Research shows that older patients with hip fractures have better outcomes if their primary management is directed by geriatricians rather than orthopaedic surgeons (Prestmo A, Hageen G, Sletvold et al, 2015). This is not really surprising as we are constantly told that older people (more than 70 years) often have multiple comorbidities that mandate a holistic approach to clinical care rather than multiple independent specialist inputs.

A common criticism of the acute care of older people is that their only access to such care is via emergency departments. The initial assessment and management is undertaken by doctors whose primary focus is dealing with the immediate acute presentation, usually with little or no knowledge of pre-existing medical illnesses or baseline status. This can result in a decision to admit to hospital for a clinical problem that turns out not to be an acute problem or one that has already been investigated. Hospitalisation is especially disruptive and traumatic for frail older people and can of itself precipitate a crisis that results in failure to discharge the patient from hospital.

It is fashionable, but facile, to suggest that these older patients with multiple health issues would be better managed in community settings and preferably in their own homes. So are there realistic alternatives to EDs as the point of access for acute care?

The standard model of primary care in general practice is not a practical alternative for these patients. The fact that they have been referred to an ED demonstrates that they have outstripped the normal capacity of GP-based primary care. However, better access for GPs to investigative technologies and more allied health support have been proposed as part of the solution. In order to have a significant impact in reducing referral to EDs, the transfer of resources would be substantial and unfortunately the impact of reducing hospital based services would probably be greater than that of increasing community-based ones, at least in the short term.

The medical assessment unit (MAU) has been developed as a less frantic approach than the ED and should have some merit for older patients. So long as these units have good access to investigations (radiology etc.) and skilful input from experienced clinicians, then they can manage cases that would otherwise result in admission. However, they still suffer from lack of prior knowledge of the patient and liaison with community based professionals such as GPs, community nursing units etc. If well run, MAUs risk becoming victims of their own success and exploited as a way of leap-frogging outpatient waiting lists. It has even been suggested that MAUs generate activity that would not otherwise exist.

There have been some models of very good care for patients with specific chronic illnesses based around dedicated units with direct access. Cystic fibrosis, chronic kidney disease, haemophilia and oncology are examples. These patients have complex and specialist needs that cannot be delivered in an ED setting or even by general physicians. Perhaps being frail and elderly should be recognised as a condition in itself that requires specialist management targeting rapid functional assessment and intervention. If these patients could be identified before they have an acute crisis then they could be referred when the need arises to a specialist frail-elderly unit and not an ED. Even a pilot project on a small scale would be worth trying to evaluate this approach.

The problem of delayed discharge is in the EDs and the acute hospitals, but the solution probably isn’t.