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  Increasing numbers of older people are having surgery, with high rates of postoperative morbidity and mortality. Integration of perioperative medicine services with primary care offers an opportunity for early implementation of evidence-based preoperative optimisation. This proactive approach may reduce downstream burden on the health system in terms of sequelae from postoperative complications, and is expected to improve patient outcomes. Aims: To evaluate enablers and barriers to primary care engagement in preoperative optimisation; To co-produce a strategy for primary care-led, integrated preoperative optimisation of older patients. Methods: Stakeholder interviews with 38 clinicians and professionals explored enablers and barriers to integration of primary and secondary care services in preoperative optimisation of older people. Interviews revealed themes, used to develop a survey validated by 12 expert raters. A purposive sampling frame was developed, to deliver generalisability of practice size (compared with NHS Digital data) and geographic spread. A bimodal strategy for survey distribution was employed to maximise response rate, using paper surveys at primary practice meetings where this fit within the predetermined sampling frame. Results: Stakeholder interviews revealed: Barriers: - low volume of referrals to surgery per GP - unclear referral pathways - Unclear roles - lack of education - time restraints Enablers: - Frailty a priority for GPs - appetite for genuine integration - recognition of surgery as a high risk period Interim results of survey (closing July 14): Enablers: - 85% of GPs believe preoperative optimisation improves postoperative outcomes - 49% of GPs feel that they could identify potentially modifiable risk factors - 81% of GPs feel it is the role of primary care to discuss modifiable risk factors with patients Barriers: - 52% of GP’s had referred zero or 1 patient (>65yo) to a surgical specialty in the past month - 12% of GP’s felt they had adequate to deliver preoperative optimisation - 55% of GP’s were not aware of having access to perioperative medicine services Discussion and conclusion: As increasing numbers of older people are having surgery, with high levels of multimorbidity and frailty, there is an escalating need for whole-system integrated surgical pathways designed to handle patient complexity. The first phase of this quality improvement initiative identified a need in primary care for education and access pathways, to build cross-sector relationships and upskill clinicians in order to create an environment within the workforce that will be receptive to formalised integrated perioperative medicine services. Lessons learned Relational factors are key to developing integrated pathways fit for purpose. Work is needed to build cross-sector clinical relationships that complement structural and organisational changes. Limitations Survey findings are limited by a response rate of 30% (interim analysis). This is the expected response rate for a survey of primary care. This likely results in an underestimate of key findings, as clinicians with an interest in perioperative medicine are more likely to have responded. Future research Next steps include co-production of a multidisciplinary educational workshop with local primary care practices, and co-development of a primary care to POPS e-referral and communication pathway.

Breaking down barriers: evaluating enablers and barriers to early integrated preoperative optimisation of older people having surgery