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AbstractOlder adults constitute a large proportion of patients undergoing surgery and present with complexity, predisposing them to adverse postoperative outcomes. Inequalities exist in the provision of surgical care across the United Kingdom evidenced by increased waiting times in areas of social deprivation, a disparity in the provision of surgical care across geographic locations as well as a variation in the medical management of comorbidities in surgical patients. Addressing inequalities in the delivery of perioperative care for older adults necessitates a multi-faceted approach. It requires implementation of an evidence-based approach to optimisation of older surgical adults using Comprehensive Geriatric Assessment and optimisation methodology at scale, development of an age-attuned, flexible, transdisciplinary workforce, a restructuring of funding to commission services addressing the needs of the older surgical population and a change in culture and professional and public understanding of the needs of the older surgical patient.

As delivery of healthcare becomes more complex, there is an increasing need for collaborative working between specialty teams. Recognition of this need has led to new models of care, for example surgeons, anaesthetists and geriatricians working together in the perioperative pathway. Although there is emerging evidence that these collaborative approaches are effective, there is little guidance on who is responsible for the patient throughout the healthcare episode. Government policy and legislation has increasingly focused on the need for a single named clinician to be responsible for the entirety of a patient’s episode of care, with overall liability resting with the hospital trust as the provider organisation. This discrepancy between delivery of healthcare by teams and responsibility resting with an individual raises questions: how can clinicians and hospital trusts ensure synergistic patient care while maintaining clear lines of responsibility? Who should provide information to patients throughout the pathway? Who should the patient expect to be the point of contact? This dichotomy emphasises the need for new guidance to support the patient, the clinician and the provider organisation as shared models of care evolve and become embedded into routine practice.

The demand for surgical intervention in older people is rising due to the growing older population with multimorbidity. Yet older people continue to have reduced access to surgery and have more adverse postoperative outcomes than younger people. Current models of preoperative risk assessment and optimisation are poorly suited to this complex surgical population. Furthermore, there has been little emphasis on perioperative management of older people in national anaesthetic and surgical curriculums. New models of care and training in perioperative medicine for older people are evolving, with national reports calling for collaboration between geriatricians, general physicians, anaesthetists and surgeons. Such collaboration is necessary to impact clinical service development, research agendas and education and training. In this article, we discuss the challenges and potential solutions in the establishment of quality surgical care for older people.