Older people

14 older people consented to participate and were interviewed. Respondents were aged between 75 and 90 years old, were evenly split between males and females, and included participants with hearing and/or visual impairment, mobility impairments, and with one or more long-term condition. One participant asked to be interviewed in the presence of their carer (a spouse). The interviews lasted between 16 and 92 min (table 1).

Healthcare professionals

The 13 HCPs came from different professional backgrounds and from different geographical areas of England. All of the participants were working, or had worked, with older people with frailty, for a duration of 2–30 years (table 2). The interview duration ranged between 33 and 160 min.

We identified patterns about the conditions to enhance CGA across the two data sets, then classified these patterns into the eight domains of the NASSS framework and to the framework of acceptability.25 33 Here, we present the four domains that were most important for both the patient and professional participants: frailty (the condition), intended adopters (both professional and lay), organisational factors (such as workforce challenges) and acceptability (of technology and assessment).

Frailty

Among HCPs, there was an appreciation of the complexity of frailty. Regardless of whether they have a need for acute care or not, all older people with frailty have complex needs due to having multiple long-term conditions, impairments and/or socioeconomic factors:

Most of them are aged 80 almost all of them are frail and so they have multiple chronic conditions, they have got polypharmacy they tend to need some help with one or more activities of daily living. (HP13, Pharmacist)

HCPs from different professions tend to provide a comprehensive assessment that involves physical, psychological and social needs for older people with acute and non-acute care needs. However, there is a need to provide older frail people with assessment prior to a crisis developing:

All the domains yeah, the psychological, physical all those you know functional, environmental you know do you live in a house, a flat, bungalow, do you sleep upstairs, any falls you know any equipment in the toilet, that kind of thing and social you know do you get out. (HP12, Physiotherapist)

So, if you’re trying to keep somebody weller for longer, then any of those proactive interventions rather than waiting until they get to crisis point. (HP9, Occupational therapist)

We interviewed older people with frailty who were socioeconomically disadvantaged and/or experienced sensory or physical impairment that can exacerbate the complexity of their care needs. For example, Carol had financial challenges, restricted mobility, visual impairment, multiple long-term conditions and a high risk of falling. Carol had limited choices in access to care because of her restricted ability to travel to appointments, lack of a support network and no access to technology:

I’ve been a single person all my life and I get the basic state pension. So, I’ve never ever been able to afford the technology that people use every day to day in these days and that’s the reason I don’t have it. (Carol, 81–85 years old)

On the other hand, Karen lived alone but has regular communication with family and friends. During her health and care journey, Karen was able to enact her own health decisions and avoided long NHS waiting time for tests and referrals:

I only saw the consultant yesterday, so the next steps haven’t been put in place yet. Unfortunately, I have had to pay privately for it and the NHS seems to be in such a mess and the doctor did want to send me off for tests but she couldn’t justify so, more or less saying well you know it is as it is we can’t do anything more for you because we haven’t got proof that this test or that test is something we can do, something we can justify. […] I’ll have to pay for that privately otherwise I will just be waiting too long. You know I am getting on I don’t want the last two or three years probably of my life to be sitting around at home feeling sorry for myself. (Karen, 75–80 years old)

Intended adopters

Some HCPs indicated that an HCP occupational background may inform the scope of assessment during the CGA, and the quality of the CGA that they offer. A nurse who led a frailty team showed appreciation of the range of HCP backgrounds in their team, which enabled them to involve the most suitable HCP (eg, in terms of their skill set), to meet the unique needs of the older person:

obviously if it was things like their ability to perform their physical activity to daily living that maybe something that I would involve one of, I’ve got a colleague who is Band 4 assistant practitioner whose got a therapy background she’s very good at looking at the nuts and bolts of how people physically manage […] I will also do joint visits with OTs and physios if we’re feeling that we need to, that there’s a, that the referral makes it sound like this is very much that mixed picture of it’s not just a medical requirement or a strict nursing requirement that there’s an overlap with where my therapy colleagues would come in. (HP2, Nurse)

This contrasted consultant geriatrician (HP11) who also led a frailty team. HP11 indicated that regardless of the different backgrounds of HCPs in their team, there should be no differences in the CGA that they provide to older people with frailty. However, HP11 highlighted that some professions may have limited ability to understand the complexity of older people’s care needs. This was congruent with the views from older people who thought that their care needs could be managed better by an HCP with knowledge and experience of older people with frailty:

