Zoe Wyrko is a Consultant physician at University Hospital Birmingham and is the Honorary Secretary for the BGS. She tweets at @geri_baby
The Future Hospital Commission (FHC) report, like so many other recent publications, acknowledges that our hospitals are not set up to meet the needs of the majority of people who use them. Where the FHC differs, however, is that it clearly states that routine incorporation of Comprehensive Geriatric Assessment (CGA) into the care of vulnerable older people is a way to address this.
I have not yet come across a geriatrician who thinks that CGA is a ‘bad thing.’ It is what all of us do, adapted for the situations we find ourselves working in – whether in the community, in an orthogeriatrics service, or at the interface between primary and secondary care. CGA also has an advantage over ‘frailty’ in that we can actually define it. What it isn’t, though, is a checklist that can be written down and completed by any interested person. The ability to carry out CGA in the most complex of patients is a culmination of a minimum of five years of higher specialist training as a registrar in Geriatric Medicine, followed by the experience that comes with consultant practice.
So, should the initial optimism from the first read of the report (someone has finally noticed what we do, and do well) be rapidly replaced by an overwhelming sense of panic. How are we going to cope with the volume of work that could soon be foisted upon us? Is this a threat or an opportunity?
Colleagues have mentioned to me that there are marked similarities between the FHC report and the National Service Framework for older people. The document is full of good ideas, but without any financial support or incentives behind it, the recommendations will not come to fruition. I think it is worth noting however that the NHS is in a very different place now to it was just 12 years ago. The numbers of frail older people are increasing, there will be no new money for the foreseeable future, and services are at breaking point in some areas. We also now have the insidious privatisation of even essential aspects of the health service.
Services within England must now be commissioned (I acknowledge that the other parts of the UK are still ahead of NHS England on this one). Having a good idea and a willing employer is no longer enough to build an empire. I regularly hear the opinion from colleagues around the country that their local CCG do not know what they want, or have come up with some unworkable ideas that feel more like a step backwards than a stride into the future with associated benefits to patients’ care.
So … is the FHC report actually a heavy duty piece of ammunition? As Professor Knight stated in his blog on Monday the benefits of CGA are improved outcomes for the patient (less chance of dying or being institutionalised following an acute hospital admission), together with lower financial costs for the commissioners and providers associated with fewer admissions and shorter hospital stays. We have a well written, heavily backed document from an organisation other than the BGS, which ties in with agendas put forward by the Francis enquiry, CQC, the Health Ombudsman and the Kings Fund (to name a few). It states that CGA, and specialists in geriatric medicine, are the future. We need to use this document to bolster existing services and design new ones, when all around us others are having services and budgets cut. We need to tell the commissioners what they need to commission. And by keeping ourselves fully occupied, it prevents work being
British Geriatrics Society 
Thanks Zoe – I agree that the expertise of a geriatrician is required, somewhere, in the CGA process. But there is much that services can and must do to organise themselves to provide CGA in addition to employing – or deploying – a consultant geriatrician.
The key components are:
– It has five domains (medical; psychological; environmental; social; functional).
– It must therefore be populated by a multidisciplinary team with clear lines of contact and accountability.
– A single professional should co-ordinate the process so that there is a component of case management (this does not need to be a doctor).
– It is not just about assessment but establishment of a treatment plan, which should have measurable objectives (or goals), against which future management should be iterated.
Lots of services that interact with frail older people do not operate over all five domains, are not populated by a multidisciplinary team, are not coordinated by a single professional and are not iterated forward. If we could establish these processes wherever frail older people come into contact with healthcare services, we’d be a long way to meeting the stated goal of comprehensive geriatric assessment.
A geriatrician can sit in the middle of this model, or they can be called in as a consultant. They need to be in the system somewhere but they shouldn’t be seen as the be-all and end-all.
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