- personal reflections by our immediate past President

In a mutually unguarded moment, the BGS Executive required me to provide a personal restrospective on the BGS Plan 2000-2 that spanned my term of office.

Any positive conclusions to be drawn reflect the combined strengths of colleagues on the Executive and Council, the team at HQ, and many individual contributors across the BGS membership. For the Plan’s deficiencies the buck stops here. In the context of these comments, I have decided in general not to mention names but I wish immediately to single out the support, hard work and enormous commitment to the Plan’s implementation provided respectively by the Society’s current President, Bob Stout, and by the Administrative Director, Richard Lynham.

As a preliminary reminder, the Plan had a somewhat “New Labour” style evolution through the convening of exploratory “focus groups”, consultation across the UK and the England regions, modification to reflect feedback, final refinement towards consensus, and the eventual full endorsement of the UK BGS Council. Speaking personally (with no political bias) I have in retrospect no doubt of the validity of that approach in this particular context. I’ll do my best here to avert any charge of spin!

The above were additional to the usual steady trickle of not always edifying press coverage (everything from alleged scandals of care in hospitals and homes to the health concerns of the late Queen Mother), and regular events (such as the IAG Congress). In such a climate there is always the risk of strategy falling victim to response.

A rehash of the corresponding Annual Reports of Council (to which you are referred) would be unpractical and pointless here. The Plan’s specific initiatives predictably resemble a “rolling” BGS agenda (Thematic elements of the 2000-02 strategy) based on certain core objectives. The essential question is whether, if at all, its implementation advanced the cause of the speciality in line with those objectives as follows:
(1) A common shared purpose, (2) Policy influence – national and international, (3) Public awareness and engagement, (4) Academic and professional development, (5) Effective collaboration and (6) Effective structure and infrastructure?

Advancing geriatric medicine through a common shared purpose
How within the Plan did the BGS score against this ostensibly self-evident parameter? On the whole I believe pretty well, especially amongst the growing ranks of trainees, with whom the future rests. Both at the launch stage of the Plan and subsequently however, consensus statements were difficult to elicit and formulate, and were muted to a degree suggesting that our field is still not entirely at ease within itself. While creative tensions might reflect healthy diversity, a lack of recognisable core principles would, conversely, pose more of a problem. Key issues of speciality identity on which geriatricians agree were eventually endorsed by your Council and I sought to summarise them in an early “President’s Column” (see the fuller listing in the January 2001 Newsletter):

• Comprehensiveness - the consistent application of specialist geriatric medical skills and training to the health needs of older people across the spectrum of care (acute, intermediate care and continuing care),
• A genuine commitment to multidisciplinarity,
• The promotion of effective interrelationships between all providers of health and social care for older people,
• The translation of these principles into viable, efficient local services within realistic resources (ensuring access for older people without delay at the point of need),
• The embodiment of the above within the knowledge base of undergraduate medical teaching, postgraduate training and academically led research into ageing.

That is to say, without each and all of these you do not have geriatric medicine in a developed form. In case they seem at first sight too broad and philosophical, you might, for example, care to test their applicability to current discussions about the balance of geriatrician deployment between acute hospital and community aspects of specialist practice. They have been (and remain) highly germane to the Society’s advice to Government. I suggest that their rehearsal (the equivalent of the ubiquitous “mission statement” remain part of any future strategic review).

Advancing geriatric medicine through policy influence
Against this objective significant progress occurred over the period of the Plan. Formal devolution triggered the consolidation and further development of already strong advisory and working links between the BGS and the Departments of Health in Northern Ireland, Scotland & Wales. England, with a history of only tenuous links to its DoH, (and with no England Council) faced particular new challenges and opportunities with the highly structured initiatives of the NHS Plan, the NSF and the National Directorate for Older People. Both collectively and through the involvement of individual members, the Society had a substantial input over the period. As President, I had opportunities to work closely with the National Director, to meet with Ministers, to be involved in key policy groups and to present evidence to Commons Select Committees. A formal, unprecedented mechanism for regular consultation of the BGS with the Directorate and the DoH in England is now in place, albeit very much in parity with other “stakeholders”.

Thus across the UK the plan’s practical goal of enhancing the political interface has been significantly realised.

The parameters of political engagement, however, continued (and continue still) to present challenges across the UK, as follows:

• In determining standards, where lies the margin between specialist expertise and “general” enhancement of awareness, attitude and basic training for all involved in health and social care?
• In consequence, how best should limited financial resources be selectively deployed?
• How does the specialty (represented by individuals or groups) work with Government, but sustain and promote its own independent values and standards where there is perceived variance?
• To what extent do geriatricians at local level with limited time and manpower engage with laudable but historically untested initiatives? Many such initiatives may readily be seen to have a partial or marginal impact on core need. While involvement may be desirable to inform and influence, it may be at risk of lending unjustified credibility and of diverting their own and other scarce resources.

