There’s no need for a battle of ideas between hospital and community geriatrics. We need more of both.
Professor David Oliver is Former President of the BGS, a visiting Fellow at the Kings Fund, and a consultant in geriatrics and acute general medicine at the Royal Berkshire NHS Foundation Trust. He tweets @mancunianmedic.
The Covid-19 pandemic has seen a range of fantastic blogs on this site and publications in Age and Ageing. As a former BGS Secretary and President it has been fantastic to watch the society’s website, newsletter and scientific journal go from strength to strength and its public influence grow.
In recent weeks, two separate BGS blogs written by two geriatricians I know and admire, Nottingham’s Professor Rowan Harwood and East Kent’s Dr Shelagh O’Riordan, highlighted to me a philosophical difference of emphasis within our wonderfully diverse speciality that I hope doesn’t grow beyond that into an internal battle of ideas.
I am not suggesting that they are in dispute with one another, just selectively citing them to make a broader point.
Professor Harwood, reflecting on the pandemic response and older people urged us to “Stop Demonising Hospital Care” which was “Neither futile, nor intolerably burdensome”. Professor Harwood has argued elsewhere that we should not passively accept that hospitals are unsuitable environments for acutely ill elders which will routinely harm them, but ensure that they are fit for purpose.
Dr O’Riordan, writing on the need for more integrated services and joined-up working across all sectors in any locality, majored on the work to support more older people outside hospital and argued that during the pandemic, “the risk to advantage ratio of admission to hospital will be more towards staying at home” with an imperative to provide “more care based at home”
My view is that they are both right. The views are perfectly compatible and each has done great deeds in improving care for older people with frailty within acute hospitals community services.
I just want to caution against polarising schism in our multidisciplinary speciality which pits advocates for prevention, community primary care and care homes versus acute or elective hospital care. We need them all and have value to add in every one of them and not a “hospital bad, community good” or vice versa narrative.
You might think this is a straw man that doesn’t need slaying. But I have been around geriatric medicine and all the commentary and social media surrounding it long enough to see a pattern. There are plenty of people prepared to label hospital admission as inevitably a bad thing for older people, never what they want or need and even to argue that geriatricians and our teams need to be moved out of hospital or spend far less time working there.
Others still feel we are sending too many frail older people home too soon with inadequate rehabilitation or follow-up. They argue that plenty of older people and their families do value admission especially when the same level of treatment cannot be provided locally in community settings. And they feel that the relentless focus on patient flow, “fit for discharge” and “everyone prefers to be at home” prevents best practice, is driven by overfull hospitals with too few beds and regards older inpatients as an inconvenience rather than the hospitals’ core customers. The recent mass transfer of inpatients with possible Covid-19 to Care Homes has confirmed that view in some eyes.
It is worth reflecting on our speciality’s history in the UK. Our origins in the 1940s were in long stay care in old Poor Law infirmaries (where the inpatients would most closely resemble today’s care home residents), with day hospitals, domiciliary visits and early ortho-geriatrics following. By the 1970s the speciality was still relatively small, despite some high profile big-hitting leaders.
A Royal College of Physicians working party in the 1970s advised that to be most effective, geriatrics needed “access to the full facilities of the general hospital” so that older people could have parity of access to acute care and its investigations and interventions, and also that geriatricians could practice in the mainstream.
In 2020, we are just behind Cardiology as the second largest Internal Medicine Speciality in the UK. At nearly 4,000-strong, the BGS is the largest speciality medical society. Much of this is precisely because our geriatricians are nearly all dually trained in Internal Medicine; we contribute at registrar and consultant level to a substantial amount of the acute medical take and inpatient care. Being indispensable and credible acute end medics has done us no harm.
Colleagues in other nations are constantly surprised at how numerous and embedded we are in the UK. In many systems, geriatricians remain marginalised and working in niche areas defined by others and have relatively little traction in acute hospitals.
In a second blog following from this one, I want to discuss the diverse range of roles we now play in the UK, the settings we play them in and why there really is no need to pit community against hospital roles.