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Responding to the Health Committee's Inquiry on health care needs, the BGS responded as follows:

The Society welcomes the opportunity to contribute to this debate and would comment on particular questions as follows:

In considering future demand, how should the effects of the following be taken into account:

• recent policy announcements, including Commissioning a patient-led NHS
• technological change
• an ageing population

While Commissioning a patient -led NHS may ensure that older people with intact cognition will be heard the same cannot be said for the frail older person being admitted to hospital who can often suffer from Dementia and or Delirium. They require specialist care.

The Society stresses the importance of a broad group of professionals required to provide care for older people. The key skill of the speciality is a multi-disciplinary team approach delivering a comprehensive assessment to frail older people. The Society recognises the importance of many models of care but believes a medical assessment and treatment model has its place in a multi-faceted continuum of care. This report focuses on the challenges of training, recruitment and retention of specialists in geriatric medicine in the UK as well as highlighting the issues responsible for a shortage of specialists required for an expanding population of older citizens.

The National Service Framework for Older People (1) came into force in England in March 2001. It espouses 8 Standards to be applied to the Care of Older People and has been broadly welcomed by geriatricians, emphasising as it does the specialty nature of medical care of older people, particularly in the areas of:

• Better acute hospital care for older people
• Falls and fractures (and their prevention as well as treatment)
• Stroke (treatment and prevention – with good evidence that well coordinated stroke care saves lives and reduces disability). The inclusion of stroke mortality as a nationally required outcome measure by which hospital trusts are judged has had an impact in creating new consultant posts specialising in stroke.
• Intermediate Care and rehabilitation
• Mental Health (not strictly the remit of this report but recognising the combined physical and mental health problems in frail older people)

Although still in its infancy as a formal part of health and social care, Intermediate Care (as part of the NSFOP for England) is now a reality with investment in both hospital and community based services evident. In 2002, a year after the launch of the NSFOP, the BGS surveyed 153 lead consultants (with excellent 75% response rate). It examined geriatricians’ involvement with NSF developments. In general, good early progress was reported in implementing the NSF. However there are substantial implications for demands on consultant time with consultant geriatricians providing leadership for ‘specialty led multidisciplinary teams’ and involvement in:

• Acute medical Care with a high proportion of medical emergencies occurring in frail older people
• Specialist clinical leadership in management of Stroke and Falls
• Comprehensive assessment of older peoples in various settings
• Specialist input into intermediate care whose main aim is reduce the need for acute hospital care
• Planning activities for NSF developments

In the 5 years since its inception the NSFOP has had a significant impact on demands for the specialist expertise of geriatricians and a number of new posts have been created or adapted to fulfil the needs to service the NSFOP.

The recent changes to the General Practitioner contract have led to older people facing major obstacles when seeking help in a crisis.

The consequences are both immediate and far-reaching for vulnerable older people and those informal carers on whom they depend. The immediate crisis may result in an unwanted or unnecessary hospital admission in which the crisis is worsened by its late discovery the next day which may eventually lead to inappropriate premature institutional care.

Increasing demands are being made on geriatricians. As a result, the Society has for many years been putting the case for more geriatricians. In July 1998, the BGS published its recommendations for the provision of consultant geriatricians which were then recalculated (2)(3). They calculated that an expansion from 764 consultants to 1700 in England and Wales would be required by 2005 taking into account the needs of patients aged 75 and over, the requirements of academic staff within the speciality and the wider pressures being placed on the speciality. The latest Consultant Census carried out by the RCP in 2004 (4) enumerated only 1075 WTE in the UK and for England and Wales 913, well short of the original target of 1332. For reasons described below a large shortfall is likely for many years.

Difficulties in filling consultant posts - Despite being the largest medical specialty in the UK, the RCP surveys (annually since 1993), have indicated a lower growth in posts in geriatric medicine (3.9% per annum) compared with the average for medical specialties of 6.5% per annum. In the last year, despite Geriatric Medicine being the largest medical specialty, expansion in Geriatric posts (12 between 2003 and 2004) is less than in other acute specialties (e.g. Cardiology up by 28 posts, respiratory Medicine 26, gastroenterology 25 and Endocrinology & Diabetes 20).

