Abstract
Increased specialization and adherence to shorter working hours have fragmented medical care and, except in the largest hospitals, have all but destroyed team-structured work practices. Hospital geriatric practice adds another complication to this melting pot. Over the past 50 years geriatricians have highlighted many of the foibles of their fêted specialist colleagues and revealed how common conditions present in different ways in the elderly, but does the segregation of elderly patients facilitate better management 1 or contribute to service fragmentation?
The development of geriatrics in the context of the NHS was partly a professional aspiration and partly a managerial convenience. With the advent of free healthcare the hospital service became congested with patients whose mental and physical disabilities made their return to the community a problem. The geriatrician was seen to have diagnostic foresight and rehabilitation skills which their specialist colleagues appeared to lack. In this way elderly patients who had previously languished in general medical and surgical wards could be taken out of the acute hospital environment. Hospital managers were quick to grasp the financial advantage of this denouement because it allowed acute hospital beds to be cut.
As the specialty burgeoned so the number of geriatric hospital beds increased and the beds of other specialties decreased. Servicing these beds became the domain of the senior house officer grade, but these posts were rarely the first choice of aspiring young doctors. The compulsory inclusion of geriatric medicine in higher medical training helped to keep these posts filled but this did not increase their popularity. Furthermore the perception of the mentally competent elderly patient, constituting more than 50% of those aged over 70, 2 was that these wards were not the ideal hospital environment in which to recover from an inter-current illness since they would be mixed with substantial numbers of the demented or incontinent chronic sick. Today, with the emphasis on patient choice, it would be interesting to conduct a survey of the intellectually bright elderly population to seek their views on their designated inpatient accommodation and those charged with their management. Equity of care remains an important consideration. 3
With the current emphasis on having emergency medical departments run by consultants trained in emergency medicine, 4 the elderly should have the opportunity of being managed in the same environment as younger patients – at least for the first 48 hours. Thereafter their accommodation is likely to be decided by their chronological age and not their medical needs. It is important to remember that age does not define a disease profile or an organ specific disorder. Age is arbitrary and prone to abuse by managers wishing to downgrade the service provided in order to constrain expenditure.
Geriatric practice in hospital appears to follow two different models or variations thereof: Model A: the geriatrician is a passive member of the specialist team and oversees the ongoing management of those patients in whom a speedy return to the community is problematic. Model B: the geriatrician takes control of the patient's management on arrival in the hospital.
In both situations the geriatrician usually has access to community hospital beds which serve as a buffer between acute hospital management and return to community-based care.
If patients were able to choose between these two models it is likely that the majority would opt for model A. It might be better to delegate a patient's non-acute care back to their GP and, where necessary, a community hospital setting with better funding for social services than to persist with current practices. In this context the present government has stated that it intends to move a significant swathe of healthcare from the institution to the patient's place of residence. This is impracticable during the acute phase of a patient's illness, but thereafter, if the funding were available, this service is likely to be earmarked for those patients with the most disadvantaged social circumstances such as those without appropriate family support and the chronically disabled. In the past this sort of shift of NHS resources would have been achieved by moving financial support from the specialty which had previously delivered that care; in this case the majority of the patients identified for this political incentive will be the elderly. Logically, therefore, the specialty to be robbed of financial support would be geriatrics.
Accommodating government interference and the wishes of patients is a perennial challenge to the medical profession. However, in regard to the future role of geriatricians and the need to deliver consultant expertise at the point of entry to the acute hospital setting, there is a practical solution.
If geriatricians were absorbed by the four major acute specialties – cardiology, chest medicine, gastroenterology and endocrinology – as specialist colleagues (many already have these specialist skills), then the smaller district general hospitals should be able to provide a comprehensive, consultant-lead emergency department service 5 without having to appoint additional ‘acute physicians’. We should not forget that junior doctors, apart from those who opt for the non acute specialties (dermatology, rheumatology, neurology, etc.), regularly deliver care in the emergency department to adults irrespective of age and have gained considerable expertise and experience in emergency medicine by the time they attain consultant status. Dumping these skills in order to make way for a new echelon of specialists – the emergency physicians – is counterproductive, degrades continuity of care and adds to the current trend of ‘pass the patient’. Furthermore, the appointment of specialists in Acute Medicine and their deployment in emergency departments has failed to demonstrate a reduction of mortality in patients over 65 years of age. 6
These proposals are but one aspect of improving the management of the acutely ill patient. Hospital refurbishment or rebuilding is the other major requirement if we are to add quality, dignity and privacy to the patient's hospital experience. Some geriatricians might object to their current autonomy being challenged, but we should not allow the kudos of empire to overrule our attempts to serve the best interests of patients.
Footnotes
DECLARATIONS
Footnotes
Acknowledgements
None