Amit Arora is a consultant physician in care of older people and Chair of the England Council of the BGS.
The Francis report, Bruce Keogh’s mortality review, the winter beds crisis, A/E crisis and Future Hospitals commission report from the Royal College of Physicians and some statements from the Hon Health Secretary have a common theme- Care of Older people. It comes as no surprise that finally the realization seems to have come that care of older people can be improved and though expensive, it is worthwhile.
The Future Hospitals Commission report from the Royal College of Physicians was discussed in detail on this blog last month. The report has recommended that there will be consultant presence on wards over 7 days and patients will spend their time in hospital under care of a single consultant. It also recommends that acutely ill patients in hospital should have the same access to medical care on the weekend as on a weekday. It also mentions that health and social care services in the community will be organized and integrated to enable patients to move out of the hospital on the day they no longer require an acute hospital bed. Hospital procedures for transferring patient care to a new setting will operate on a seven day basis with 7 day support from services in the community.
The Academy of Royal Colleges is currently preparing a report and has taken input from a wide range of specialities including geriatric medicine. This report’s origins come from concerns around higher mortality during weekends. It has been widely suggested that consultant delivered care enhances patient safety. Although the report has not yet been published it is likely to include recommendations on seven day working for consultants in most medical specialties including general medicine, acute medicine and geriatric medicine.
This report from the Academy of the Medical Royal Colleges has the potential to improve if not transform the care of older people. Older people have the potential to suddenly deteriorate largely due to frailty and low physiological reserves and once ill they take much longer to recover. What is also well known is that in medicine clinical experience counts! It therefore makes sense that all medical patients in the hospitals especially patients over the age of 65 years should be reviewed daily by senior and experienced doctors unless specified otherwise. However, One of the biggest challenges we face a s a specialty is a small geriatrician work force amidst an ageing population and increasing demands on our precious little time.
It is possible that for the purpose of this report, the term ‘consultant’ does not necessarily mean that the doctor is a holder of a consultant contract in employment terms but a doctor who is considered to be skilled and knowledgeable enough to be able to conduct a safe review of patient. This could mean senior trainees nearing CCT, staff grade equivalent doctors, and specialty doctors etc. .
UK data suggests that about 50% patients in hospitals are under the care of general physicians, geriatricians or acute physicians and these specialties largely share somewhat similar training. Whether there is any merit in providing some kind of cross working with development of skill mix is plausible.
This report will hopefully also identify the need for time and resources required for daily review of these medical inpatients. The resources required to deliver this cannot be under-estimated in an already stretched system. It requires support from managers, occupational therapists, physiotherapists, discharge co-ordinators, social care not to mention support from the nursing staff and junior medical staff.. Radiology departments, Endoscopy services and theatres would also need to be running full lists. A political and monetary will is probably paramount as weekends constitute “Out-of-hours” work in contractual terms.
Another challenge is to ensure speedy transfer back to a care home on a weekend. The value of local and national leadership amongst health and social care cannot be under-estimated here. This will remain a challenge as most care homes are privately owned and seem to be under pressure anyway.
The present short supply of geriatricians may mean they will need to innovate and use more efficient working systems perhaps by more delegation, skill mix, resourcing more trainees, adopting newer ways of working and possibly in reach and outreaching into community services. This poses several challenges- Will they need to act as senior consultants supported by a lot more junior staff than currently? Or will they crumble under the immense work load? Can they achieve this via increased local funding or is this something we need to look at nationally? There is no doubt it is not going to be easy, how hard it will be remains to be seen. Will we be able to continue to recruit to the specialty? Will some geriatricians move away to more lucrative and sunnier destinations like some have already done?
There are also on-going discussions about a new contract for GPs, junior doctors and consultants. Like it or not, seven day working is going to come in some shape or form for most doctors. It will however bring its own challenges. – watch this space, our working lives are going to change for ever; enjoy these weekends whilst you can.
British Geriatrics Society 
7 day working, if introduced properly, will be of benefit to staff and patients. No more 12 day stretches with accompanying fatigue, the ability to go to the bank and get my car serviced without having to book leave or rearrange duties, and knowing that there is appropriate responsibility for patients even when I’m not there is a good thing.
Trying to do it on a budget, however, will not work. It will lead to disenfranchisement and probable emigration..
Thanks for a thought-provoking blog. We need to contextualise the section about a “shortage of geriatricians”. In many ways recruitment to the specialty is in good health. In November 2012 there were 621 junior doctors undergoing their specialist training in geriatric medicine, working towards consultant posts, and there are more registrar posts in geriatric medicine than in any other speciality. Applications for specialist training in geriatric medicine are also up and geriatric medicine was the only acute medical speciality to see a rise in the number of applications compared to 2012.
But the NHS is making more consultant geriatrician posts than ever before – which makes us look, in some places – as if we’re in short supply.
The challenge of 7 day working is to realise that the geriatrician is but one (highly important but small) cog in the machine required to deliver seven day care which is horizontally and vertically integrated. In my hospital, we already have a 7 day consultant geriatrician presence and we staff it with minimal implications for lifestyle or job planning but when we identify patients ready for discharge we are told that integrated care, community mental health and social services are only available for routine discharges Monday-Friday, 9-5. The challenge to our local health economy is for these services to become available at a meaningful level that meet the geriatrician and hospital-based teams in the middle.
It is also important from a registrar perspective that it does not lead to a division within the consultant rank ie new/junior consultants being offered 7 day contracts whilst other consultants remain on 5 day contracts. As a final year registrar, I do not mind working out of hours/nights/weekends as a consultant, but it is also fair that this must be adequately remunerated and not done on the budget.