Increased demand has outstripped supply in all acute medical specialties, a situation which has deteriorated over the last few years. Taking all medical specialties, the RCP survey in 2004 (4) noted that 36% of Advisory Appointments Committees failed to make an appointment , with especially high failure to appoint in acute/general medicine(56%), geriatrics(50%), rehabilitation medicine (47%) and Palliative care (44%).

The problem for geriatric medicine has been compounded by:

• The parallel (and faster) expansion in other specialties (notably cardiology, gastroenterology and respiratory medicine), attracting trainees away from geriatrics
• A trend (unquantified) for consultants to move ‘sideways’ into more attractive vacant posts
• The danger of unfilled posts being withdrawn
• An increasing number of consultants who wish to work part-time (41.5% of SpRs in the 2004 survey were women). Likewise the number of part-time trainees is increasing, which lengthens their training period.
• An 8-10 year hiatus between the current recruitment rate of doctors and the expected increase in medical school output
• Geriatric (Old Age) Medicine is the largest medical specialty in the UK and has a central place in the acute and rehabilitative care of older people with ever increasing demands on its consultant staff. The senior medical workforce of the specialty has increased by nearly 4% per year in the last 13 years to over 1100 in the UK this year.
• In the 13 years since the Royal College of Physicians established an annual consultant census, the number of consultants in geriatric medicine has risen from around 650 to over 1100 in the UK. As this paper will demonstrate, the work demands have increased even more and there is concern about a growing shortfall of consultants.
• This report attempts to quantify the medical workforce shortfall in the specialty of geriatric medicine and draws attention to the reasons for a widening gap between the work demanded of consultant geriatricians and the availability of consultants to do the work.
• Based on a requirement of one geriatrician for 35.000 population there is a current shortfall of over 600 whole time equivalent (WTE) consultants in geriatric medicine in the UK .

1.4 the increasing use of private providers of services

2. How will the ability to meet demands be affected by:

2.1 financial constraints
2.2 the European Working Time Directive

Hospital doctors provide a 24 hour, seven day a week service. As the largest contributors to emergency medicine, geriatricians and their trainees have been profoundly affected by the restrictions imposed by the implementation of the European Working Time Directive (EWTD). The RCP and BGS have examined this issue in great detail and have concluded that it will be impossible with the projected workforce supply to approach legal working hours for between 6 and 8 years (if ever). The calculations upon which this conclusion is based are presented later.

 The EWTD (with associated ‘hikes’ in pay for working outside the normal working week), ‘family-friendly’ Human Resource Policies and ‘flexible working’ are pragmatic steps to encourage recruitment and retention of staff and provide the work-home balance which promotes quality of life for the workers in health and social care services.

Indirect effect of the EWTD - The indirect effect on consultants (of altered work patterns by junior medical staff) is having an even more dramatic effect:

• less day to day continuity of care and ward cover by junior staff who work full shifts and increasingly are engaged in working in Medical Admissions Units
• Frequent absences due to being off duty

Many consultants in medical specialties declare that they are the only doctors able to provide continuity of medical care in a consistent manner. However if shift working became necessary, even that continuity would be lost.

Direct effect of EWTD - In the RCP surveys, consultants were asked to estimate the average excess hours worked over 48h (the legal limit for the EWTD), In the year 2000, geriatricians reported an excess of 6.4 hours. From this it was calculated that an additional 160 WTE geriatricians would be required comply with the EWTD. In the 2004 survey, despite an increase of 4% per annum in consultant numbers, the situation had deteriorated with geriatricians working 11.4 hours above 48h EWTD legal maximum.

