Keith Miller is a GP in Leeds and a member of Leeds West Clinical Commissioning Group. He tweets at @keester76
We all know we have an ageing population. We stare with trepidation at the impending challenges of the ageing baby-boom generation, and the increasing numbers of people living with multiple long-term conditions. We also know that the NHS is developing through a time of unprecedented change, and the financial efficiencies it must realise require fundamental reorganisation of the way we have come to deliver services to our populations. Primary and community care are the answer.
I’m a GP. I’d actually like to be a Geriatrician. Were it not for MTAS, I probably would be. GP jobs were offered first, and I jumped in fear of impending unemployment. But being a GP has left me in no doubt that the way we provide care for the elderly in our communities and hospitals is not perfect. You know the drill: octogenarian slowly declines in the community; undergoes a number of reviews in primary care; hits crisis; is admitted to hospital; is successfully assessed and treated; sits in acute hospital waiting (enter prolonged length of stay here) for appropriate community care packages to be implemented. Often inefficient, and sometimes actually detrimental to optimal health, the way we provide care needs to change.
As part of work I do for the local CCG, I have been involved with innovations such as the expansion of the Interface Geriatrician (IG) resource within the city. The IGs provide geriatric expertise at the acute interface, working in A+E and with the primary care access line. In addition, they work closely with integrated health and social care teams in the community, and engage with groups of GP practices, providing proactive care for people identified as being at high risk of hospital admission. Anecdotally, this is showing a lot of promise. Geriatrician expertise needs to be brought into primary care.
Believe it or not, GPs don’t always receive a good press. We are specialists in primary care. We can do a lot of things better than we currently do. I want to spend more time proactively managing my most complex patients, who are often elderly and require regular review and high levels of care. I am well placed to bring my primary care focus to elderly patients in the community. I think I would make a very good community-based geriatrician, if an acceptable career path allowed me to do it. I don’t want my primary care expertise to be ignored, and I wouldn’t expect to have to start again at CT1. Were I to retrain as a geriatrician, why would my daily experience of managing elderly patients in care homes and the community, working with multi-disciplinary teams to deliver care, count for no more than foundation training?
Don’t get me wrong, I know I lack sufficient core medical training to competently bear the responsibility of acute hospital placements – but I don’t want to work in hospitals. Why do my 4.5 years in general practice, as well as 18 months post-foundation training in A+E, elderly medicine and psychiatry, count for nothing? Ought there not to be an alternative training pathway in geriatric medicine that allows community practitioners to retrain as community geriatricians without starting all over again at CT1? In the spirit of integration, can there be no expansion of tailored training schemes for specialist generalists with community-focussed expertise? Move aside, Geriatrician, I want your job – and I’d like you to redesign training in geriatric medicine for me to attain it.