They all do the same because they’ve all had their advanced […], course the advanced assessment healthcare assessment course. They’ve all done the same course ok,. (HP11, Consultant Geriatrician)

You could have one doctor who is in the practice who specialised in old people you know just for the aged to sort of he specialised in the aged. […] where old people could feel they could go […] rather than a general practitioner maybe somebody that was for the old and the frail. (Barbara, 81–85 years old)

A general practitioner (GP) (HP3) thought that the ability to deliver CGA depends on the investigative and communication skills, and previous experience of staff, and it is not restricted to a particular background:

So, I tend to work on a concept that I don’t like thinking about professions doing things I like to think about competencies. (HP3, GP)

Some HCPs suggested that HCPs may require training to improve interpersonal skills, in terms of communication and attention to detail, to ensure enhancement of CGA. For example, HP12 (a physiotherapist) shared their personal experience of developing their investigational skills when providing remote CGA over time. HP7 (a nurse) shared their experience of supporting new HCPs in their team to learn how to pick-up non-verbal cues during home visits, to support identifying care needs and provide CGA.

Organisation

Interviewing HCPs from different geographical areas of England allowed us to explore organisational limitations, which would require innovation to increase readiness for new forms of technology-informed care delivery.

Some HCPs made references to fear and resistance to trying new ways of care delivery. For example, a nurse (HP2) referred to themselves as ‘a dinosaur’ when it comes to trying new technologies. Similarly, a frailty assistant practitioner (HP1) also indicated that practitioners may need support from colleagues while a consultant geriatrician (HP11) shared the challenges they had when using technology and the time needed for training to use new technology:

There’s also the training aspect of it. Training takes a long time you go in and sit down and have training whatever new technology comes you have to find time to go for training and you actually don’t get to understand its use until you start using it and the problems that you get when you start using it. (HP11, Consultant Geriatrician)

Almost all HCPs discussed the negative impact of using different clinical databases in various settings on their ability to share and/or access patients’ records. HCPs discussed the importance of having a well-established information sharing process between HCPs in different settings in enhancement of CGA. HCPs shared their experiences of meeting the challenges in information sharing. For example, sharing data in regular multidisciplinary team (MDT) meetings provides access to the GP medical records for HCPs who work in the community, which enables them to effectively support the older people with whom they work. Some organisations have a sharing document that all HCPs involved in CGA can use to input and share data, which staff found beneficial in terms of the availability of information and efficiency in obtaining key information when needed:

I’ve not seen they’ve had a CGA, their clinical frailty scale is this, blah, blah, blah never seen it never ever. Never ever, ever seen it. So, information is not coming it is not flowing. (HP12, Physiotherapist)

I just from previous experience I knew these sorts of things I needed to have so I made sure that I discussed it with the CCG and got them to put this in place because I didn’t want to be spending exactly like the nurse, two hours, trying to get information when in five min I can have that information. (HP10, Consultant Geriatrician)

So, for me to be able to know what medicines somebody is on, I have to have access to that or I’ve got ask somebody who has access to check for me ok. (HP11, Consultant Geriatrician)

Lack of staff capacity was perceived as a limitation for delivering CGA by all HCPs, which may inhibit delivery of timely support which an older people may require. Some older people recognised the limited staff availability and the increasing demands on the GP practices that inhibit continuity in care. For them, lack of continuity decreases their engagement with their care:

More of us, more availability […] I mean we are running its sort of like a virtual ward model but it’s going to be, we have less staff on at a weekend. So, our capacity to take new referrals on a Friday and over the weekend is a lot less. (HP9, Occupational therapist)

When you see the doctor, you know you barely it’s a locum that I see I don’t see my own doctor. (Shirley, 75–80 years old)

Other older people with frailty understood the current workforce challenges in the NHS and suggested that improved communication between HCPs and sharing information may mitigate the current lack of continuity:

GPs talk to each other and that you know if you go in and you see somebody who is not your designated GP you know that fine well that the notes are there […]. So, you feel perfectly happy that you know whoever you are seeing, knows what they are talking about. (Lois, 86–90 years old)

However, we identified that when an older person can identify a key contact person to support them, this can mitigate a lack of continuity in their care, because they key person can co-ordinate their care and ensure the continuous flow of communication:

So, I sort of stayed involved in this case as a coordinating factor because you know it happens when too many people are involved things the outcome might not be good or the people can get lost in translation and so I managed to speak to the mental health team and everything and draw all the people that the GP had referred to, to a point where I said now, you need to take this forward. (HP12, Physiotherapist)

Acceptability

We identified elements that might influence acceptability by older people with frailty, that should be taken into consideration when enhancing CGA.