• For geriatricians’ work to become ‘legal’ (48h per week), an increase of 357 (33 %) WTE consultant geriatricians would be required.
• To comply with the desired limit by most Trusts of 40h a week (10 Programmed Activities) an increase 54% in WTE would be necessary.
• In relation to all medical specialties, projections (4) indicate that unless current work pattern changes, consultants will work
• more than 48h (EWTD limit) till 2008
• above contract till 2010
• more than 40 hours till 2012

The general conclusion is that most acute specialties will be forced to operate a full shift system at all levels.

increasing international competition for staff
early retirement

To what extent can and should the demand be met, for both clinical and managerial staff, by:

changing the roles and improving the skills of existing staff
better retention
the recruitment of new staff in England

The disappearance of Senior Registrars with Calman reforms some years ago meant that many new Specialist Registrar (SpR) posts were created on the basis of ‘history or equity‘ rather than their capacity as good training slots. So some ‘dead-end’ registrar posts, previously not considered suitable for training have been incorporated into SpR rotations, with several deficiencies possible:

• No research opportunities or the need to rotate to a research oriented department
• Services inadequate to offer exposure to the specialty elements now required for accreditation, especially in relation to rehabilitation, subspecialty work, long term care, and the new service elements emphasised in the NSF such as falls, stroke care and geriatric specialisation within acute services.

The demands of acute medicine compounded by the dramatic effects of the European Working Time Directive (EWTD) are widely believed to be detrimental to the quality of specialty training and hence are likely to adversely affect recruitment to the specialty. Most obviously, the majority of SpRs in Geriatrics have been forced into partial or complete shift work in the service of acute emergency medicine, with a detrimental effect on specialty training (a situation also occurring in other specialties which contribute to emergency medical care).

The requirement to choose a specialty at an earlier career stage has reduced the market for geriatrics which (as an acquired taste) previously relied heavily on ‘late converts’. The additional effects of “Modernising Medical Careers”(MMC), a Government scheme to shorten post-graduate medical training (to be implemented between 2006 and 2008) will force doctors to choose their specialty even earlier in their career than hitherto and might further disadvantage the specialty.

Competition for trainees with other medical specialties which are expanding as fast or faster than geriatric medicine

A recent survey of recruitment of SpRs in geriatrics (5) gives cause for concern. In 2005, certain areas of England (Yorkshire, Mersey and NW Thames) noted a sharp rise in the number of unfilled SpR posts while in Scotland, Northern Ireland I and Wales there appeared little difficulty in recruitment.

Additional problems for academic geriatric medicine - In its recent submissions to the RCP Workforce Unit (RCP 2000 census) , the BGS Workforce Committee has noted that only 91 out of 965 posts were academic appointments (9.4%) compared with 16.3% average for medical specialties. Academic Departments tend to be small but some are sub-departments or affiliated with other groups. The 12 who gave detailed replies averaged 4 members of permanent academic staff (but varied from 1 to 9). 18 of 50 identified posts were non-clinical in nature. 2 of 12 departments were headed by Senior Lecturers.

There are several factors which cause difficulties in recruitment to academic posts:

• Geriatrics is fairly recent specialty without a long track record of academic work
• As an expanding specialty, there are plenty of NHS posts to choose from
• The generality of the specialty makes research themes hard to identify, though sub-specialties emphasised by the NSFOP have helped
• Departments tend to be small with varied research interests which make for a lesser impact
• Small departments amalgamated with nearby departments of medicine lose their identity
• Geriatric Medicine has never been an attractive target for mainstream research funding and in general does not attract strong support from the local medical schools. The specialty has depended very much on the valiant efforts of the Charity Sector: Groups such as Research Into Ageing, the Stroke Association and the Alzheimer’s Disease Society to fund research.
• The relatively low level of research activity and patchy research training at registrar level, recently highlighted in submissions to the BGS Training Committee.
• A low proportion of consultant posts in Teaching hospitals: in the 2000 census only 273 out of 965 (28%), compared with medical specialties such as cardiology (38%) and gastroenterology (37%).

international recruitment

How should planning be undertaken:

4.1 To what extent should it centralised or decentralised?
4.2 How is flexibility to be ensured?
4.3 What examples of good practice can be found in England and elsewhere?

