The Community – Where Life Happens
Adam Gordon is Associate Professor in Medicine of Older People at the University of Nottingham and is about to demit as chair of the British Geriatrics Society’s Special Interest Group for Community Geriatrics. He considers here where community geriatrics fits in the spectrum of healthcare for older people. He tweets at @adamgordon1978
Most people spend most of their lives not in hospital. This, contrary to the peculiarly hospitalist view of most physicians, is the case even for older people with frailty. It’s odd, therefore, for geriatrics, a medical specialty that prides itself on holism, on adding life to years, on focussing on health rather than disease, to still do most of its work in hospital. Most of the people with long-term conditions are “out there”, most of the people with frailty are “out there”, most of the opportunities to modify the trajectories of ill health and functional decline are “out there”.
There’s a lot of work “out there” – to put it in some proportion, the NHS Alliance reports that there are currently around 340 million GP consultations per year, while NHS providers report a further 100 million patient contacts from community-based services. This compares with 21 million A&E attendances per year.
Where is “out there” when it comes to health care? If you accept the classification that Community Geriatrics is a discrete speciality, as currently outlined in the Higher Specialty Training Grids for Geriatric Medicine, then it’s everything that’s not an acute hospital – community hospitals, intermediate care, care in care homes and in people’s front rooms.
When presented this way, it becomes clear that the competencies required are really quite broad and could range from specialist input in a geriatric rehabilitation setting for intermediate care, to helping GPs with diagnostics and management planning in complex patients, to working with community stroke teams, to assessing patients who fall at home, to supporting patients with frailty recovering from fractures, to supporting patients with Parkinson’s Disease in community.
And that’s before we even mention the care home setting, where the best way to structure care in small long-term care institutions - harnessing the expertise of staff, taking account of the high prevalence of dementia and functional dependency, and considering the pressing need to plan for the end of life – is only just being understood.
So maybe community geriatrics isn’t a discrete subspecialty after all. Maybe colleagues from the full range of subspecialties, from orthogeriatrics, to geriatrics rehabilitation, to falls and movement disorders, ought to be getting out more.
That might cause a problem, though. I frequently tell my hospital colleagues that there are not enough geriatricians to look after all the older people with frailty in hospital. If we’re to take the challenge of older people with frailty in the community seriously, then we could end up even more thinly spread. Many geriatricians are reticent to step out of the hospital – where the bulk of their expertise lies and most of their training has taken place. There is evidence that community geriatrics posts, even when advertised, go unfilled.
Existential crisis alert! If we’re to work out a way forward we need to be honest with ourselves as a specialty. Are we really about “holism, health and wellbeing”, or are we really just hospitalists for older people, with sub-specialty expertise in an array of problems commonly experienced when such people come to hospital? If it’s the latter, we probably need to change the BGS tagline. If it’s the former, then we need to find ways to work with those already out there in the community to optimise care pathways for older people.
The good news, if we are going to do this (and I believe we should, because I do believe in the mantra of holism, health and wellbeing), is that there are lots of colleagues out there in the community, from general practice, mental health, community rehabilitation services and care homes, who are ready to meet us in the middle. Stepping out of the hospital won’t isolate us, it will connect us with one of the constituencies we need to make the lives of older people with frailty better.
As I step down as Chair of the Community Geriatrics Special Interest Group at the BGS, it’s clear that we have lots to do – and that, in many cases, we haven’t even worked out how to do what we need to do yet. But it’s also clear that we have one of the most vibrant, dedicated, multidisciplinary and multispecialty SIGs in the Society. We have GPs, community matrons, occupational therapists, physiotherapists, old age psychiatrists and, yes, geriatricians, all scratching their heads in unison to work out how to tackle the big issues. Come and join us, we’ll help you get “out there”.
People interested in standing for Chair of the Community Geriatrics SIG can find more details here. If followership’s more your thing, email to join the SIG ScientificOfficer [at] bgs [dot] org [dot] uk