People living with frailty, particularly frail people in care homes following the Covid-19 outbreak have been in the news recently, sadly for the wrong reasons. Arguably, the irony is that this demographic is too often forgotten. However to continue this approach with our heads in the sand will have drastic consequences for the NHS.
The growing frail, older population is increasing pressure upon hospital services.1 Local commissioning groups have begun to focus their attention towards the management of frailty in primary care settings.2 GPs are obviously well placed to deliver these services as they are local and offer clinical continuity on a broad spectrum. However, frail adults require a deeper level of care, demanding time, patience and skill.
The future challenge for community services is the growing volume of complex patients, which has already seen a shift towards video consultation and new innovations. The proliferation of new community mental, nursing and residential care homes being built rapidly to support the ageing demographic will require additional resource and collaboration with secondary care clinicians towards a more effective model of care.
When thinking about how the NHS cares for people living with frailty, what should the future be like? In an ideal system of how frail adults should be looked after, the following should be the norm; robust and deep discussion around advanced care planning, how their multi-morbidity should be prioritised and managed, optimised medication prescriptions, timely comprehensive assessment and access to appropriate treatments, engaging and purposeful therapy are some elements that we should strive towards.
Frustratingly, to have these thoughts in the present day almost feels like I’m writing a fiction novel, the practicalities of consistently delivering such care appear unimaginable. However, having a utopian approach allows us to identify an issue and work towards the crystallisation of a solution that supports change and takes us a step closer to the ‘ideal’.
Primary and secondary care collaboration essential for frail patients
The utopian vision doesn’t just stretch to what care we deliver to people living with frailty. It requires the underpinning infrastructure of the NHS to be in place; a combination of general and specialist consistent community support, a skilled multidisciplinary workforce that feels professionally fulfilled by their work, shared learning and opportunities to develop professional relationships and well developed processes of communication, both virtual and in-person.
However, asking ourselves to build a better version of our NHS without the tools feels naive and immature. Luckily, there are numerous policies, reports, articles and peer-reviewed studies highlighting the problems our current NHS faces and offers solutions towards the imaginary utopia, but why does it all still feel so agonising and wishful?
The ‘how’ we get to these solutions is the difficult part of this process. How do we unpick the less tangible, defined and quantifiable areas that feel like such barriers but are integral to its success? I imagine clinical relationships have been developed over numerous years (emails, telephone discussions, and letters) without having met one another.3 The perception of clinicians may be very different in reality. The emotional labour required to heal fractured relationships and collaborate effectively would be immense. The allowances to be generous to our historically tribal counterparts for their perceived limitations without knowing the true challenges they face daily would require thought and compassion. Personal agenda, self-interest, ego and traditional perceptions must all be left at the door, if any true progression is to be made.
Ultimately, rivalry will dismantle any hope of future collaboration, an irrational fear of a particular group being successful, may lead to worry that their own job role may soon disappear. The reluctance to share information, highlighting each other's inadequacies and errors all further dig a trench of division. The notion of there being one space and two rivals competing for superiority is at best, irrational. The protectionism of our own and our individual professional self-interest will only ever lead to the continuation of the status-quo. If true ‘human’ innovation is to endure, then we must lower our guard to one another.
Trust and the development of relationships must be at the heart of any post-viral ambition. The words, “the world will be a very different place after this” has been proclaimed by numerous people in both the real and virtual world we live in.4 An underlying hint that the pandemic will be the catalyst for an innovative leap to a place where primary care can manage their demographic with virtual consultations and AI algorithms should be pursued with great caution.5
Health innovation needs to include human connection
At a time when social and physically distancing has made our hearts ache for connection, we should be wary of the purveyors of virtual solutions that vie to sway our opinion to a contactless healthcare system, sacrificing what makes us human for economic efficiency. The sorrow we feel at the loss of human connection could become the everyday norm as we step into this new world.
There could be a belief that we don't want to go back to the old ways and that the future is upon us, but actually we didn’t get everything wrong. Clinicians have developed skills far-beyond what can be gauged over a telephone or virtual consultation, leading to a reliance on tests, remote decision-making and rudimentary heuristics. The ‘curtain-raising’ sentence that initiates the consultation as a person closes the clinic room door, or the pause of someone about to leave the room at the end of an appointment, only to discuss the thing that made them book the appointment to begin with…. “I found this lump, can you take a look”. This connective vulnerability must never be lost.
The nurturing of relationships between clinicians therefore must require the opportunity to do exactly that, ‘to relate’. To sit together and share their joint sense of responsibility, to bear their weaknesses and challenges and lower our guard to one another, and learn, they are also too similar and fragile.
Innovation should not be focused upon technological evolution, but to pause, reflect on our own evolution and what makes us human. The development of human and social capital between clinicians and organisations from a level that sees and feels the everyday challenges, these problems being mentally unpacked, emotionally processed and interpreted together, not from the distant corridors of CCG buildings.
Shared learning, educational events and joint clinical working all begin to foster a platform where clinicians can relate to one another, innovation could actually identify new methods of collaboration and meet these future demands whilst retaining our all-important human touch.
Richard Waterworth, Trainee Advanced Clinical Practitioner, Warwick Hospital, Lakin Road, Warwick
- Office for National Statistics (2018). MYE1: Population estimates: Summary for the UK, mid-2017. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/ datasets/populationestimatesforukenglandandwalesscotlandandnorthernireland
- Sampson, R, Barbour, R, Wilson, P (2016). The relationship between GPs and hospital consultants and the implications for patient care: a qualitative study. BMC Family Practice
- The Health Foundation (2017). The impact of providing enhanced support for care home residents in Rushcliffe: Health Foundation consideration of findings from the Improvement Analytics Unit.
- Castle-Clarke, S (2018). What will new technology mean for the NHS and its patients? Four big technological trends. The Health Foundation, the Institute for Fiscal Studies, The King’s Fund and the Nuffield Trust.
- NHS England (2019). The NHS long term plan. Available from: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf