Community geriatricians can make a massive difference to older people’s lives and post hospital recoveries, so why are they so thin on the ground?
Quite how many consultant geriatricians divide their work time between acute and primary settings is unclear. Not even the British Geriatrics Society can say for certain. The split, for those that do, tends to be 50:50, with the focus of non-acute hours on the community hospital and, to a lesser extent, visits to residential, nursing or patients’ homes. More rarely, consultant geriatricians employed by primary care trusts work entirely in primary care.
Social Care Institute for Excellence head of older people’s services Annie Stevenson says the work of clinicians taking on the community geriatrician role is pivotal to the kind of integrated service required by older people. She laments, however, the apparent paucity of their numbers.
“They offer a holistic expertise and are able to assess those with complex needs and pathologies where they live as part of a multidisciplinary team approach,” she says. “And yet only 5 per cent of care homes - just the kind of setting where, ever since the Community Care Act of 1990, you will find older people with long term conditions - have direct contact with a geriatrician.”
Ms Stevenson cites the death of her father-in-law from undiagnosed peritonitis as a tragic consequence of the lack of access to specialist healthcare while in a nursing home.
“In his case there was a lack of medical input at the right time,” she says.
“Older people with chronic health conditions are living longer and their numbers are growing. They can easily be overlooked and risk becoming victims of the divide between social care and health. Community geriatricians should work alongside every care home so no one suffers from what happened to my father-in-law.”
Hard evidence of the benefits of the impact of the community geriatrician is out there but, like the other numbers, can be hard to come by because of the lack of research funding attracted.
A multicentre trial led by Bradford Teaching Hospitals foundation trust compared the care given to older people in the general hospital and community hospital settings once they had become medically stable. Those randomly chosen for community hospital care were shown, six months post-discharge, to be more independent (walking outside and shopping, doing housework and preparing meals) and more satisfied with the care received. The community hospital also demonstrated it had a similar order of cost effectiveness.
“It is certainly easier to integrate services between the acute and community setting using this model,” says John Young of University of Leeds and Bradford Teaching Hospitals foundation trust.
“The visiting geriatrician is able to take on a link role between the two services. It is also good from the patient perspective as it often offers good continuity of care.
“About one third of the admissions to our elderly medical assessment unit go home after a stay of two days at the most. Another third will be discharged to intermediate care.”
Fewer acute admissions
In Bradford, where the model of locality based community care was established in the late 1990s, a range of intermediate or rehabilitative care services are available - community hospitals, day hospital, hospital at home, rehab in care homes or rehab in a social assessment unit. Without the intermediate services something like 2,000 patients would be admitted to acute hospital beds.
Professor Young explains that the main responsibility of the community geriatricians is medical care to the 100 or so beds this model incorporates. They also have strong working relationships with the 25 community matrons in the city’s care homes.
“What struck me is how few patients who have been in hospital and then go home say that they wish they had spent longer in hospital,” notes Graham Mulley, president of the British Geriatrics Society and a consultant geriatrician in Leeds, where he, along with his four consultant colleagues, spends 50 per cent of his clinical time working for NHS Leeds Community Healthcare.
“We don’t know the numbers of consultant community geriatricians across NHS England but more current vacancies are asking for an interest in community work,” he adds. “There is no uniform model for provision and centres appear to be setting up services to meet local needs.”
An ideal geriatrics service
- A well equipped and well staffed geriatric assessment centre in an acute setting taking direct admissions for older people with confusion, immobility, incontinence or falling and facilitating investigation within six to 12 hours
- Following diagnosis and initiation of treatment, rapid discharge with intermediate care - to home or a community unit
- Equal consideration given to the discharge process as to all other stages of care
- A discharge summary sent in good time on day of discharge to receiving team accurately outlining diagnosis and treatment plans
- Academic chairs, research, training and development posts in community geriatrics as a maturing discipline