Move Aside, Geriatrician!

Keith Miller is a GP in Leeds and a member of Leeds West Clinical Commissioning Group. He tweets at @keester76shutterstock_98521136

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.

10 thoughts on “Move Aside, Geriatrician!

  1. May I suggest the RCP Diploma in Geriatric medicine ( Good care for older people is not the sole right of a geriatrician, but certainly the time provided to deliver effective comprehensive geriatric assessment through employment in the role of ‘a geriatrician’ provides a head start. Maybe considering as a registrar I have a designed 45-60 minutes with an older person in clinic can make a big difference to the 7-10mins afforded in most GP practices, without comparing training level. I would agree entirely that GPs have the skills and competence to look after older people but time for good CGA is vital.

  2. Keith, despite the provocative headline I have a lot of sympathy with your argument and am supportive of the idea of GPs with training in geriatric medicine and a special interest value-adding to the service. My concern is not so much people like you who have the passion, the skills and the commitment to look after older people with complex needs. It is more (See excellent articles in BMJ this year by Martin Roland, Jean Haggerty, Dee Mangin – all primary care experts) that current mainstream general practice and system incentives are organised around short consultations, single disease thinking and QOF points. There is overwhelming evidence that common conditions affecting older people such as falls, incontinence, osteoporosis, falls, osteoarthritis, frailty etc get much worse quality of care than conditions which appear in the QOF, that older people receive worse care for than younger people for the same conditions. Also that the model incentivises harmful over-prescribing driven by single disease thinking (e.g. antihypertentives that make older people fall over) and doesn’t incentivise rationalisation of treatment (for instance there is a QOF for medication review but it doesn’t seem to stop polypharmacy). The BGS report “failing the frail” has identified serious gaps in GMS services delivered to care home residents – who are all on GPs’ lists and therefore GPs have a contractual obligation to deliver equitable care to them without a LES a DES or a QOF. And the National Audit of Intermediate Care has identified a huge amount of (unacceptable) variation in the primary care contribution to care outside hospital. Finally, commissioners have often negotiate block contracts with providers of community health services which have inadequate performance spec and inadequate specialist involvement. In short, we need more people with your enthusiasm and skill and passion and geriatricians can never care for all older people with complex needs – we are only a few hundred whereas Gps are nearly half of all registered doctors. However, primary care needs to change its offer to meet the needs of people with several things wrong with them at once and we need a radical rethink of pay for performance incentives and primary care led commissioning of integrated services

    David Oliver

    • Hi Dr. David Oliver,

      As you know here in Edmonton , Alberta we are evolving a model of cooperation with Care of Elderly FM and Geriatric Medicine while moving towards a Alternative Relationship Payment Plan for Specialized Geriatric Services . This will enable Specialized physicians to consult on the complex frail elderly in the continuum ( community, Continuing Care , Restorative/ Rehabilitation and Acute Care) .

      Professor Dr . Jean Triscott

  3. David and Philip, thank you for your thoughts. The title was deliberately provocative in the hope of encouraging people to read it, and to stimulate debate. I entirely agree with your arguments about the time and space dedicated to older people within general practice, and the lack of incentivisation of proactive and comprehensive care within QOF. I hope this will change over the coming months and years. In Leeds, we are exploring a number of initiatives around freeing up GP time (perhaps within Federations/associations of practices) to offer such direction, which would be over and above the skewed and narrow focus of the GMS contract. This would most likely be done within a framework of regular MDT meetings (including GPs, geriatricians, therapists, pharmacists, nursing and social care, mental health profs), with regular care input from integrated health and social care teams. I do feel this is an opportunity for primary/community care to re-shape the way it delivers complex care and review. The blog had to be kept to a limited number of words, so I did not have sufficient space to discuss the systemisation of GPwSI role to provide this care, but this is certainly something I think could be more formally developed (I do enjoy being and will continue to be a GP, but I would love to spend more time proactively reviewing my frail and elderly patients than our current system in primary care allows).

    • Interesting, “Geriatrician” only seems to come with emotional baggage in English. Colleagues in most other countries don’t have issues with the word – their patients don’t have an issue either. Geriatrics comes from the greek for old man “geri” and healer “iatros”. It was coined in the early 20th century by Ignaz Nascher in the US but geriatric medicine comes from when Marjory Warren started working at the West Middlesex Hospital in the 1930s with frail older people who had been neglected and rejected by society. By adopting a methodical, multidomain approach she showed that many could be helped to enjoy better lives and that they should not be left to die in hospital. So, although the word might sound harsh, the specialty has done much to pioneer the development of adequate services for frail older people over the last 80 years. Geriatricians, are understandably, reluctant to abandon such a proud history – even if the word, in English, comes with unfortunate connotations which themselves are largely driven by societal ageism.

  4. I have to confess, I didn’t choose the title with any nod to negative connotations of care of the elderly nomenclature. It was chosen to be slightly provocative to encourage people to read the blog and to stimulate debate. At the root of this blog is a recognition that there are increasing pressures on the medical workforce, which needs to be re-imagined in order to meet the expectation of our ageing population. I am more than happy to be a GP, but I would like to spend more time with (and feel more up-skilled to deal with) complex patients with multiple co-morbidities, be it as a GPwSI (as a more formalised role) or a community geriatrician (if it’s ok to use that word!?)

  5. Hi Keith, I realise you posted this some time back but I just came across it today whilst googling “GP spcieal interest geriatrics”. I agree that training needs to change, in the Netherlands you can train as a community geriatrician or nursing home doctor – training covers geriatric medicine in a community setting, old age psych and palliative care – how brilliant? In the States many “community geriatricians” are actually family physicians with a special interest in geriatrics/elderly medicine. The London offers a “bolt-on” ST4 year working with a MDT led by a geriatrician in a hospital setting, I am considering this (I am currently ST3 GPVTS) but have already done a year long OOPE in India during ST2 and ST3 and I am keen to be done with all the eportfolio box ticking so I might look into arranging a similar post independently. I hope to also to the dimploma in geriatric medicine later this year. I would love to do either the masters in gerontology at Kings College, there is also a masters in Advanced Dementia care….I also have an interest in art therapy and volunteer to paint with the elderly in nursing home settings. Anyway I would really love to chat about this further with other GPs apssionate about the care of the elderly. I have recently joined the BGS and will be at the Spring Conference next month. Hope to see some GPs there. Katherine

    • Hi Katherine, I have only just seen your post and it is good to hear of your ambitions. I am sure there are a lot of GPs who are interested and equipped to carry out this intermediately-specialist (!) level of work, but not all GPs are. We are looking at ways to expand this in Leeds West (our CCG) to develop, support and appraise the role of a GPSI. I hope your own ambitions to develop your interest are working out. I was unable to attend the conference last year, but will attend the community geriatrics conference in Oct. Regards, Keith

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