Transforming the surgical pathway for older patients

Overview

The Perioperative Care for Older People undergoing Surgery (POPS) service at Guy’s and St Thomas’ NHS Foundation Trust (GSTT) has improved patient outcomes, tackled inefficiencies and reduced system costs through adopting a multidisciplinary approach to assessing and providing treatment for older people.

What the organisation faced

Guy’s and St Thomas’ (GSTT) identified that a significant proportion of surgical patients were aged 65 and above. At this age, people are much more likely to have multiple health issues including frailty, comorbidities, poor physiological status, cognitive impairment and multimorbidity. For example, research shows that 67 per cent of people over 65 years old have multiple comorbidities.

At GSTT, this led to increasing last-minute cancellations as older patients were more likely to be deemed unfit for surgery. If surgery did go ahead, patients were at a greater risk of complications, contributing to long hospital stays and increasing the likelihood of readmissions to hospital. Combined together, these put added pressure on patients, their families and the trusts’ resources. 

Improvement

Recognising the need to provide targeted support for older patients, GSTT established the Perioperative Care for Older Patients undergoing Surgery (POPS) service. Initially established as a two-year pilot project, its success led to its expansion across all elective and emergency sub-specialty services. 

The service centres on comprehensive geriatric assessment (CGA) and optimisation. Each patient’s medical, psychological and functional capabilities and limitations are assessed at a ‘one-stop’ clinic. This then informs a personalised optimisation plan, which may include a range of interventions to support patients to improve their health, such as dietary advice, exercise support, alcohol moderation or therapy. Shared decision-making is embedded throughout. Healthcare staff work with patients using the BRAN technique to weigh the benefits and risks of surgery, consider alternative treatment options, and explore the option of not having surgery. 

The POPS service is delivered by a multidisciplinary team, involving professionals such as geriatricians, nurses and therapists. Staff work as cross-disciplinary team members to ensure care delivery is as streamlined as possible. To support the development of these teams, GSTT has established numerous educational resources and programmes. For instance, they run a perioperative care programme for doctors in their foundation years, which includes a four-month rotation within the POPS service.

Outcomes

The impact has been significant. The service now supports 1,600 – 1,800 elective and 3,000 emergency surgical patients a year. Among those assessed and optimised, two-thirds had a new diagnosis made, three-quarters had medications changed, and half received lifestyle or therapy interventions.

These interventions have reduced cancellations, complications and length of hospital stay. For example, a randomised control trial in elective vascular patients showed a 40 per cent reduction in hospital stay compared with routine pre-operative care. Additionally, one-in-seven patients decided not to have surgery after discussion with a geriatrician-led service, saving valuable resources while supporting patient choice.

This service also delivers economic benefits. A health economic analysis showed that costs were £1,165 lower for patients supported by the service.

The success of POPS at GSTT has provided a blueprint for similar services nationally and internationally, demonstrating its adaptability across different trusts and care settings. POPS services now exist in over 40 hospitals across the UK, more than ten sites in Australia, numerous locations throughout Europe, and are currently being developed in Singapore.