In the second half of her two-part blog on geriatric medicine in New Zealand, Vicky Henstridge asks: what about the doctors? Read part one here.
It is oft quoted that New Zealand is like the UK, but 30/40/50 years behind (pick your decade). In general this is not true, we do have mobile phones, the internet and microwave ovens that defrost, pluck, stuff and roast your chook. However, in the field of geriatric medicine, there are definitely parallels to the changes that occurred in the UK over my lifetime.
Geriatrics is still seen as ‘other’, a nebulous rehab-and-sort-out that occurs to patients after their medical or surgical problems have occurred, on units separate to the real world of acute care. Older patients are still referred to as suffering from acopia, though how the average 20 year old would cope with acute renal failure, severe rheumatoid arthritis and an ejection fraction of 20% I wouldn’t like to comment.
The pendulum is swinging, but there is certainly a huge degree of ignorance amongst colleagues, to whom the idea of a Geriatrician working on the front line is an anathema, and who still see age as a contraindication to intervention. These dinosaurs are a dying breed, due in part to the development of Acute Geriatrics as a sub-speciality , and also the pressure to look at evidence-based medicine in the older person. Cardiologists need to teach other cardiologists that age alone does not define outcome for intervention to the stenotic aortic valve.
This being said, with great challenges come great opportunities, and Kiwis embrace change to the benefit of individuals, communities and society as a whole. Whilst the time taken to develop a formal business case will be familiar to those practicing in the NHS, it is much easier to institute a change of practice or develop a service, providing you can do so without significant additional staffing. Stroke Units are a great example; the geography of New Zealand means that the hub-and-spoke model relies hugely on the air ambulance service and adds time to already time-dependant therapies. Thus, stroke thrombolysis is available at even the smallest hospitals, with acute stroke units available in most. This is reminiscent of cardiology services in the UK in the 1990’s when I was a house officer in a small district general hospital on the Welsh border.
This is not to say that state of the art facilities aren’t available, either at tertiary centres, or increasingly close to home. A state of the art cancer centre has just been built next to my hospital, with the aim of treating patients closer to home, and the main hospital building was designed to allow another floor to be built when demand requires, and it is hoped that this might include purpose built Acute Geriatric services. In the meantime, there is an acceptance that front-door medicine is front-door geriatrics, and there is a movement across Australia and New Zealand to develop Acute Care of the Elderly (ACE) units, providing high quality multidisciplinary care to frail older patients. Models vary, and look similar to some Frailty or ACE Units in the UK, excepting that we tend to look after patients for the whole length of their hospital stay, rather than concentrating on initial assessment or the first 48 hours. Again, this is built of necessity, but results are encouraging.
So, in conclusion, is Geriatrics in New Zealand like that in the UK 20 years ago? In terms of starting from a blank sheet and developing more acute services, then definitely Yes, there is huge scope and these are exciting times. In terms of looking at healthy aging across society, health and social care then I would humbly suggest that New Zealand is years ahead of the UK.