5. How should planning be undertaken:

5.1 To what extent should it centralised or decentralised?
5.2 How is flexibility to be ensured?
5.3 What examples of good practice can be found in England and elsewhere?

5.3.1 The above three issues will be answered together as follows:

5.3.2 The Government has recognised the need to increase rapidly the number of consultants not only to improve compliance with the EWTD but to address important health targets such as reducing deaths and morbidity from heart disease and stroke, and to improve detection, speed assessment and improve outcomes from treatment of an array of cancers.

5.3.3 A number of general measures are in various stages of development

• The current expansion of UK Medical Schools and opening of new ones is welcome but will take 10 or more years to have an impact on consultant numbers.
• “Modernising Medical Careers” is an important initiative to shorten the time from basic qualification to attainment of specialist training, Initial implementation has just begun. One positive effect in terms of specialty recruitment may be the release of funds from a number of discontinued Senior House Officer posts which could be used to fund new Specialty training posts, an idea which the Joint Committee on Higher Medical training (JCHMT) has recently (January 2006) indicated a willingness to explore, provided the specialist training capacity can be found.
• Recruiting consultants from abroad – never a strong card, since few countries in the developing world have well-developed geriatric services (apart from the moral and ethical objections to such a strategy)
• The Workforce Numbers Advisory Board controls workforce numbers in the NHS. Doctors are the remit of a subsidiary Committee, the Medical Workforce Review Team. In previous years, strict controls or ‘ceilings’ were imposed on specialties to curb the unbridled expansion of popular specialties at the expense of less popular ones. Encouragement by provision of some central funding was given to unpopular specialties which were either politically sensitive (e.g. psychiatry) or necessary for key health targets such as cancer (requiring an infrastructure in specialties such as histopathology and radiology). As the impact of the EWTD on doctors numbers became apparent the restrictions on SpR numbers has been eased especially in acute medical specialties.
• In Geriatric medicine, 80 new SpR posts were allowed in 2003 and a further 30 in 2004. Because of the subsequent emergence of difficulties in filling SpR posts, no further SpR numbers were allocated in 2005.

New workforce planning arrangements - The Strategic Training Authority (which issues certification of Specialist training) has recently been replaced by the Medical Education Standards Board. This is likely to diminish the power of the professional Colleges to decide where training posts should be placed. At the Department of Health, there has been a radical review of NHS workforce planning. The new NHS workforce arrangements are in their early days, but it is now clear that the traditional way of replacing ‘like with like’ is considered a concept of the past. We now have to consider the total workforce needs for health and social care needs of a particular patient group. It is also clear that the traditional professional roles, boundaries and overlaps of roles are being challenged.

The Older Peoples Care Group Workforce Teamwas established in December 2001 to take a broad view of the workforce required to care for frail older people. Amongst its early priorities was to help with filling the ‘medical gap’ in the care of older people, especially in relation to supporting new initiatives in Intermediate Care. It was proposed in 2002 (with mixed support from the Royal College of General Practitioners) to create a large number of General Practitioners with a Special Interest (GpwSI) in care of older people (and a number of other specialty areas).

5.3.6 Unfortunately this initiative has been largely unsuccessful because:

• There are few GPs not already involved in Elderly Care Services who are interested in this work
• There was deep concern that this sort of work would distract GPs from providing basic services (in the context of a severe shortage of GPs especially in inner cities)
• Pre-occupation with establishing a new GP contract and a new range of General Medical Services (GMS 2)

References:

Department of Health (2001) National Service Framework for Older People

Bendall J, Evans JG, Bowman C, Main A (1998) Manpower Planning in Geriatric Medicine (Internal BGS publication)

British Geriatrics Society (1998) General Internal medicine / Geriatric Medicine. Statements of principles and recommended practice, consultant manpower projections to provide and effective service

Federation of the Royal Colleges of Physicians of the United Kingdom (2004) Census of Consultant Physicians in the UK, 2004

British Geriatrics Society (2005) Internal survey of National Training Numbers (Registrars in Geriatric Medicine)