Internationally through representation on the Councils of the IAG, the BGS has continued to have a voice. You may possibly recall however, the concerns I identified at the Valencia Forum about the apparent narrowness of commitment to hospital-based secondary care for older people within (for example) the forward programme of the WHO (see President’s Column, May 2002).

Advancing geriatric medicine through public awareness and involvement (including the media)
Although your Council favoured a major and professional drive in PR, progress over the period has been tempered by funding constraints, but perhaps also by a measure of reticence within the ranks. That said, the commitment, energy and skill of the Administrative Director and the HQ team working with office bearers, standing committees and others have resulted in professional, timely and influential responses to most emerging media issues to an unprecedented degree. These have included rapid response press releases and media interviews, where relevant in tandem with other organisations (see collaboration below).

Our history is one of a predominantly medical professional society, nonetheless enjoying fruitful relationships with other groupings concerned with advocacy for older people. Compared with other specialities of medicine (and we are currently the largest), we have perhaps been rather reticent in promoting the field to a wider public and even to older people themselves. Perhaps we should ask “why?” since in today’s climate of concentrated high-pressure communication, survival and development might come to depend on strong public support.

There was general agreement that the opening of Marjory Warren House by the Secretary of State for Health, and the presence of guests and representatives at the occasion from a wide spectrum of organisations and backgrounds contributed usefully to the recognition and awareness of the Society’s importance nationally.

Strategies under this heading that were not pursued systematically within the Plan included (for example) (1) the Society’s possible role as a charity in the raising of funds for Research & Development, (2) the pro-active pursuit of public information or education campaigns about health, medical need and ageing, (3) any systematic reconsideration of the Society’s nomenclature. A commonly voiced view (that I do not wholly share) is that (1) & (2) can remain de facto “delegated” to other major charities and organisations, such as Age Concern and Help the Aged (without necessarily any strategic collaboration). Useful groundwork towards these goals nevertheless took place within the plan in consultation with office bearers and other colleagues in these organisations.

Part of the agenda entailed a review of the relationship with our Patron, HRH the Prince of Wales (who is Patron of four other charities in ageing). A measurable enhancement of the Society’s interaction, both with His Royal Highness and his staff, as well as with the other “Prince’s charities” was achieved.

On (3), (a recurring topic of informal exchange, though not an explicit item in the Plan) I’ve taken the liberty of commenting separately (see Appendix).

Advancing geriatric medicine through academic and professional development
The Plan coincided with a period of unprecedented pressure and change affecting many clinical academic disciplines and departments. In pursuing the objective of promoting academic leadership, the issues for academic activity in our own field were thoroughly analysed in a paper presented for the Association of Professors of Geriatric Medicine (and subsequently Council) by Bob Stout, concluding with 13 recommendations. These constitute a clear forward agenda. Involving the Society’s academics corporately in the development of a shared strategy has so far proved elusive. Currently an increasing number of academic departments is facing closure, and this remains a source of grave concern for the future of the speciality.

It has, however, proved possible to strengthen the Society’s special link with the charity, Research into Ageing during the transition to its more integral relationship with Help the Aged. We were indebted to them for supporting the first highly successful Research Masterclass for BGS trainees, and more are planned. RIA has also now joined with the BGS (via the Dhole Bequest) in funding a two-year clinical fellowship. The position of Hon Medical Advisor to RIA continues to be held by the Chair of the Scientific Committee.

The Plan prescribed the development of a BGS 5-year rolling CPD programme to support members in readiness for governance and revalidation. This is now largely in place, thanks to the imagination and persistence of the Society’s CPD Director and others. It depends on a range of resources, including national meetings, branch and regional activity and the BGS website. Distance learning and assessment capability is now being piloted in collaboration with (and with support from) the Novartis Health & Age Site. The possibility of a web-based CME supplement to Age & Ageing is currently under consideration by the Editorial Board.

The Plan stressed the developing role of Sections and SIG’s as catalysts for the focusing of expertise, research, and collaboration with other professions, organisations and scientists. All the indicators, including the emergence of new SIG’s, suggest this continues to be a fruitful strategy.

Advancing geriatric medicine through effective collaboration
The Plan set out to explore how the collaborative and multidisciplinary ethos of the specialty might be better supported and more clearly developed and expressed in BGS activity at national level. Progress was achieved in a number of directions.
The joint working group and subsequent joint publication with the Royal College of Nursing on the Gerontological Nurse Specialist were major steps forward. Not only was there a strengthening of the relationship between the two organisations on which to build, but the concept of nurse specialisation in the field was, it is to be hoped, significantly nurtured and encouraged. Organisational bridge-building has also continued with the representative groups for physiotherapy (via AGILE) and occupational therapy (via OCTEP), speech and language therapy and dietetics. Discussion has also begun with the College of Optometrists.

The open membership of Sections & SIG’s continues to be seen as one of the best avenues to develop and consolidate cross-professional research and CPD interests, and to involve other professions in the Society’s activity. The interdisciplinary days at Autumn and Spring meetings have so far enjoyed variable support both from physicians and from the professions allied to medicine and are under review.

