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President's column

It is good to see the BGS continuing to exert an influence at the level of national policy, leadership within clinical communities, among the wider media and in increasingly important social media.

Some of this advocacy is clearly badged as the work of the BGS or members of the Society with particular expertise. Much of it is “behind the scenes” and an exercise of soft power, for instance through advice, research and input to audits, consultations and guideline groups.

We are in the process of appointing a new communications lead and policy manager as well as re-branding and redesigning the website – all informed by the membership services review to which over 500 of you responded.

We have had ample evidence of such activity in recent months.

NICE Guidelines on older people

I am pleased to see a succession of NICE guidelines, all relevant to the care of older people with complex needs, rather than single diseases. In short order we have had “The transition between inpatient hospital settings and community or care settings” and “social care support for older people with multiple long-term conditions”, following on from the 2013 Guidance, “mental wellbeing of older people in care homes”. All have had significant input from geriatricians and all represent a significant departure for NICE into social care.

Speaking to colleagues at SCIE (Social Care Institute for Excellence), they found the rigour of NICE’s approach and their focus on clarity and simplicity of messages powerful in helping their cause with healthcare colleagues,  as social care has tended to approach evidence very differently from health.  

Meanwhile, I and other BGS members had considerable input into two recent reports. The first, from NHS Providers, authored by Paul Burstow, the former Liberal Democrat Care Minister, “Right Place, Right Time. Better Transfers of Care” was highly relevant to the daily work of geriatricians and colleagues in our multidisciplinary teams. This is the topic explored in our front page article where Rose McNamara highlights the need for ‘older people exclusive’ emergency departments, similar to Paediatric EDs.

I have also been advising the National Audit Office on work they are doing on hospital bed occupancies and delays (either for “internal” or “external”) reasons. Not long afterwards, the full detail behind Lord Carter’s Review on NHS Hospital Productivity was released, with attempts to tackle delayed transfers again, though this time without our input.

The Nuffield Trust and Health Foundation “Quality Watch” report, “Winter Pressures what’s going on behind the scenes?” highlighted the rising tide of demand at hospital front doors and problems with downstream “flow” and “exit block”  at the back end, largely driven by the rising number of older people with frailty and complex co-morbidities.  

Whilst these are issues in which the BGS and its members have such an important stake, it’s good for us to rebalance the public conversation. I and several colleagues have repeatedly challenged the horrible, depersonalising term of “bed blockers” to the point where it has started to get through. LBC Radio’s excellent Shelagh Fogarty said live on air that we should not use the term, as did NHS Confederation Chief Rob Webster on BBC outlets, as did Care England News on its twitter feed. 

Whilst not explicitly speaking on behalf of the BGS, Zoe Wyrko was on national BBC TV discussing delayed transfers of care for older people. I have also been on ITN News, BBC Breakfast and BBC Inside Out as well as Shelagh’s LBC series “Not going home”, along with clinical colleagues from my trust. 

This has given us a chance to combat ageist language, to ensure that neither older patients are labelled as a problem for a predicament beyond their control and to get the message across that social care should not be blamed for the huge cuts inflicted upon it.

It has also presented us with an opportunity to highlight the great work that staff do in our frontline services, to help older people stay at home, to help them leave hospital sooner and to aid their recovery from acute illness or injury.

The Recent NHS Confederation Report, “Growing Old Together. Sharing New Ways to Support Older People” was packed with examples and evidence from the acute, pre- and post-acute pathway for older people. I was one of the commissioners, as were senior geriatricians Linda Patterson and Anita Donley and several other professional groups with a stake. It’s a great resource to share and dip into.

A number of the examples in the report were from services where geriatricians play a key role, including that in Sheffield Teaching Hospitals. Prof. Tom Downes will always tell you that the work on improving patient flow in Sheffield is a team effort and not a personal enterprise but despite his modesty he did a great job on the Today Programme with John Humphries and on BBC TV News talking about the Sheffield work and by extension how good geriatric care looks.

If we want to widen our influence and spread our message as geriatricians, we need to look beyond clinical organisations and publications aimed largely at clinicians and academics. Organisations like the NHS Confederation, NHS Providers, NICE and the BBC have much needed clout and profile. And crucially, messages can be expressed in less technocratic and more accessible terms, backed with practical examples of frontline staff driving change despite austerity and performance pressure, and with human stories to make the dry technocratic talk real.

But clinical audiences matter too, which is why I am delighted with two other developments.

First the Acute Frailty Clinical Network: I was one of those who helped secure the initial start-up funding and recruit the first wave of ten hospitals. A further eleven have now joined. However, among geriatricians, it is Prof. Simon Conroy who has provided consistent clinical leadership to the network. 

