The pandemic has meant practitioners caring for older people have had to respond to new challenges. What lessons have been learnt, the benefits to practice, and the different ways of working that will be retained in the future?
Practitioners providing care and support for older people are used to adopting and adapting quickly to new ways of working. But the pandemic has meant they have needed to respond to situations never experienced before, from carrying out remote consultations to using digital technology to communicate with patients and families.
During the pandemic health and care professionals have been overcoming challenges, and developing solutions to safeguard older people. Here are just some of the lessons practitioners say they have learned so far.
The pandemic has been a ‘game changer’ in how practitioners carry out consultations. Clinicians in primary and secondary care needed to use digital technology for consultations for social isolation purposes.
Even though practice surgeries and hospitals are gradually returning to seeing patients, many are continuing to use digital tools, including email and video, to diagnose and treat patients without face-to-face contact. Practitioners, however, are mindful that remote consultations are not necessarily appropriate for older patients who need face-to-face access or who might have difficulty accessing new technology.
Dr Liz Lawn is clinical director of the North West Surrey Locality Hubs service, a community-based integrated health and care service for older people living with frailty run by CSH Surrey, and she is also deputy honorary treasurer for the British Geriatrics Society. She recalls how at the start of the pandemic the service moved from seeing patients face-to-face to telephone assessments. While the locality hubs can offer video consultations, Dr Lawn explains that this approach is rarely used because many of the service’s patients are older people living with frailty and only a small number can access this technology, typically with the support of their families.
More frequent use of phone consultations also have their disadvantages. Dr Lawn says some patients have hearing difficulties. Others, she says, miss the “social” element of visiting a hub to see practitioners face-to-face, “which has pretty much gone because of Covid restrictions”.
As we emerge from the pandemic, Dr Lawn says the service is now offering a mixture of home visits and telephone consultations, is sure it will “retain some telephone follow-ups as some people find this more convenient”.
Care homes are not a setting traditionally associated with new technology. But during the pandemic Covid-19 has resulted in a digital transformation in residential care, with health professionals connecting with care homes virtually.
“Access to virtual healthcare has definitely improved,” says Liz Jones, policy director at National Care Forum. But while there is “a place for technology and remote support”, she says it is important to know when a virtual call or remote monitoring tool is appropriate or not, and that there remains a need for access to face-to face-care.
Communication with patients and families
In care homes and secondary care, technology, such as video conferencing, has been used as a way to stay for patients and families to stay in touch.
“A lot of staff have been routinely using tablets and smart phones to help patients have interactions”, says Dr Dawne Garrett, professional lead older people and dementia care, for the Royal College of Nursing (RCN).
“We’ve learned so much more about the use of technology in supporting others. It’s been hugely helpful, and while it’s not for everyone it’s worth a try,” she says.
Tom Bartlett, a consultant geriatrician at Poole Hospital, Dorset, and a member of the British Geriatrics Society’s clinical quality committee, says that while more visitors are coming to the hospital now, practitioners are still using different ways of communicating to families via MS Teams and Zoom calls. Patients and families “still have that opportunity to talk with their loved ones online”, he says.
Communication among teams
During the pandemic practitioners have not only been learning about new ways of communicating with patients, but also their own teams, with pandemic restrictions making remote meetings via video conferencing a necessity. Dr Lawn says the change has “actually been very beneficial”.
She says that with travel time to meetings no longer an issue, “people who might otherwise have not been able to attend a meeting now can”, while video conferencing has been “very effective” in enabling more members of the extended healthcare team to join meetings to discuss specific patient cases. Video conferencing has also made training sessions more easily accessible, she says, adding that this approach has been “a real success and I’m sure will continue”.
Dr Bartlett says that at his hospital practitioners are doing “lots of our teaching and learning together online”. “There’s a lot more access to people, which is good for consultants SPA time (Supporting Professional Activities Time),” he says.
