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Interface between primary and secondary medical care

Interface between primary and seconday medical care in the new NHS in England, Wales and Northern Ireland.

The Care of Frail Older People by GPs and Consultant Geriatricians


Update (Feb 2009): The DH has published the new guidance for PwSI - the new term for GPwSI from 2003. I am going to write a short article for the newsletter on this now. You may wish to update the link from our website which is a link accessed from the Best practice guides page at present.

1.  Introduction

The care of the older frail patient in community settings is complex and comes within the responsibility of many different clinical professionals including General Practitioners and their teams, community nurses, physiotherapists and occupational therapists, secondary care clinicians including geriatricians, psycho-geriatricians.

Frail older people are vulnerable to poor quality services, to some extent reflecting ageism within the delivery of services. Pitt stated “ Most developed societies do little to enhance the image of the "senior citizen," who is liable to be patronised, marginalised, or simply ignored and is seen as a problem for an overburdened welfare state” 1. Frail older people benefit from “Comprehensive Geriatric Assessment”, which requires an assessment of activities of daily living, mental well-being and the need for social care as well as a thorough medical assessment. Poor quality services may neglect this medical assessment: for example, non-specific problems (such as falls, immobility) may be managed poorly because of the lack of an adequate medical diagnosis. Poor quality services are therefore likely to be ineffective. Poor quality services may also neglect physical and mental abuse by relatives and ‘caring’ institutions, abuse that commonly is not recognised.

The General Practitioner is central to the coordination of this care. For most frail older people, he or she is the ultimate case manager orchestrating the medical care of the individual on a daily basis and seeking the advice of others with specialist knowledge and skills when needed. This may be through referral to the professions allied to medicine or to other clinical colleagues – such as General Practitioners with Special Interest or Consultants - either in intermediate or secondary care. In the “New NHS” – discussed in detail later – there are more players in this area, and this potentially causes confusion. In these circumstances, the clarity of a joint and team approach cannot be underestimated. A particular potential area of confusion is the part played by different medical practitioners – particularly the respective roles of General Practitioners, General Practitioners with Special Interest and secondary care clinicians. This paper seeks to address the team working between these groups to the maximum advantage of the frail older person.

The best approach to this vulnerable section of our society has been considered in this statement by the British Geriatrics Society and the Royal College of General Practitioners. The production of this document was initiated by a conference in June 2006 between the British Geriatrics Society and the Royal College of General Practitioners to which other professionals were invited and who contributed widely to the discussions. These included community and practice nurses. It is recognised that the sign-up of other organisations such as nursing, physical therapies and pharmacy is required. But this first attempt at a document throws down the challenge for us all to collaborate to produce further guidance on joint working to optimise the care of frail older people. Therefore, this document is not the end of the process but the start of a joint programme of work between the British Geriatrics Society, Royal College of General Practitioners and others to optimise the care of one of the most vulnerable sections of our society.

2 The New NHS and specific purpose of this document

The National Service Framework for Older People set out a plan for the optimal health and social care for the start of the 21 st century and, although introduced for the NHS in England, Wales and Northern Ireland , it includes many central elements that are held to be true in any country and at any time. This document was written in a period during which health policy in England, Wales and Northern Ireland was moving towards a model where care is delivered in community settings as opposed to hospitals - on the basis that this might be more cost effective or preferable to users. And so, the National Service Framework for Older People stimulated the growth of intermediate care services, and subsequent policy initiatives have continued this process by introducing community matrons to case-manage certain frail older people in the community.

The National Service Framework recognised some of the complexity of the task. It required that services deliver p erson-centred care. This meant that NHS and social care services should treat older people as individuals and enable them to make choices about their own care. The National Service Framework stated that this should be achieved through the single assessment process, integrated commissioning arrangements and integrated provision of services, including community equipment and continence services. Regarding intermediate care, the NSF stated that older people should have access to a new range of intermediate services at home or in designated care settings, to promote their independence by providing enhanced services from the NHS and councils to prevent unnecessary hospital admission and effective rehabilitation services to enable early discharge from hospital and to prevent premature or unnecessary admission to long-term residential care.

The development of intermediate care and the introduction of community matrons has significantly changed the health and social care landscape towards greater community provision of health care: part of the “new NHS” referred to in the title to this document. The good news is that there is a real opportunity for the care of frail older people in the community to improve. But difficulties remain. For example, Intermediate Care services are often fragmented, some with questionable standards of clinical governance. Lessons from good practice need to become routine practice.

One of the many necessary conditions for effective services for frail older people is adequate medical input. This may appear self evident, because the health problems in older people arise from acute illnesses occurring in the presence of chronic illnesses. It follows that it is vital that these conditions are diagnosed, their prognosis established and their treatment given. However, there are no accepted standards for the medical requirements in services for frail older people in the community.

The core care of the frail older patient in the community remains the responsibility of the General Practice team. Because of this, the requirements for good General Practice in this area have been included in the General Practice curriculum statement 2. At the same time greater sub-specialisation of primary care doctors has led to the development of General Practitioners with special interests in older people and General Practitioners with “extended knowledge”. The Royal College of General Practitioners website gives information and advice for those wishing to pursue an interest in General Practice with Special Interest 3.

However, the “new NHS” represents a transfer of provision from secondary to primary care doctors, and this has stimulated growth in the development of community geriatric medicine 4. Historically, General Practitioners and community geriatricians would interface either through referral to out-patient clinics, or through requesting domiciliary visits. But now opportunities exist for secondary care doctors as well as General Practitioners with Special interest or extended knowledge to support the work of matrons, provide services to care homes, and to provide input to intermediate care settings.

We are currently witnessing the development of community geriatrics services in this area. Many different models have developed, largely dependent upon the views and experiences of the enthusiasts who have taken leadership roles for project development and the resources available to them. Some have deliberately chosen to develop demonstration projects so as to illustrate what high quality care can achieve, aiming to model good practice to encourage improvements in other neighbouring services and leading by example. Others, particularly those arising in primary care, have taken a population based approach based upon the needs and resources of a PCT (a unit of primary care health organisation) or primary care practice.

The purpose of this document is to give guidance upon good ways of primary and secondary care doctors and their teams working together.

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