When geriatrician Dan Harman and his colleagues pondered what to call a new centre for older people they were opening in the northern English city of Hull, they chose to honour, not a dignitary or celebrity, but a local 96-year-old who embodied the notion of living later life to the full.
Jean Bishop, who died three years after the centre opened in 2018, raised hundreds of thousands of pounds for the older people’s charity, Age UK, and never lost the joyful spirit which led her to don a home-made bee costume as she rattled her tin around the city, says Harman.
Fondly recalling “the bee lady”, as she became known, he adds: “I hadn’t really understood, as a clinician, the power of branding . . . This new facility was based around living well and ageing well. And so having Jean’s name on it was really important [in driving] uptake of a different offer of care.”
This “different offer” involves inviting older people in for a “comprehensive geriatric assessment” which spans everything from their physical condition to their emotional health — an approach that is yielding remarkable results.
More and more people are living long enough to be diagnosed with frailty, which comes when a person loses their ability to withstand the setbacks or stresses of everyday life both physiologically and psychologically. There is now a growing focus on how best to manage a condition that puts an enormous strain on services worldwide.
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The guiding philosophy behind the Jean Bishop Integrated Care Centre is that frailty should be treated as a long-term condition “in the same way that you would treat heart failure or emphysema,” he says.
This means delivering proactive and reactive care to forestall or address problems before they can take root. Previously, he says, patients often “presented late and in crisis with an episode of confusion, a fall [or] an episode of immobility, and their care was often episodic, disruptive, and hospital-based”.
The sustainability of entire health systems may depend on improving the outlook for people living with frailty, suggests Richard Lewanczuk, strategic adviser to Canada’s Alberta Health Services and an international expert on care for older people.
Lewanczuk says the greatest cost to any healthcare system is hospitalisation and considering the group most likely to be hospitalised are frail older people, “therefore frailty is the single biggest contributor to healthcare cost”.
Much of the rising burden is attributable to “social factors” such as a lack of care in the community or of co-ordination between different public services, he adds. “That leaves this common theme: if we could predict who’s going to end up in hospital, maybe we could intervene proactively to prevent the need for hospitalisation.”
Harman says he and his colleagues aim to pinpoint the people who most need support by using data to identify those in danger of mild, moderate or severe frailty — or at no risk at all.
“If you are severely frail, you’re four times as likely to end up in institutionalised care, and five times as likely to die, within the next 12 months, and six times as likely to have two or more hospital admissions,” he says. “So in utilising this approach, we can get our resources to the people that need it the most.”
Data drawn from records of patients at Hull Royal Infirmary shows the impact. Comparing the 12 months before the introduction of the centre’s comprehensive assessments to the 12 months after it, emergency room attendance fell by more than 53 per cent, and occupied bed days by more than 71 per cent among moderately or severely frail people.
Joint working between different public services in Hull and the surrounding area has been aided by the establishment of an “ageing well” board on which multiple public sector organisations are represented.
A similar conviction that breaking down divisions between public services is vital to ensure care fits around patients’ needs, rather than the reverse, is evident more than 160 miles south of Hull in the county of Surrey.
Epsom and St Helier University Hospitals NHS Trust has entered into a partnership with the county council and groups of GP practices to establish Surrey Downs Health and Care (SDHC) which provides adult community services.
Malin Farnsworth, a geriatrician, says this integrated way of working allowed clinicians to “follow the patient on their journey” without being hampered by rigid institutional boundaries.
“I often think of the privilege that it is for us to be able to see a patient one day in [the emergency department], the next day in their home if that’s what they need, or in a clinic another day, or in a nursing home . . . and having, often joint decision making,” she says, involving GPs or the wider multidisciplinary team (MDT).
Her fellow geriatrician, Christopher Sin Chan, says that under the innovative SDHC model, all the partners have equal share of responsibility for delivering community services. “That breaks down a lot of the barriers that you would traditionally get [when] someone who worked in the hospital would never dare step outside into community services, because it was a different organisation,” he says.
Data collected by SDHC shows the effects of this approach. Frailty patients whose care had been proactively reviewed by an MDT showed a 37 per cent reduction in GP contacts, a 22 per cent reduction in community nursing contacts and a 38 per cent reduction in emergency department attendances.
Farnsworth says there are professional challenges. “It requires some culture change, it’s looking outside what you’re used to” for clinicians trained to expect the nexus of treatment to be the hospital.
But staff are buoyed by feedback from older people who much prefer to be treated at, or close to, home. “They like it and we see how they do better,” says Farnsworth. “That’s really an ongoing energiser and a motivation to keep on doing what we think is the right thing for a lot of patients.”
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