There’s no need for a battle of ideas between hospital and community geriatrics. We need more of both. [Part 2]
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.
Earlier this week I wrote about ongoing and sometimes over-polarised debates within British geriatric medicine, BGS membership, and government policy around community versus acute hospital care for older people with frailty who require skilled assessment and treatment.
I want to follow this by exploring the range of our current contribution.
We have helped transform care for older people with fractures and there is now a parallel movement for older people undergoing surgery. We have been a driving force in improving care, safety, and quality for acutely ill patients with dementia, delirium, falls, and frailty and embedding good practice in post-acute rehabilitation and discharge planning.
In the UK, people trained in geriatrics have driven most of the developments in stroke services and still deliver most of the care.
We have advocated for fair and tailored access to palliative care for inpatients, have provided rapid ambulatory outpatient assessment and often led clinical services for groups (for instance older patients with Parkinson’s Disease) who need more frailty-friendly offers as they age.
Additionally, via initiatives such as the Silver Book on Urgent Care, the Scottish Older People in Acute Care collaborative and the Acute Frailty Clinical Network, and our presence in local services, we have made great strides in ensuring that older people can have early specialist comprehensive geriatric assessment at the hospital front door with access to early community support. Many physicians working in Acute Internal Medicine have geriatrics backgrounds. This is all the epitome of a role at the hospital/community interface.
Meanwhile, for several years now, we have been the organisation leading the campaign to improve healthcare for care home residents, publishing a whole suite of good practice resources, influencing NHS England Priorities in 5 and 10-year plans and leading local care home support services in many parts of the UK.
We have had similar involvement in a range of intermediate care and community service models, from Hospital at Home, to “discharge to assess” to community rehabilitation teams and work within community hospitals and in ambulatory care. These models deliver care closer to home and support assessments within people’s homes. We have made the running at national level with BGS and NHS England campaigns and resources around identifying and supporting people with frailty living at home.
We have campaigned relentlessly to highlight and combat age-based discrimination in services whilst at the same time wanting services to be age-attuned. And we have repeatedly pushed for a meaningful long-term social care solution that does not leave older people and their families at the mercy of a disjointed and confusing system at a time of crisis.
In a way, all this has helped us reclaim our original routes. Increasingly, we have been involved – just as Dr O’Riordan suggests in her blog – in leading community-wide planning and using our expertise to inform population health approaches.
The BGS itself has now diversified its membership since I first joined in 1993, to reflect the multidisciplinary nature of comprehensive geriatric assessment and the team-based nature of our discipline. Our members who come from other medical specialities, notably GPs, nurses, allied health professionals, pharmacists, and social care professionals have added greatly to the Society’s work and are especially prominent in the thriving community geriatrics and GeriGPs groups, and of course the Nurses and AHPs Council.
As for any Community v Hospital battle of ideology: there is no need.
If we pulled our expertise out of acute hospitals – where the published evidence base for our skills is still strongest, we would leave many older people with frailty, multimorbidity, functional or cognitive impairment looked after by non-specialists, with no-one to help drive up standards and awareness in the acute care setting. And we would miss the chance to assess more people early in their presentation and try to facilitate their discharge back home. This is the situation in many nations who don’t have our numbers of geriatricians or footprint in acute care.
You might say that if we shifted our emphasis to prevention or community services then no-one would need hospital admission. Yet, some people’s illness or injury is so severe that hospital is the only or best option. Many parts of the country lack anything like the capacity required to prevent most admissions. In fact, around 80% of admissions in over 75s involve people not referred by their GP because, in crisis, people will still come to hospital.
The evidence for the prevention of large numbers of admissions and reductions of hospital activity via community models and interventions remains patchy – although hospital at home and enhanced healthcare support for care homes do seem to deliver on this.
At the same time, we know older people value intermediate care and community support which enables them to return home or remain there or die there with palliation. We know there is a huge amount of unmet need in care home residents (who outnumber hospital inpatients 3 to 1). We know that there is growing interest in integrated primary care models, calling on the expertise of secondary care trained specialists, and in home-based crisis responses.
For all this, there are only around 1650 geriatricians in the UK with perhaps one in four having substantive or partial community roles1 compared to over 40,000 GPs.
There are not enough of us to see all or most older people with frailty to a degree that can make a difference at population level, rather than providing excellent services for the people we can and do get to.
We can make a good fist of seeing most or many of the older people presenting with acute illness or injury to hospital and using our lengthy internal medical training and presence in the hospital.
We can be the specialists in community and primary care providing expert leadership, clinical expertise and advice to much broader multidisciplinary teams supporting care homes, intermediate care, crisis response, ambulatory care, and early supported discharge. And we can help to shape wider public health and prevention and more integrated working across organisational boundaries.
There is more than enough work to go around. There are not enough of us and the multidisciplinary teams we work in to do all of It, though we should campaign for further workforce expansion to meet the needs of an ageing population.
Our presence can benefit patients in all settings wherever they turn up and also older people who are not yet patients. There is a broad range of leanings within our speciality to accommodate those with an acute generalist, acute subspecialist, primary or community interest and skills and sometimes move between them over a long consultant career.
There is no need for an intra-speciality culture war over any of this.
1 There is no conclusive workforce data at this time therefore this is an educated guess.