Deadline approaching for ACCEA awards

BGS Logo CMYKMark Stewart is Committees Manager at the British Geriatrics Society.

Each year, the BGS supports applications from its members for the annual Advisory Committee on Clinical Excellence Awards (ACCEA), which recognise and reward NHS consultants and academic GPs who perform ‘over and above’ the standard expected of their role, acknowledging personal contributions.

I’m writing to advise those of you planning to apply for the 2015 ACCEA that the deadline for seeking the support of the BGS is 5pm on Friday 8 May 2015.

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Coalition, co-production and collaboration

C4CCEd Gillett is the Communications & PR Manager for the British Geriatrics Society. In this blog he introduces the work of the Coalition for Collaborative Care

As the current coalition Government goes into pre-election purdah (you should read our BGS policy paper on the general election, if you haven’t already), another very different coalition is just beginning to spread its wings. This is the Coalition for Collaborative Care, which now boasts the BGS as a partner organisation alongside ADASS, National Voices, NHS England, the Royal Colleges and many others.

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Health & social care costs: big data, or huge problem?

UntitledRachel Elliott and Matthew Franklin are reporting on behalf of the Medical Crises in Older People (MCOP) research team. Read the first part of their blog on identifying health & social costs here.

As part of a programme developing and evaluating care in older people, our recent study in Age and Ageing reports health and social care costs over a three month period for older people discharged from Acute Medical Units (AMU) by applying unit costs to patient-level data obtained from six different agencies: hospitals, primary care, social care, mental healthcare, ambulance services, and intermediate care. This is the first study to do this in England, but obtaining resource use data from individual services for this analysis took months, which was costly and of no use for real time patient management.

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The week in Leicester

3473317431_1aefd602bf_oTom Dening is a Professor of Dementia Research at the Institute of Mental Health, University of Nottingham.

Leicester is at the centre of England but not always at the centre of events. However, it’s had a great few weeks recently. For those of us interested in ageing, end of life and so forth, it’s had double cause to celebrate. King Richard obviously, but also it’s been the last week of a 6-week national tour of the play Inside Out of Mind, which ended its run at the magnificent Curve Theatre.

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How we built a Geriatric Service in the ‘largest hospital in Europe’

137130702_e8290e0c4c_oCaroline Whitton is a Geriatrician working in NHS Greater Glasgow and Clyde currently based in the Victoria Infirmary, Glasgow which is soon to be subsumed into the South Glasgow University Hospital. She has several educational roles which include Foundation Programme Director, Consortium Lead for NHS Education Scotland and Associate Director of Medical Education for NHS Greater Glasgow and Clyde.

For me, the adventure began when I was asked to deputise for my Clinical Director at a meeting to discuss junior doctor staffing of a new admissions unit. The meeting was hosted by the medical directorate, and I was the lone geriatric voice amongst a cast of many. From that meeting began a process that has, for the time being, taken over my professional life! Do I regret my initial impulse to go along? No – because it initiated a journey which has enabled me to be involved with the design of a completely new service. It has made it possible for me to influence the way in which I provide care to my patients and deliver training to my junior colleagues.

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Identifying health and social care costs for older people

queueRachel Elliott and Matthew Franklin are reporting on behalf of the Medical Crises in Older People (MCOP) research team at the University of Nottingham.

As part of a programme developing and evaluating care in older people, our team wanted to know the distribution of health and social care costs of older adults discharged from Acute Medical Units (AMU) in England across six care services (primary care, hospitals, intermediate care, mental healthcare, social care, and the ambulance service). This is the first study to do this in England.

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Open visiting: one year on

5157747099_6f301964c6_oLast year as part of my MSc. Module I planned and implemented a scheme to introduce open visiting in my Trust. The Trust  agreed to pilot it as flexible visiting in its older people’s wards and we launched a new Visitors’ Code

The scheme was partly a response to evidence of  Delirium prevention and Dementia care, but also to patient-driven campaigns such as John’s campaign ; a post Francis  response to incorporate PPI, and to settle the demons from my own personal and professional experiences over the years. One year on it is proving successful with positive feedback from patients, visitors and staff. Relatives have told me with relief what a difference it makes with many positive examples such as some families saving money by using cheaper public transport from remote villages instead of expensive taxis.

