Autumn Speakers Series: “Interface medicine”

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.

The NHS England Five Year Forward View: A crucial document for our speciality, for the care of older people and for Health and Care Services in England.

David Oliver is President of the BGS, Visiting Fellow at the King’s Fund and Consultant Geriatrician at the Royal Berkshire Hospital, Reading. In part 1 of a 2-part blog, he discusses how the NHS “Five Year Forward View” is important for people involved in the care of older people.

October 23^rd 2014 is memorable to me, as it’s my 23^rd wedding anniversary. It’s also now of significance to the rest of us, as the date that NHS England’s “Five Year Forward View” plan was published. I realise not many of you will have had the time or necessarily inclination to read it, though at only 39 pages it’s an easy canter.

I also know it hasn’t attracted much Twitter activity from fellow BGS members. But it’s a document which I suspect will have far reaching influence and implications for the services we all work in. These implications seem largely positive. Let me explain why.

A new kind of geriatrician – introducing interface geriatricians

Gillian Fox, Alison Cracknell, Sadia Ismail and Eileen Burns are all Consultants in Interface Geriatrics at Leeds Teaching Hospitals NHS Trust

Leeds Teaching Hospitals has a 60 bedded general adult medical admissions unit and a 60 bedded Elderly Admissions Unit with comprehensive geriatric assessment (CGA) embedded to either facilitate discharge to community services with ongoing assessment and/or rehabilitation where needed or begin treatment and investigation before transfer to an elderly care ward.

As part of the Leeds acute care model, 2012 saw the introduction of Interface Geriatricians (IGs). This service was developed with initial funding from the PCT (later CCGs) aiming to avoid admission where appropriate. We have developed a model for working for the IG that covers 3 key areas of interface – community, PCAL (primary care access line) and the emergency department (ED).

The Future Hospital Commission: future-proof doctors need training in geriatric medicine

Dr Adam Gordon is a Consultant and Honorary Associate Professor in Medicine of Older People at Nottingham University Hospitals NHS Trust. He is Deputy Honorary Secretary of the British Geriatrics Society and also edits this blog. 

The report of the Future Hospital Commission, published last week, suggested we needed “a cadre of doctors with the knowledge and expertise necessary to diagnose, manage and coordinate continuing care for the increasing number of patients with multiple and complex conditions. This includes the expertise to manage older patients with frailty and dementia.”

The most evidence-based way to manage frail older people is Comprehensive Geriatric Assessment (CGA). CGA has consistently been shown in large meta-analyses and systematic reviews over the last 20 years to improve outcomes for older patients. These include – but are not limited to – decreased risk of cognitive decline and death, increased likelihood of functional independence and a lower probability of readmission to hospital.

Doctors don’t “do” CGA – it is delivered by a multidisciplinary team (MDT). It requires assessment across multiple domains (medical, psychological, environmental, social and functional), accompanied by case management and iteration of management plans.  The role of doctors is to provide diagnosis and prognosis, to initiate medical treatments where necessary and to do so with consideration to the broader management plan agreed with the MDT.

If doctors are to do this they need first to understand how CGA works.

2013 – The Year of Francis

When writing the history of the NHS, historians will dub 2013, “the year of Francis”. His name is invoked in the majority of lobbying documents and reports produced recently.

In the June issue of the BGS Newsletter, Professor David Oliver analyses the report: “Patients First and Foremost“, the Government’s response to the Francis recommendations.

Professor Oliver says: “As Francis himself has pointed out, many of the recommendations he made are things that we as doctors, nurses and allied professionals, whether delivering hands on care or in leadership roles, should have been getting on and doing in any case, without waiting for the Final report, or the government response. And those actions would be equally important in any of the four nations, the Irish Republic and beyond. Francis should not be seen as an “England only” issue.”

Closing acute hospital beds for older people – the way to save our services?

Prof David Oliver is a Consultant Geriatrician in Berkshire and a visiting Professor in Medicine of Older People at City University, London.  He is President Elect of the British Geriatrics Society.

At the recent King’s Fund Integrated Care Summit, I shared a speaking platform with David Prior – the new Chair of the Care Quality Commission and a man of experience and sincere commitment to improving patient care. In the course of his talk, he stated that “far too many patients are arriving at hospitals as emergencies, with accident and emergency departments out of control and unsustainable in many parts of the country.”  He added that “the healthcare system is on the brink of collapse” and “if we don’t start closing acute beds and investing instead in community care, the system will fall over”. He stated that with “almost half of hospitals providing care which is either poor or not terribly good,  the pressure means that regulators cannot guarantee there will never be another care disaster such as Mid Staffs”.

Health in care homes: can we do better?

Dr Adam Gordon is a Consultant and Honorary Associate Professor in Medicine of Older People at Nottingham University Hospitals NHS Trust and the University of Nottingham. He also edits this blog.

Arrangements to provide health care to UK care homes are often inadequate.  In the British Geriatrics Society’s Failing the Frail Report, based on a national survey by the Care Quality Commission, 57% of residents were reported as being unable to access all health care services required. In 2011, a collaboration of health care groups led by the British Geriatrics Society published Quest for Quality, which went so far as to describe existing arrangements as “a betrayal of older people, an infringement of their human rights and unacceptable in a civilised society”.

So, can we do better?

Since 2008, the Medical Crises in Older People (MCOP) research programme at the University of Nottingham has been working to better understand the challenges and opportunities that society faces in providing effective healthcare to care home residents. As this work draws to a close, we are hosting a conference entitled “Health in care homes: can we do better?” in Nottingham on June 14th, 2013.  Details of the conference can be found here.

Streamlining admissions

Dr Sean Ninan is a Specialist Registrar in General (Internal) Medicine and Geriatric Medicine working in the Yorkshire deanery, UK.

When I was 20 I travelled round India, a wonderful beguiling country with some of the worst administration I have ever encountered, much of it unchanged from systems introduced during the Empire.

I have fond memories of the trip but there were many frustrating experiences too. Taking out money from the bank, for example, was particularly painful.

You enter, make your way to reception and explain that you would like to take out some money. They ask you to take a ticket, and you wait in the queue. After some time, patiently waiting you reach the front of the queue.

“Saving, deposit or withdrawal?”

Acute care for older people

Dr Simon Conroy is Head of Geriatric Medicine, University Hospitals of Leicester, Honorary Senior Lecturer, University of Leicester and an Associate Editor for Age and Ageing journal.

Acute care for older people appears to be the topic de jour. The increasing number of older people attending acute care should not be a surprise given the demographic pressures, yet many hospitals still appear slightly taken aback by the increasing age, complexity and number of patients accessing urgent care.

A range of efforts to reduce hospital attendances do not appear to have attenuated the patterns over recent years. GPs are being performance managed on avoidable admission, emergency departments are beholden to the 4-hour wait and in-patient teams are hounded on a daily basis to discharge yet more patients.

Is there a better way? We hope so. At a forthcoming conference hosted by the Royal College of Physicians, we will bring together relevant stakeholders to share ideas and thoughts about how to make things better. Importantly the speakers represent all stages of the patient pathway.

Link

Innovative approach to care of the older patients celebrated in the Daily Mail

Following the Francis Report we ought to be taking every opportunity to highlight excellence and quality in Health Care of Older People being delivered across many NHS trusts. This article from the Daily Mail reports an innovative scheme from Nottingham.  It is an example of the sort of thing we ought to celebrate.  Click on the hyperlink above – I’ll let the article speak for itself.