Unique medical social work role improves outcomes for older surgical patients

By Paul McKie
The proactive care of older people undergoing surgery (POPS) was established in 2003 by Guy’s and St Thomas’ NHS Foundation Trust and was the first of its kind in the UK. It is a multi-disciplinary service that aims to improve post-operative outcomes in older surgical patients. The team comprises geriatricians, clinical nurse specialists, an occupational therapist, and a social worker.

POPS accepts referrals from surgical consultants, anaesthetists, pre-operative assessment clinic nurses and occasionally from GPs. Patients often have multi-morbidity (the presence of three or more medical conditions) or functional problems such as limited mobility, or difficulties in managing their personal care needs.

The team uses a comprehensive geriatric assessment (CGA) to pre-operatively assess and optimise medical, psychosocial and functional issues.  A CGA is an evidence-based method for managing older patients. It is designed to determine a frail older person’s medical conditions, mental health, functional capacity and social circumstances. The purpose is to carry out a holistic plan for treatment, rehabilitation, support and long-term follow up.

The use of pre-operative CGA in services such as POPS is increasing throughout the UK and is different from more traditional models of pre-operative care which tend to have a narrower focus on anaesthetic fitness.

Psychosocial approach

In practice, I adopt a psychosocial approach assessing both the psychological and social impacts of an illness or surgical procedure. Practising as a social worker within a health setting, I am influenced by Malcolm Payne’s reflexive-therapeutic view of social work. From this standpoint, I work collaboratively with each patient and strive to enhance well-being. I continually try to adapt my practice to the patient’s needs and hold great importance in the person-centred approach. I endeavour to improve my practice through continuing professional development and to date I have obtained additional post-graduate training in counselling and psychotherapy. These complement the person-centred approach and also assist in the holistic focus on the individual and their environment.

Take Ernest, for example, a 74-year-old gentleman seen pre-operatively in the POPS outpatient clinic. The proposed surgical procedure was a bowel resection and colostomy formation. He was referred to the POPS clinic by the colorectal surgeon to help him prepare for the procedure. Ernest lived at home with his wife and said he was increasingly relying on her support which made him feel helpless and put a strain on their relationship. He felt anxious about his future and about how the surgery might change his lifestyle and reduce his independence.

Ernest is representative of a client group that is at high risk of adverse post-operative outcomes. In part, this poor outcome in older patients can be attributed to medical co-morbidities and age-related conditions such as cognitive impairment and frailty.

When working with Ernest I found that his emotional problems related to a difficulty in adjusting to his rapidly changing circumstances. It was essential that he was involved in the decision-making to maintain his self-confidence. Providing a space for Ernest to explore his anxieties helped him gradually adjust to his new circumstances and the prospect of living with a stoma bag, all at a pace that was manageable for him.

Social work interventions included liaising with the local authority social work team in order to arrange a daily care package. This package not only met Ernest’s physical needs but also helped alleviate the burden of care experienced by his wife. It helped Ernest and his wife link in with their local carer support service and this peer support helped his wife acknowledge her own needs and limitations, and ultimately helped her to continue to safely care for her husband as part of a larger package of care.

Challenges

The POPS social work role is an autonomous position, requiring me to work with professionals from both health and social care. I am conscious of the risk of professional isolation which I try to remedy with regular external social work supervision; this is accessed privately and is partly funded by the POPS team.  Other avenues of support include engagement with other NHS social workers in the trust. This peer support ensures that I remain steadfast in my social work values and ideals and minimises the risks associated with autonomous working.

In the current financial climate I have found providing quality care a challenge.  Many POPS patients do not fit neatly into the high eligibility criteria set by local councils yet they require social work support. A creative approach is required to supplement statutory social services provision with the breadth of community and voluntary services available. Of late, I am heartened to see a move towards improving the relationship between health and social care. It is my hope that with the Department of Health’s framework document Integrated Care and Support: Our shared commitment encouraging health and social care services to work together, the chasm between these two sectors can be narrowed, allowing for a more shared understanding of a patient’s needs and risks. Such a collaborative approach would improve the care of vulnerable older patients undergoing surgery.

Unique service

Working as a social worker in the POPS team, I feel lucky to be part of a unique service that proactively responds to the individual needs of each patient. It is my hope that the uniqueness of this social work role will become more commonplace in future surgical practice, and that the increased visibility of social workers in the NHS will become a valued and necessary component in multi-disciplinary working.

Paul McKie is the social worker on the POPS team