However, I see that some staff remain resistant to open visiting and wonder where such entrenched ideas originate. The lack of a supportive ward infrastructure was always a problem, but not insurmountable. Historically, hospital wards were of a Nightingale design, long wards with rows of beds with the nurses’ station at the head to facilitate maximum surveillance with minimum staff. I suspect the idea originated from Bentham’s 18th century Panopticon or ‘inspection house’ and was an effective means of control. Foucault took the idea further, using the metaphor for modern day surveillance which led me to wonder if the real reason for the rejection of open visiting and PPI is because it dilutes the power base and hinders the ‘medical gaze’ so cleverly constructed by not only architects but also healthcare professionals?

The tables appear to be turning with the public now, quite rightly, staring right back and old hospitals demolished with modern structures to replace them. But are we merely replacing one form of surveillance with another and entering a postmodern dystopian Orwellian nightmare?   Sanitised social quarantine is in danger of being replaced from the structural to the cerebral, from a panopticon to an oubliette, and has no place in care of older people with cognitive impairment. Coupled with sensory deprivation from necessary infection prevention measures and the omnipresent cultural hegemony in whatever era we find ourselves in, partnership working is a humanistic way to resist toxic organisational cultures and must be welcomed and embraced to promote excellence in the care of older people.

Liz Charalambous

Photo credit: Memphis CVB via flickr

Book review: Manual of Nutritional Therapeutics

$_58Margot Gosney is Professor of Elderly Care Medicine at the University of Reading and Consultant Physician at the Royal Berkshire NHS Foundation Trust. Here she reviews the Manual of Nutritional Therapeutics.

The 6th edition of this very detailed book has just been published: the fact that it has continued to be relevant and required reading since its first publication in 1983 indicates its usefulness. The American editors have gone out of their way to cover subjects not only in great detail, but also to provide very relevant and up to date references to support the chapters.

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Dropping the drugs: Who? What? Why?

UntitledDanielle Ní Chróinín is a geriatrician at St. Vincent’s Hospital, Sydney, who has a keen interest in research, education, and anything related to geriatric medicine. Her paper on deprescribing is published in the latest edition of Age and Ageing and can be accessed online now.

Mr. T. is an 85 year-old man who has been attending your Geriatric Clinic for the last couple of years. He has a background of hypertension, ischaemic heart disease, osteoarthitis of his knees, and constipation. He now has moderate dementia, with a progressively worsening Mini-Mental State Examination score, 17/30 today. His wife, with whom he lives, has taken over the shopping and financial duties.

Blood pressure is up, once again, at clinic today. His current medications include aspirin, a statin, a calcium channel blocker, an ACE inhibitor, laxatives, donepezil, paracetamol and tramadol. If you shook him, he just might rattle…

Polypharmacy is ridiculously prevalent- 42% of over-50s in Australia are taking five or more medications; terms such as ‘hyperpolypharmacy’ (≥10 drugs), have been coined, in an attempt to stratify polydrug recipients in the context of a multiple-medications epidemic.

So, would you stop any of Mr. T.’s drugs? Which ones? Why?

Immediately, or when he becomes frailer, more demented, more dependent, or when his life-expectancy has dropped to months? The evidence base for making these types of decisions is limited. And individual doctor (de)prescribing practices vary widely. In a survey of Antipodean physicians specialising in the care of older patients, we sought to explore the factors which influence our decisions to ‘stop the drugs’.

A hundred-and-thirty-four busy physicians kindly lay down their prescribing pens to answer our survey. Given a list of factors which might influence their deprescribing practices, these doctors most commonly rated limited life expectancy (96.2%) and cognitive impairment (84.1%) as very/extremely important to deprescribing practices. Interestingly, the age and gender of the doctor appeared to influence  the answers supplied. Older respondents less commonly rated functional dependency and limited life expectancy important when deprescribing. On the other hand, female participants, and trainees, more often rated adherence to evidence-based guidelines important.

Confronted with a series of five case vignettes, physicians were more likely to stop many of the listed medications as the case described a patient with increasing dependency and cognitive impairment.

