Round and about the UK - National Council Reports

The England Council has finally had its first meeting at BGS headquarters, having previously travelled to Scotland, Wales and Hammersmith.

The two key roles for the council are to ensure two-way communications with the England regions and to do everything possible to influence the Department of Health with the views of consultant geriatricians in England. To this end, members of the council have the opportunity to meet with Ian Philp and civil servants from the Department of Health twice a year. The last meeting in November covered reimbursement, the work of the Change Agent team, the Government’s “Choice” Project, progress with Evercare and concerns about evaluation of the Evercare projects before their funding comes to an end. Your council member will be able to give you more information about all of these issues which have received considerable discussion at recent council meetings.

Meeting the Parliamentary Under Secretary
In December, as Chair of the England Council, I was invited to meet with Stephen Ladyman, Parliamentary Under Secretary of Health, to discuss geriatrician’s concerns about the progress of Intermediate Care. I concentrated on the issues of intermediate care and the progression of the NSF in hospitals. The main points I tried to put across to him were that:

• Within hospitals geriatricians are now not only leading on stroke and falls, but taking an extremely large load of the emergency take
• The efficient and effective management of older people across the spectrum of care from home to hospital, and back home again, is absolutely key to unlocking the congestion in hospitals and delivering the other aspects of the NSF Plan
• the “technology” of geriatric medicine is comprehensive assessment, and specialist geriatric input is completely integral to that process
• Much of the Intermediate Care that has been delivered is patchy, small scale, does not involve specialist geriatric input, does not have a single point of access, and in many places, is not significantly contributing to overall whole systems approach
• There appears to be no national governance of Intermediate Care. The Government has no idea how many schemes there are; how many patients are going through them; or the outcomes in terms of institutionalisation, death or discharge home
• Much of the implementation of the NSF is unfortunately approached as a tick box or non-critical activity by PCTs. Funding is not flowing through, as it is in cardiology and oncology. An illustration of this point is stroke care, comparing the proportion of stroke patients getting into a stroke unit (30 - 35%), with heart attack patients getting into a coronary care unit (95% plus)

Our discussion then moved on to the nature of comprehensive geriatric assessment, its linkages with the Single Assessment Process and indeed, Mr Ladyman and the Government’s believe that if the NSF is delivered, then all patients will receive comprehensive geriatric assessment as part of the single assessment process before, for example, entry to long term care. The reality on the ground was set out by both Ian Philp and myself.

I believe the Minister listened and is sympathetic to the argument that Intermediate Care needs to be improved. On the other hand, there is the tension between wanting to take more central action and the increasing drive of the Government to look for local solutions to local problems. It is very difficult to know if a half hour meeting makes any difference but the proof will be if a) any more initiatives on Intermediate Care transpire in the next six months; and b) whether he follows up on his offer at the end of the meeting to see a representative of the BGS at least twice a year.

Single Assessment Process
At January’s council meeting, Mr Ray Wharburton, who has led the Single Assessment Process for the Department of Health attended to update geriatricians on progress and to hear our experience. He made a number of points - one of them being that it was never the intention to have a single tool but there is now a single assessment summary that must be used by all Health and Social Care Communities in England. There are now three accredited assessment tools for overview assessment, namely MDS Homecare, Easycare and FACE. A major piece of ongoing work is the linkage between the Single Assessment Process IT Systems and the NHS Care Record Service.

We are fortunate in geriatric medicine in having Beverly Castleton seconded to the Department of Health to work on this detailed and complex project, and a number of members of the England Council have volunteered to offer their advice and help the implementation process. It was emphasised that although the SAP must be implemented from this April, most communities will be using interim solutions, which may still be paper based, until the NHS core IT system is in place. There are going to be a number of SAP roadshows involving the department and Ian Philp over the next 6 months.

The message Mr Wharburton took away from the England Council was that it would appear that although a lot is going on in the community, so far this has had very little impact on hospital services, and indeed in some areas geriatricians are still not aware of progress at all. Linkages with mental health is a specific issue that was raised as being of considerable importance. It is clear that the department wishes to engage with all doctors and I hope that we will be able to publish over time, good practice examples in the BGS Newsletter.

An issue that has caused considerable debate at both the last two meetings, has been the interface of geriatric medicine with acute medicine, and pressures in A&E and Intermediate Care. This is linked to concerns about training and career progression as consultants. This interfaces with the issue of acute physicians that is being currently debated within the RCP London. The Council is keen to hear the current views of consultants and trainees in England. By the time you read this you will probably have seen and returned a questionnaire. From this it is hoped that we will start to develop guidance to help people think through these issues at a local level.

Finally, the council is continuing to review significant issues and ensure BGS input wherever possible. These include Evercare, the NSF for chronic diseases, reimbursement and the CHI review of the National Service Framework.

David Black
Chairman : England Council