Working Together Across the Great Healthcare Divide
It’s traditional to start any piece of writing on older people with frailty with a reminder that there are a lot of them, and that there will be a lot more of them in the future. This will not come as a surprise to frequenters of the British Geriatrics Society website. Nor will it be a surprise that the chance of a proportionate rise in the number of specialists in Geriatric Medicine seems vanishingly small. In years to come, the majority of people with frailty will not be looked after by people with the G word in their job title.
But were they ever? In terms of the raw number of clinical interactions, a substantial majority of the work of the NHS happens in primary care. And while Geriatricians have a very good track record in providing sophisticated support for colleagues in secondary care, perhaps we’ve been slower off the mark with models supporting our primary care colleagues.
At a recent (well, recent-ish) meeting of the Scottish branch of the BGS in Aberdeen, we held a session showcasing various models of care that are improving the care of older people with frailty across the north and east of Scotland. The details of these models vary but the key thing that ties them together is that they involve GPs and Geriatricians actually working together as colleagues to try to make things better. Sounds strange, I know, but bear with me.
A key component of many of the strategies presented (by us in Grampian and our colleagues in Tayside) was a link between each GP practice and a named Geriatrician. The linked Geriatrician deals with all “geriatrics” outpatient activity for their practices (and in Tayside much of the inpatient work, too). This has naturally led to Geriatricians visiting practices and speaking to the GPs to discuss ways to capitalise on that relationship. The result varies from practice to practice (which is kind of the point), but it frequently involves regular face-to-face meetings for clinical discussions, for example for proactive discussion of people living in care homes or involvement of the Geriatrics team in practice multidisciplinary team meetings, and development of models to address polypharmacy.
These regular meetings are great. They provide a way for “low level” issues to be discussed and headed off without the rigmarole of a formal referral and, in our experience, reduce the number of people who need to come to the outpatient department and even (whisper it) to hospital. But the main benefit is having a chat over a cup of tea and a chocolate hobnob and building a relationship with our colleagues. Once you’ve had a chat with someone about holidays, or the bypass, or Bake Off; and once you’ve seen their real, human reaction to the terrible difficulties that people with frailty sometimes face; it’s very hard not to want to help them when they ask for help, or to react with stress-induced brusqueness if they bleep you during a ward round. And I think it works the other way, with us asking our GP colleagues to stretch themselves even further to help us honour a person’s wish to stay at home, or in dealing with the poorly worded request on a discharge letter from our department with good grace.
So, is what I’m suggesting simply that we should be reaching out across the Great Healthcare Divide to speak with our colleagues? Well, I am suggesting that but I’m suggesting more than that. I think that we should be designing systems that encourage, even necessitate, this sort of working. I believe that this building of mutual trust improves care for the people we look after. I know that it improves the working environment for me as a Community Geriatrician. And I hope that it makes things easier for my GP colleagues, and for the wider primary care team. I think that this model of service provision is the future of geriatric medicine and I would enthusiastically encourage colleagues across the country to adopt it.