For me, an exciting feature is that the hospitals on board have not  been “cherry-picked” as those with lots of geriatricians or with well-established acute frailty services, but include smaller units and some just starting out on their journey. The full list of hospitals involved and presentations at the recent shared learning event are on the web. 

I was also delighted to see a superb edition of the RCP London Future Hospitals Journal in February. The contents are all free. The whole issue is crucial to our speciality, whether as geriatricians, general internal or acute physicians in specialised areas like stroke or surgical liaison, or working in community interfaces. It includes contributions by colleagues involved in Internal Medicine specialities discussing the future of the hospital and of expert generalism.

There is an essay on support for older people undergoing surgery, by several of our members. I was also commissioned to write a piece on “the past, present and future of geriatric medicine” and where it fits in with acute and general medicine. President-elect Eileen Burns joined me and we hope it will prove a useful resource for members and a marker for the next few years.

Having been an occasional columnist for the BMJ, I am now contracted to write a weekly column, called “Acute Perspective”. I have been going since July 2015 and my column is free from the paywall. I only get 450 words and I aim to cover a diverse range of themes beyond the day job. Nonetheless, as Eileen and I argued in the Future Hospitals Journal, Acute Hospital Medicine equates increasingly with geriatric medicine and so I regularly write on themes of interest to the BGS community. 

Recent columns have included “Preventing admissions from care homes”, “Who is to blame for emergency readmissions?”, “ Why I sometimes let people stay longer in hospital”, “Welcoming carers onto the wards”, “Rehabilitation is part of medicine” and “End of life scare stories”. I always put several linked references into key documents and  the  “rehabilitation” and “care homes” ones in particular have attracted a lot of interest. I am hoping that having some short punchy pieces on these kind of issues will help the cause of services for older people and I certainly get lively responses post publication.

Future hospitals

Speaking of ‘future hospitals’, it has been gratifying to see that the second phase of the RCP (London) ‘future hospital programme’ features as one of its four model projects, North West Surrey’s locality hubs, demonstrating how geriatrics and general practice can work together to improve delivery of services to older people with frailty (page 7).

Finally, talking of frail older people, most of you will be aware that the BGS has produced a series of reports on the need for better care for care home residents, going from “quest for quality” to “failing the frail” to the widely endorsed “care home commissioning guidance”. We have also posted a number of blogs and newsletter items showcasing good practice in support for care home residents and many of our members are deeply involved in leading and delivering support to care homes in their local services.

The commissioning guidance (written with considerable input from GPs involved in care home work or commissioning) is crystal clear that a whole range of inputs is required for care home residents due to the complexity of their health and care needs and that “GMS” services from GP surgeries are not sufficient on their own and that there are significant care gaps.

We are also aware of the huge pressures from demand (increasing) workforce (dwindling) and resource (shrinking) on our GP colleagues – some of whom are, of course, BGS members.

The recent BMA LMC conference passed a resolution that support for care home residents would be better off sitting outside GMS contract and alternative models should be commissioned instead, as it was no longer possible for GPs to do justice to care home residents given all their competing demands.

I wrote a press release which was supportive of GPs but nonetheless said that care home residents had rights under the NHS constitution, the equality act and current GMS services to a full range of primary and community health services and urging the contract not to be changed without adequate alternatives in place. This was then picked up in media, notably The Guardian.

The responses were lively to say the least. Many GPs wrote to me in private supporting our view. Several others responded on twitter or below our statement or the Guardian piece pointing out that they weren’t proposing that care home residents were deprived of care, merely that the GMS contract should no longer support this. Some appeared to respond to what they thought I had said (quite pro GP) rather than what I did say. 

Nonetheless, when I pointed out that we had for years proposed enhanced support for care homes, including the commissioning guidance and highlighted the issues of equity of access, I feel most critics realised that we agreed with them all along.

All of this brought big online traffic to our site and those key publications. Our ultimate goal, as an organisation, is to improve the quality of care for older people with frailty and complex needs in all settings. The means include developing evidence, guidelines, research and resources, improving education and training, and promoting more integrated models of care. They also include being part of the wider public debate and stirring some attention and interest, even if we generate some “reaction” along the way. 

The saga over the BMA vote was a case in point of using the momentum of a breaking news story to enhance the BGS’s influence. More of the same, I say.

Education education education

On the education front, nurse specialists in older people’s care is a growing area of importance. King’s College London has produced its first class of graduates from its prestigious Older People’s Nursing Fellowship Programme. I was among the lecturers who participated in the delivery of the programme, along with several well-known names among the BGS membership. We feature a few of the graduates. 

Finally, the nominations process for a new President Elect is now open. The candidate will succeed Eileen Burns when she steps up to take on the President’s role from me in November. I would urge our excellent members to put themselves forward.

David Oliver

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