusted partner. This creates a safe environment in which any healthcare professional can escalate concerns about an unwell patient, while surgical teams readily seek POPS advice on geriatric syndromes and medical complexity.
I would suggest that this degree of integration supports the development of integrated practice units, which are increasingly recognised as a way to deliver safer, value-based care11.
In Singapore, healthcare can at times be delivered in silos. The Ministry of Health, Singapore, highlighted this in 2026: “Allied Health Professionals (AHPs) play a vital and growing role in Singapore's healthcare system, yet fragmented and siloed care delivery have limited their full potential”12. There is also an opportunity to empower nurses by involving them as architects of care, rather than simply as participants13.
A national frailty screening programme will benefit patients
The NHS’s adoption of frailty screening at a national level14 demonstrates what can be achieved in an area that many countries might once have considered an insurmountable challenge. This approach has helped enable vulnerability-led, rather than age- or condition-led, care. It has also supported better-targeted, proactive perioperative geriatric services, as demonstrated by nurse-led screening to identify patients with frailty who may benefit from preoperative prehabilitation.
Singapore does not yet have a national frailty screening programme. This is partly due to the lack of local consensus on a practical definition of frailty15,16. Existing frailty initiatives also tend to operate in silos, with wider collaboration and integration into mainstream care still needed16. However, Singapore’s Frailty Policy Workgroup has been working on this since 202316.
Geriatricians bring value
Seeing how the POPS team interacts with patients and colleagues, and how senior geriatricians contribute at national and professional levels, has helped me recognise the value that geriatricians bring. Through our work across teams and the interdisciplinary nature of our specialty, we coordinate care, improve processes and contribute to better outcomes. Ultimately, this brings value to our patients, colleagues, hospitals and country.
The personal touch of POPS
On a personal level, our entire team is grateful to the POPS team for accommodating our many requests. This included providing flexibility and breadth in our perioperative placements, navigating competing administrative demands and adapting to unforeseen circumstances. The team even went beyond by arranging sessions with other NHS trusts and recommending geriatric conferences.
We also had the opportunity to discuss leadership, including how to build a team and develop a service. This dedication reflects the way the POPS team works with its clinical partners every day, consistently going beyond in all that it does.
Thank you for giving me the privilege of sharing these reflections. I look forward to incorporating these lessons into my work upon my return to Singapore.
| Have you got a story to tell from a visit to see how services for older people are delivered elsewhere? Let us know what you learned. And don’t forget the BGS’s international offer. We can create membership and education packages suitable for the workforce in other countries. Get in touch with Geraint Collingridge (g.collingridge@bgs.org.uk) to explore options. |
Disclaimer: These reflections are personal and do not reflect the opinion of any Hospital, Institution, nor the Ministry of Health, Singapore.