Over the period of the plan, the proximity and effectiveness of collaboration with the Medical Royal Colleges has increased considerably to mutual advantage. Training, workforce and CPD matters, but increasingly also issues of national policy, have on numerous occasions (where relevant) been approached jointly with enhanced influence as a result. There is a strong functional link with the Clinical Effectiveness and Evaluation Unit of the London College through our own Clinical Practice Evaluation Group now reporting to the Scientific Committee. I wrote recently (September 2002 newsletter) about the excellent start that has now been made in working together with the Royal College of General Practitioners, and of course our colleagues in the Section of Psychiatry of Old Age of the RCPsych share common cause with us in the Brain Ageing and Mental Health Section.

The Sections and SIG’s have also fostered links with related learned societies, for example the National Osteoporosis Society, British Cardiac Society, British Thoracic Society, British Pharmacological Society, Diabetes UK, Parkinson’s Disease Society and others.

The potential of closer collaboration in the UK with our “relatives” in Biological and Social Gerontology (through the BSG and the BSRA) has yet to be fully realised in spite of significant efforts on the part of the respective executives. This is partly a fact of history – the emergence of three strong and autonomous groups in Britain, in contrast with some other settings internationally where a more natural shared evolution (partly for reasons of critical mass) has occurred. But we will probably remain impoverished both scientifically and perhaps politically if this logical affinity cannot be realised.

It was gratifying that the BGS finalised its joint project and publication with the American Geriatrics Society in the development of agreed guidelines on the prevention of falls. Collaboration is also underway with the National Institute of Clinical Excellence (NICE) through the involvement of individuals in Guideline Development Groups. This is in addition to the responses provided by the BGS as a recognised stakeholder in a variety of topics on the NICE agenda (coordinated by CPEG in conjunction with Sections and SIG’s).

A further example of the inherent strength of working closely with other major charities was the Joint Report on ‘Implementation of the National Service Framework and Intermediate Care seen from Geriatricians’ and Older People’s perspectives’ published by Age Concern and the British Geriatrics Society in 2002. Data were collated from two separate national surveys – that of Age Concern on the involvement of older people themselves in the local implementation of the NSF, and our own on the involvement of geriatricians. In this way the Society was able with minimal resource commitment to balance its proper involvement with Government against independent scrutiny of the impact of policy (from the perspectives of the service users and of our own professional specialty).

There can be no doubt (in spite of the workload involved) that this broad growth of networked activity and of external collaboration is in the best interests of the BGS.

Advancing geriatric medicine through effective BGS structure and infrastructure
Members will be well aware of the structural changes which have now been formulated and which are essential to future effectiveness. They are detailed in previous newsletters and I will not rehearse them here. The need for structural review to meet the Society’s strategic objectives was a defined remit of the Plan and the proposals now in the final stages of implementation should serve us well. These have, as you know, been driven principally by the combined requirements of (1) charitable status, (2) UK devolution and (3) the need to regain momentum academically. With respect to (3) the President and the revised Academic & Research Committee should be better enabled by the new structure to take forward the major challenges with respect to academic geriatric medicine.

In the area of infrastructure, the Administrative Director and the HQ team (currently the best and strongest the Society has ever had) deserve enormous credit for what has been achieved. After a period of stringency, the finances are showing signs of renewed vitality, with significant inroads already made on the premises mortgage and the possibility of a whole range of more creative resource deployment ahead. Marjory Warren House is more than justifying every penny invested in it, and still has considerable potential for exploitation as a resource. Considerable progress has been achieved with minimal investment (other than hard work) in setting in place the Central Information and Research Database to support research collaboration and also to inform and strengthen the Society’s networking of expertise. The support for the Society’s Committees is now even more refined and effective.

As we have already seen, England faces particularly complex challenges in the shake up of the Regions and the resulting lines of accountability for the standards of local services. Regional branch activity is fundamental and crucial, both to the delivery of effective peer support to the membership, to the CPD programme, and to lines of communication within the Society. The England Council has now been configured (as a key component of restructuring under the Plan) and should be fully elected and operational by spring 2003. Alongside its role in national and UK policy, it will provide leadership in the evolution of relationships with Primary Care Trusts, Strategic Health Authorities and Health & Social Care Directorates. Regional data collection has already proved an invaluable resource in monitoring the impact of health policy on practice and services in our speciality and it is to be hoped that this will become even stronger.

Conclusion
The “ship” undoubtedly moved along over the period of the 2000-2002 Plan. Time will judge the extent to which the direction of travel the Plan charted was the desired one. Strategy may have occasionally fallen victim to “response mode”. It was, however, for me an unforgettable privilege to convene and gather some of the incredible wealth of expertise within this Society that brought the Plan into being. That support and the Plan itself served as invaluable anchors and made my task more straightforward.

I wish my successor and the whole leadership team well in moving on to the next phase. I hope very much that their shared experience will prove as rewarding as mine certainly was.

Cameron Swift
Immediate Past President