Posted by: ayrshirehealth | August 13, 2014

#TeamHappy by @rowan_wallace


Acute medicineI am a Geriatrician. A Consultant in Care of the Elderly Medicine. A doctor specialising in Ageing Health. A member of the Department of Medicine for the Elderly. There’s no getting away from it. I look after older people, or ‘oldie poldies’ as they are known in my family. This isn’t a derogatory term. It describes those who sing loudest at the table at family parties, those who tell the best stories, those who slipped a pound note into your small hand when you were leaving the house and those who command attention and respect when they speak.

It’s a terrible cliché to say that I do what I do because I like old people – clearly one cannot like everyone. I do my job because I enjoy it, I like the people but overwhelmingly I do it because I think I can make a positive difference to the care of older people in hospital and in the community.

Good ideas are entertained

Back in October 2009, I started as all new consultants do. I was full of unbridled enthusiasm, keen to make big changes, inspired by my new title but somewhat daunted by the added responsibility that came with it. Fortunately NHS Ayrshire and Arran are one of those rare health boards where good ideas are actually entertained. So by 2012, we had made big changes. NHSaaa There was a fledgling orthogeriatric service, patients with Parkinson’s Disease in North Ayrshire had a access to a specialist multidisciplinary service, we were taking more patients into our service from acute medicine and the community provision for frail older people had been enhanced with the Intermediate Care and Enablement Service (IC&ES). screen-capture-10Nevertheless, I was becoming increasingly frustrated with the traditional model of Geriatric Medicine and the consequences of being a ‘back door’ physician.

It was clear to me that, in the majority of cases, the patient journey to accessing specialist care was far from smooth, and that this was highly detrimental – not just for those individuals but also for their families – and frustrating for the staff. Imagine an individual who has spent six hours in the ED, twelve hours in the Acute Medical Receiving Unit, has been moved through three wards, and then falls, or is given the wrong medication, or still has not had the test they were told on day one was necessary, or whose family’s call has not been returned.

DirectionIt’s not surprising that someone will be annoyed – and rightly so: being admitted to hospital can be a bewildering process for anyone, but especially so for the frail and vulnerable. It seemed to me wrong to expect older people, with complex needs, to fit into a system that was never designed for them. However, the alternative model I had in mind would represent a massive shift in working culture compared to traditional geriatrics.

If you can find a path with no obstacles, it probably doesn’t lead anywhere

Frank A. Clark

So what did I do? First I demonstrated that there was a problem. This would not have been possible without the assistance of a very able final year medical student from Dundee who was working with me. Sam just happened to be the daughter of the IC&ES Team manager which was fortuitous in light of our findings. Data analysis demonstrated a significant burden of frailty and unacceptable delays in senior medical and multidisciplinary review, including mental health and functional assessments and pharmacy review.

CochraneA solid (Cochrane Database Systematic Review no less) evidence based tool exists – Comprehensive Geriatric Assessment – the application of which has been shown to improve functional independence and to reduce both mortality and acute readmission rates, but this was being applied either too late or not at all. I presented our findings to my Directorate and, shortly thereafter, was invited to a meeting by Stuart Gaw of IC&ES, who had gathered together other interested parties. By the end of the meeting, we had set a date, a mere two months hence, to begin piloting the new model.

A&E 2The primary objective was to design a system around the needs of frail older people presenting to the ED – the Frail Older Persons Pathway (FOPP). A steering group was created, including representatives from community services, social work, transport, laboratories, diagnostic services, the ED, GPs, district nurses, mental health, pharmacy and senior hospital managers, along with ward-based medical and nursing staff.screen-capture-20

So now if you are over 65 and attend the ED at UHC for any reason, you will be screened using a new Frailty Tool developed at Crosshouse Hospital.  Those for whom the FOPP is deemed appropriate receive medical and mental health assessments, delirium screening, medicines reconciliation and functional screening, provided by a multidisciplinary team located within the main hub of the ED.

Nothing about me, without me

Alongside me, the Team includes representatives from Elderly Mental Health Liaison and Pharmacy, an Allied Health Professional from the community-based IC&ES Team, an Advanced Nurse Practitioner and our invaluable admin support.  Where appropriate, patients can be admitted direct to specialty beds, including step-down beds in the community, or discharged home with IC&ES follow-up if required. The Team adopts a ‘nothing about me, without me’ philosophy, and carers and family members are actively involved in assessment and treatment decisions. Results have shown an increased use of alternatives to hospital admission, and reduced length of stay for those who are admitted, increasingly direct moves to specialty areas; patient flow has improved within both the ED and the wider hospital, and not just for the over-65s.

Longer-term analysis has revealed reductions in both mortality and acute readmission rates; feedback from patients, carers and staff has been overwhelmingly positive.

Think Frailty

HIS 2screen-capture-17We have become a truly inter-disciplinary team, able to share skills and practice with the wider ED workforce.

We are supported by Health Improvement Scotland (HIS), by whom we are held as an example of best practice for frail and older people in acute care; analysis by HIS health economists has also shown a cost benefit from our service design, which has been an exciting bonus.

We have been invited to present our model at national events, and received visitors from other Health Boards looking to share experience and learning. Ours is one of the four improvement projects featured in the HIS report on innovation in this area – ‘Think Frailty’; we are the only team of its kind in Scotland and we are the proud recipients of an ‘Ayrshire Achieves’ Award for Innovation.Ayrshire Achieves

Frailty teamHas it all been plain sailing?

No of course not. But good humour and persistence has kept us going all the way along and we are fuelled by the knowledge and gut feeling that this is a good thing.

It has not escaped my notice that ‘FOPP’ could also denote the ‘Frail Oldie Poldie Pathway’

…..  My Grandpa would be highly amused.

This week’s blog is by @rowanwallace (Dr Rowan Wallace) who is a geriatrician/acute frailologist in NHS Ayrshire & Arran.


  1. Rowan, an uplifting tale of how to make things better for people. You’ve recognized it’s not all been plain sailing but by keeping people at the centre of what you do (and not letting professional barriers get in the way) you’ve made it easy for the organization to entertain fantastic improvement.
    Best wishes

    • Thank you for your feedback. I really appreciate it. And agree that it’s only by cohesive thinking and working with the person in the centre, that good ideas come to fruition.

  2. Thanks for your blog, love the passion.

    • Thank you very much.

  3. Enjoyed reading your blog which was patient centered, good humoured and inclusive of the supportive team around you.

  4. Great stuff – brilliant to see how you'[ve identified improvements and put them into practice. Fantastic!

    – Dyfrig

  5. I love it Rowan and I am glad you are willing to keep finding new ways of overcoming traditional barriers.

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