Although HCPs perceived that older people were satisfied with CGA and the care provided to them, some older people indicated that they could not freely communicate with HCPs and express their needs, because of perceived short appointments with their GP. Furthermore, older people lacked trust in their HCPs, or the clinical decisions made about their treatment plan:

I would say the consistent feedback is normally that they’re greatly relieved that we’ve given the time ‘cos we don’t time specify our visits (HP2, Nurse)

No, it’s so quick and it’s so, I mean in person, well I wouldn’t say personal you know when you speak to a doctor like I did with my old doctor if he, it was just a different attitude towards you, it’s like a conveyor belt, you come in, you go out, you come in and you go out so, you know you just feel it’s not the same what it was before. (Shirley, 75–80 years old)

Moreover, HCPs acknowledged the variation in older people readiness to engage with new ways of care delivery:

There is a high risk of inequalities because anytime you are going introduce something different new, there are going to be people who can use it very easily and there are going to be those who can’t for whatever reasons. (HP13, Pharmacist)

This aligned with the findings from interviews with the older people themselves. For example, Karen showed readiness to engage with new ways of receiving technology-informed care because she had previous experience of using technology in her healthcare, and in communication with family members. In contrast, Shirley rejected engagement with new forms of remote appointments:

They did ask me once yes, but I said, well, I don’t know how to do it, let’s put it that way a video appointment I mean I don’t […] I have a mobile phone so, you know I just don’t know how to do it. So, the other solution was that they speak to me over the phone. (Shirley, 75–80 years old)

Lack of physical access to technology (eg, a device or internet connection) can inhibit an older person’s opportunity to learn how to use technology, which may subsequently limit their readiness to engage with new forms of technology-informed care. Therefore, those with frailty may require additional support to engage with CGA that uses technology. For example, older people with sensory impairment may require specialist adaptation to their device, or support from a carer to engage; whereas older people who are already digitally literate may only need educational input on how to use a new technology.

HCPs recognised the variation in the needs and preferences of older people with frailty and discussed how they tailor CGA to the person’s needs:

I would say we’re able to be very person-centred we’re not looking at things from a clinician’s perspective only we will explore things from the patient’s perspective in terms of what they think is their problems. (HP4, Physiotherapist)

Some HCPs thought that the presence of a carer, a family member or support network may increase a frail older person’s acceptance of CGA that uses technology. However, HCPs acknowledged the higher demands on the carer which may reduce the support they can provide, to help the older adult engage with technology. A GP (HP3) shared examples of caregivers who inadvertently disempower the older person, in terms of decision-making about their healthcare choices. Older people may, therefore, require support from a wider network, and not only their carer:

Some of them have families who help them but they still like you know eye contact, physical contact and the written word, you know paper, hard copy of anything. So, I am afraid that’s something that they’ll eventually all pop off but and thankfully the younger ones are you know quite capable of using all these devices. (Barbara, 81–85 years old)

HCPs may not be able to provide the required follow-up after an assessment, important for tracking the referrals to other services if needed and the management plan provided to the patient. Similarly, older people explained the challenges that they were facing in following-up the HCPs; for example, to find out the result of a test, or to book an appointment:

I would like to think we’re good at going out and identifying the problem we’re good at negotiating a management plan with someone it’s then how do you monitor the effect of that management plan. (HP2, Nurse)

I had to phone my practice after I’d been to see the 111 doctor and she said get in touch with your practice and I got this sort of non-committal reply oh, well you’d better start your antibiotics and I was quite disappointed that they didn’t get in touch with me because they’d given me that advice without having seen a report and I thought well I would have expected something to come back but like I said, I was really not well enough to do anything about it. (Donna, 81–85 years old)