So we asked: “Why are you stopping these medications?” The answers commonly centred on two central themes- dementia severity and pill burden. So it’s comforting to think that if I ever develop bad Alzheimer’s disease, one of these doctors might take a look at my medication list, and strike off a couple of tablets, so that I can enjoy an ice-cream unencumbered by hidden pills. Or that if I ever end up the victim of half-a-dozen different evidence-based guidelines, a sympathetic medic might kindly prioritise the top six or seven pharmaceuticals I really need.

But the fact is that the ‘right time’, the ‘right medications’ and the ‘right deprescriptions’ for frailer older persons aren’t always so clear. Such patients are most often notable for their absence from randomised trials. But a dramatic red pen-slash, crossing off the whole shebang, may not be appropriate outside of an end-of-life scenario. Our geriatric cohort can be the victims of missed treatment opportunities, and not just over-medication. Studies continue to evolve, assessing the benefit and harms of prescribing- and deprescribing- in such patients. In the interim, I admit I mostly rely on the good habit that my first bosses drummed into me: review the meds list regularly, and look at the whole person and not just the diagnosis list. It’s likely Mr. T. will thank you for it.

BGS Spring Meeting

4451736917_75a0098a01_oTom Dening is a Professor of Dementia Research at the Institute of Mental Health, University of Nottingham. 

Spring in Nottingham! What could be finer? Little spring flowers bursting out all over University Park, Nottingham Forest on the verge of play-off contention, the ice floes beginning to break up on the Trent, students shedding their furry parkas and starting to sit on the grass….

And what better way to spend your time than to check into to the East Midlands Conference Centre at the end of April for the BGS Spring Meeting? Even better, stay at the eco-friendly Orchard Hotel next door and barely have to move for 3 days. The programme has been finalised, and booking is in full swing! I’ve even forgiven them for spelling my name wrong in the advertising booklet.

I have been (peripherally) involved in the organisation of this event, which has been led by my colleague Rowan Harwood form Nottingham and the BGS events team; it’s the first time I have worked with the BGS on something of this kind. The planning for the event started about 2 years ago, so clearly a lot of time and thought has gone into the final agenda. The programme has got something for everyone and most people will probably be interested in quite a lot of the sessions. I’m of course pleased to see that there’s a whole day for the Dementia Special Interest Group but also a session on the first morning of the main conference about aggression, with three top class psychiatrists/psychologists.

My own contribution is to co-facilitate a workshop on The Geriatrician as Manager, with Stephen Fowlie, who is the Medical Director of Nottingham University Hospitals NHS Trust. He’s the real deal, being a current MD (as opposed to being an ex, in my case) and a real geriatrician (as opposed to a psycho-, as in my case). Why have we suggested this session, and what relevance has it alongside topics like falls, respiratory disease, infections and so on?

Everyone probably has their own thoughts on doctors and management, but in many ways management and clinical medicine are inseparable. In almost every case, it’s not just us doctors dealing with individual patients and their families. There are hosts of other people, especially in the typical geriatric medicine scenario of multiple complex morbidity, where the outcomes are damage limitation or end of life care, rather than cure and restitution of full function. Some of these others are members of your own clinical team, but many of them are not. They include the support staff in the hospital, for example cleaners, caterers and porters, but also (obviously indirectly!) the finance team and ultimately the Trust Board. These latter folk help to determine the success of the hospital, dealing with commissioners, regulators, the media and the public, and these things in turn influence what your hospital is like to work in.

The job of the doctor starts with assessing and treating patients as they are admitted, and extends beyond this into the relationship that they have with their clinical team. But it goes further: what we do at the coal face gets translated into the data supplying both the people who buy our services (commissioners) and those who oversee them (regulators, the CQC in particular). There is no clear cut-off point dividing our clinical activity and these other processes. Some doctors relish the complexity and the challenge of dealing with hospital systems: they may  for example show an aptitude for the politics, or they may see engaging with management tasks as a potent way to get things done. It is this area that Stephen and I will be looking to explore in our workshop, and we look forward to meeting you in Nottingham

Photo credit: 3dpete via flickr.