Eva Kalmus has been working as Interface Medicine GP at Epsom and St Helier NHS Trust since February 2015 and previously looked after inpatient beds at New Epsom and Ewell Community Hospital. She was also a community ward GP in Wandsworth and virtual ward lead in Epsom. Currently her work is focussed on discharging patients for whom the acute hospital no longer offers net benefit as quickly and efficiently as possible and improving communication, aiming for primary, community and social services to pick up where secondary care stops. She will be speaking at the upcoming BGS Autumn Meeting in London.
“Interface medicine” has a number of definitions in different contexts—it seemed an appropriate title to describe primary care-trained doctors working in community or hospital settings whose aim is to maximise quality of life for older frail patients using skills and knowledge from both general practice and geriatric medicine.
On one side are Interface Medicine GPs now titled GeriGPs within BGS; on the other are Community Geriatricians but there is significant overlap in what we do. Working together we can best support our patients—and it is a very satisfying extension to our core business.
However, there are some cultural differences between primary and secondary care. Much has already been said about the Gosport War Memorial Hospital report and some of the facts are not yet clear. When discussing it immediately following publication, I was asked questions by hospital colleagues who knew I had worked in a community hospital asking whether there is not usually a clinical team able to critically review what was happening in such a setting
As GPs, we are accustomed to making clinical decisions with only the patient and maybe their family. This is gradually changing with the development of community teams, but still many decisions within consultations are not “supervised” or shared. Meanwhile, NHS consultants have junior doctors and ward staff who should feel able to challenge actions.
Another example of a different culture is hospital doctors at all levels prescribing for inpatients from the “safety” of a computer in the doctors’ office. This amazes me as a GP, because if I want a patient to take a new medication, it is probably best to address their concerns and explain risks and benefits to them or they won’t even collect the prescription from the pharmacy, let alone actually use it!
Then there is the concept of “frailty”. Much of the research has been done in acute frailty showing the benefits of offering a multidisciplinary Comprehensive Geriatric Assessment followed by implementing a care plan in line with the patients’ priorities and best interests. This is core geriatric business and has an evidence base in terms of most important outcomes including mortality.
GPs were incentivised through QOF to compile a register of patients based on the Electronic Frailty Index. Those identified as moderately or severely frail needed a falls assessment and medication review. Some GPs did not undertake this work with much enthusiasm or conviction about its benefits.
Maybe this could have been approached differently: GPs frequently see patients with “multi-morbidity” with which “frailty” has some obvious overlap. They recognise patients with reduced physiological reserve and, from experience, know likely outcomes for the patients they instinctively identify as frail, including following emergency admission to hospital.
GPs and community teams will be motivated to work pro-actively with identified frail patients if optimistic about the value of it. The additional work needs to be underpinned by a relevant evidence base, it needs to be easy to undertake and supported by appropriate resources (multi-disciplinary teams working effectively together across organisational boundaries).
The future lies with pro-active multi-disciplinary teams, including GeriGPs, acting to identify frail patients, undertake a Comprehensive Geriatric Assessment and implement its outcomes. Members of these integrated teams need to help this group of patients and those closest to them to manage inevitable exacerbations and decompensations of their long-term conditions, ideally recording plans in advance and communicating decisions across the team and between settings.
Register for the BGS Autumn Meeting, 14 -16 November 2018, ExCel London