- BGS response

Prof Sir George Alberti has been appointed as the Government’s emergency care lead, with the task of leading development which could help deliver the reformed emergency care management so desperately needed in the NHS. Of course these developments will apply to England and Wales primarily, but will have UK wide impact. The BGS believes that geriatricians could have an important role to play in the procedures for reforming emergency care, both by ensuring that older patients who need to be in hospital do get admitted, but also in helping to develop alternatives to acute hospital care for those older people who would be better off not being there at the time of their crisis. Furthermore, in line with all our previously published policies, the BGS believes that geriatricians should be both gatekeepers to intermediate care and supervise the medical input to patients receiving it.

The Society’s response can be summarised under three headings:

Managing crises (which cause hospital admission)
The quest of the geriatrician is to ensure that frail older people get access to specialist medical input as early in their pathway of care as possible. In some situations this could mean outside of hospital, possibly using Day Hospitals or their modern equivalent. This will ensure that:
a) potentially reversible and often unrecognised illness can be actively dealt with from the beginning of the crisis.
b) older people who would benefit from not being in hospital (where they are exposed to a variety of iatrogenic and nosocomial illnesses) could have their crisis managed in an alternative way, such as intermediate care. Admissions to intermediate care could take place either immediately from the Accident and Emergency Unit or after 24 – 48 hours of acute hospital care, where this is what is needed to establish the diagnosis and address the medical problems. Our experience as geriatricians is that rapid transfer after a very short stay in hospital is likely to suit the clinical circumstances in a greater number of patients than immediate transfer to intermediate care from Accident and Emergency departments
c) other factors contributing to the crisis are recognised, i.e. factors besides the immediate medical problem, which resulted in admission. These can then be addressed early by a multi-professional team, resulting in shortened lengths of stay and reduced readmissions.

The Society sees potential to consider the value of streaming patients in the Accident and Emergency department, and Gill Turner will be meeting later this month with the BAEM to consider this further and in detail.

Whilst happy to embrace constructive change, the Society could not endorse any suggestion which denied ill older people admittance to appropriate acute hospital care. We believe that everybody irrespective of age, who suffers a breakdown in health, is entitled to a diagnosis and appropriate treatment. To implement this, sophisticated equipment and the skills of other specialists may be needed, and all patients must have timely access to such equipment and expertise, hence the need for access to an acute hospital.

As geriatricians we are keen to maximise the potential of intermediate care. At the moment this is limited by its lack of capacity and capability (due to a variety of factors). The BGS will shortly produce a paper summarising previous work it has done on intermediate care, looking at the further opportunities intermediate care could offer and outlining what is needed to exploit those opportunities.

Ongoing Care
Handling the immediate post acute phase of hospital care and the role that geriatricians should play:

The BGS recognises that over the last 10 years many models of geriatric service have evolved in response to local needs and opportunities. We would not want to be prescriptive about styles of service model, beyond defining the standards of care which are expected of specialist departments of medicine for older people (which we published last month and which can be accessed on our website – www.bgs.org.uk).

However, currently the BGS is examining the ways in which Standard 4 of the NSF is being implemented in order to see to what extent older people in hospital nationally, have access to a geriatrician and multi-professional team.
This work is likely to be published within the first quarter of next year.

Working in the Community to prevent the crises which lead to requests for hospital admission
There is a much work to be done to examine the potential for preventative health care in reducing crises. Over the next two years this will become a major agenda for the BGS.

It is to be hoped that successful implementation of the Single Assessment Process will be of considerable benefit here.

The Society is very keen to ensure that older people get a fair deal. Developments along the lines discussed, whereby geriatricians act as gatekeepers to intermediate care, will be a major step forward in ensuring that only those older people who will benefit from not being in hospital, or those who will derive more benefit from the intermediate care itself, will receive such care. The introduction of a system of streaming should of course, mean that those older people who need to be in hospital under the care of a specialist (either a geriatrician, a stroke physician or any other specialist) get there more quickly; this we would therefore also commend.

The Society has drawn attention to the workload implications for this new, entirely appropriate role. Whilst the BGS recognises that specialist medical input into intermediate care could come from GPs with a special interest, there is limited scope for this. The developing roles of the geriatrician in the community in a preventative capacity will also increase the specialist workload. In the medium to long term this can be addressed through training numbers, but in the short term it is likely that there will have to be considerable role readjustment with the result that geriatricians will be less able to play a part in the ongoing care (in hospital or in out patients) for younger people admitted through the ‘take’.

I will continue to monitor developments and keep members informed.

Gillian F Turner
Chair, Policy Committee