Dr Helen Gentles is a Consultant Geriatrician working across both hospital and community settings in Gloucestershire.
On Mondays I spend the day in the Emergency Department at Gloucestershire Royal Hospital, working as part of the ‘front door’ frailty team, alongside colleagues from Acute and Emergency Medicine. There’s never a shortage of suitable patients to see and inevitably there are many who have already been in the department too long. I work with nurse practitioners and resident doctors to assess patients and agree plans with them and their relatives. Often this will be getting them home with onward referral to community teams. As those of us who work in older people’s healthcare know well, it may take some time to have the right conversations with patient, relative, carer and/or community colleague but there are no shortcuts. I often reflect on how easy it is to admit a patient into hospital, just a second to say the word, whereas a safe and successful discharge may easily take an hour of staff time. Good communication and advance care planning are crucial components of effective discharge. When I finish my shift on a Monday, I feel satisfied at making a difference to a few patients and at the same time very aware that as I leave, more and more older people with frailty are presenting to the department. There is no doubt that we need to design our services across the Integrated Care System (ICS) and to a scale that will be able to provide the right care for the ever-increasing numbers of older people living with frailty.
Tuesdays are completely different. I head to an office in Gloucester Docks to join a community team’s multidisciplinary team (MDT) meeting. They deliver proactive care to adults of all ages, in their own homes. The team is made up of matrons including a dementia matron, allied health professionals (AHPs), dietitian, health and wellbeing coordinators and care navigator. We are also supported greatly by the input of a social worker, a housing officer, and, if needs be, we can talk to a local police officer for the vulnerable. At the MDT we will focus on the most complex patients rather than discussing them all. Patients may be complex due to multiple medical issues but equally it may be down to behaviours and their social situation.
Since working in the community, I do feel my eyes have been opened. In hospital, over the years, one sees all sorts but this is through a limited lens in the clinical environment. At home we get a much richer and truer picture, as we see the person in their own environment. As well as relatives we may also meet the lodger, the neighbour or the dog. The matrons I work with are adept at developing trust and a good rapport quickly with their patients. This allows for open and honest conversations with patients, who often confide information that they had not felt able to tell healthcare professionals previously. The team are very capable of dealing with most patients themselves, always with a real focus on delivering person centred care. I will do a joint home visit with the matrons for the more challenging cases.
Of course, working across settings like this is not without its challenges. Like many other areas of the country, we have a multitude of different IT systems for different organisations so full patient records can be difficult to access. There has been some integration so that the summary care record is available to all and we continue to move towards more integration. The community matrons now have access to the hospital electronic patient records – not an easy feat to achieve but well worth the months of effort to secure this. They now have access to inpatient records, outpatient letters and test results. This also facilitates better communication with hospital staff, if one of their patients has been admitted.
After the MDT, I meet with the matrons to discuss any medication issues, with a particular focus on deprescribing. Working in the community has given me a new perspective on medication adherence. At medical school, I remember learning how poor adherence can be but it was not always obvious when I worked on the hospital wards. There’s nothing like seeing several dosette boxes under the sofa or a mixing bowl full of various tablets being taken in a ‘pick & mix’ manner to bring this into sharp focus.
I also remember at medical school learning about abuse of older people and how common it is. Working in the community has sadly brought this to the fore and we deal with some truly heart-breaking cases. Financial abuse, whether it be by a criminal scammer or by a ‘close’ relative is a regular issue at our MDT meeting. These cases and other issues can take an emotional toll on staff and it is essential to provide time and support to deal with this. At the MDT we always take some time to focus on staff and continually aim to develop an environment where everyone feels connected and supported.
I have held this joint hospital and community role for over seven years, having previously been entirely hospital based. I find that there are many benefits working this way, each half of the role informs the other, and I’ve been able to break down a few barriers now that I have a ‘foot in both camps’. I am jointly employed by the acute trust and the community trust. I find that ‘front door’ frailty work combines well with community work. However, I know that there are other roles around the country with different combinations that work equally well such as being predominantly in the community but taking part in the acute take rota. There are so many advantages to these joint roles. Having spoken to colleagues in other regions, I realise I was lucky to have two trusts working closely together to create my role. Integrated care systems do not always work in the seamless integrated manner we would like! It can take some determination and resilience to navigate through the power dynamics and other barriers that get in the way. With the current shift to more community care, I hope there will be more joint roles created in the future, both for consultants and for all healthcare professionals. This seems fundamental to me if we are to deliver patients the joined-up care they expect from the NHS.