For senior care home management, Ms Jones says virtual tools can make it “easier to talk to groups of staff”. But for management working from home she says, “there’s a real balance between making sure you’ve got that degree of flexibility in the workforce but also that there’s still that strong support and leadership. It’s really important that senior leaders are still visible to their wider colleagues,” she says.
Staff wellbeing lessons from the pandemic
The pandemic has been an extremely stressful time for people working in health and social care, and its impact means that many could be feeling overwhelmed and at the point of burnout.
In general practice, secondary care, and the social care sector organisations have put measures in place to safeguard the health and wellbeing of their staff. This includes employers signposting them to sources of support and offering Employee Assistant Programmes (EAPs) - an employer-paid scheme that allows employees to contact an independent adviser on a confidential basis to discuss any issue that is troubling them.
Dr Bartlett says during the pandemic there has been “a greater focus on staff wellbeing”. He says his hospital has a large geriatrics department, and that by last November, when outbreaks of Covid-19 on the wards began it was “devastating” for patients and staff. “The virus disproportionately affected frail older people. There were many deaths,” he says.
He explains that for staff who “pride themselves on giving people a ‘good death’, and supporting them in their last phase of life, were now faced with the suddenness of a Covid death and that dying patients were unable to be with their families.
The emotional and physical impact of the pandemic has taken its toll on healthcare professionals. But it has also led to teams being “more aware of each other’s wellbeing”, says Dr Bartlett. His Trust, he says, has given staff access to trained counsellors, there has been “more openness” about people’s mental health and emotional fatigue, and both junior doctors and consultants have had opportunities to “debrief and offload” about issues. That “collegiate feeling and openness has continued – which is really nice”, he says.
Balancing rights and risks
The pandemic has highlighted some broader issues about balancing the risk of older people contracting Covid with other risks, such as social isolation, which has an impact on their mental health.
“Our management of human rights and management of risk is a really big lesson to be learned,” says Dr Garrett. “For example, we know that most older people living in care homes are coming to the end of their lives and we need to balance keeping them safe from Covid with keeping them safe from the consequences of a lack of social interaction,” she says.
Ms Jones says that for people living in care homes, the balance of risk from harm and risk from a lack of connection with families “has not been well served by policy makers”, adding that a “more compassionate approach to visiting” was needed.
Dr Lawn says there has been a “huge amount of loneliness and fear” within older people’s communities. And Dr Bartlett says lockdown has had a “terrible effect on older people’s mental health”, adding that “previous fit and independent people have become much more frail and people’s dementia has progressed that much more because they’ve not had the social interaction”. He warns that “loneliness is a great, untold burden and we are going to see a lot of fallout from this”.
Continuing new ways of working
As primary and secondary care gradually carry out a phased return to bringing back patients and services to primary and secondary care settings, practitioners are continuing with the news ways of working that have emerged during the pandemic.
Consultations via phone or video will remain a part of how care is delivered, and being mindful of the wellbeing of health and social care professionals will be embedded into day-to-day practice.
Lessons learned for the next pandemic
Lessons will also have been learned, retained and need to be ready to put into practice in preparation for the next pandemic. “We have always known a pandemic is likely. We learned lessons from this one and will need to get ready for the next,” says Dr Garrett. When that next pandemic hits she hopes “we will firmly engage with our older population directly”.
Ms Jones believes at the heart of any discussion about the lessons learned from the pandemic are people – “the people we’ve loved and lost and who have survived, and the people that supported them”.
And those supporting older people – including GPs, nurses, geriatricians - have been brought closer together as a result of the pandemic. As Dr Bartlett says: “Local GPs, local community matrons, and everyone within the hospital from different specialities – we’ve all worked more closely together.
“I really hope we can manage to keep this closeness going between primary and secondary care. It’s essential when caring for older people that everyone is pulling in the same direction and helping each other.”
Kathy Oxtoby is a medical journalist