I tend not to worry if people don’t read this editorial. So if you are not reading it now, please don’t feel that you’ve caused offence! A greater worry is when people read it and take exception to its content.
One such incident occurred recently. I was meeting with a respiratory physician, something of a hero of mine - good all-round bloke, excellent physician, leading researcher. We were meeting to discuss data collection in care homes but his opening gambit was, ‘I read an editorial of yours recently.’
Pregnant pause whilst I tried to work out what was coming next.
‘It said that geriatricians are the ones that do all the work.’
Pregnant pause whilst I tried to work out how to respond to what was coming next.
‘So why, then,’ he went on, ‘did I spend all of yesterday seeing sixty outliers, all old, and all ostensibly medically fit for discharge?’
And then I felt quite small. His wife is a geriatrician. It hadn’t occurred to me that she, let alone he, might read my editorial. He wasn’t, suffice to say, my intended audience.
I went on a similar emotional journey when I recently went to a House of Lords meeting designed to draw together medical innovators to speak to the Minister for Life Sciences. As I read the abstracts on the train down to London, I thought I had the whole thing pegged. The cardiologists would speak about TAVIs, the maxillofacial surgeons would speak about 3D printing of personalised body parts and the transplant surgeons would talk about novel approaches to immunosuppression. Meanwhile the practical but innovative responses of geriatricians to the everyday pressures of the NHS would suddenly seem unglamorous and I would stand unloved in a corner. But actually, it was quite different. The respiratory physicians spoke about going into the community to provide care closer-to-home for the frailest patients; the cardiologists spoke about doing simple things well to broaden access and reduce delays to PCI; the trauma surgeons spoke about how the humble tourniquet was revolutionising pre-hospital care. There was, of course, the humbling 3D printing of body-parts talk to sit through but, for the most part, it was about tackling the same issues that exercise us as geriatricians - minimising complexity, removing barriers to common-sense every day care and, more importantly, broadening access to care, often to encompass the very frail and dependent older patients that we seek to advocate for.
We can, as geriatricians, get a bit wrapped up in ourselves, especially when we are working flat out; especially when we are on a mission. And we all have been over these last few months as we’ve played our parts in dealing with the acute care crisis. If you work in a big centre like I do there’s something quite affirming about griping to colleagues about the fact that every other sod seems not to care about frail older people. If you work in a smaller centre, I suspect it can be tempting to feel isolated amongst a team of physicians and healthcare professionals, the majority of whom have never heard of CGA, let-alone modern conceptualisations of frailty.
But we have to ensure that we¹are not so wrapped up in ourselves that we fail to get the rhetoric right. The message is this: we can help.
Hospitals and health systems can flow more smoothly with expert geriatricianly input in the right parts of the pathway. But we need to have the time and capacity to do this, which means we can’t only be staffing the acute take. In the same way that respiratory physicians need to be free to staff the two week wait clinics and the gastroenterologists need to keep the endoscopy lists moving to ensure the broadest possible access to their service, we need to be able to go to the community, to attend intermediate care, and to do the orthogeriatric ward rounds.
So we need all to pull together. Patients with frailty in acute hospitals are everybody’s - by which I mean all healthcare professionals’ - business. Putting geriatricians in the right place to support the assessment and management of older people with frailty in acute hospitals, and throughout the pathway, will help everybody conduct their business with maximum possible efficiency to deliver the best outcomes for patients.
These points are highlighted in our six decisions for the incoming government document, which David Oliver expands more fully upon in his column. The issue of reaching out to other specialties is touched upon through our ongoing work with the Gold Standards Framework team. The ongoing work to expand access to POPS initiatives and to develop a CGA toolkit in co-operation with Dr Angelo Grazioli also fit with this theme. Meanwhile, the careful balance to be struck between acting as custodians of the body of geriatricianly specialist expertise, whilst giving colleagues from other disciplines routes into training in the specialty, is considered by Zoe Wyrko on her position paper on alternative routes of training.
So hopefully I’ve phrased things a bit more inclusively this time around.
I look forward to the next meeting with my respiratory colleague with interest. If, in fact, he’s bothered to read this!