The care of older people is one of the core businesses of the NHS. For many clinicians and NHS managers, there is an increasing tendency for geriatric medicine to be seen as synonymous with acute medicine.

As a consequence, it is in danger of becoming divorced from providing the breadth of comprehensive care for older people that has characterised the specialty over the years.

The essence of geriatric medicine as a specialty is to assess and treat the medical and rehabilitative needs of older people. Every ill person deserves a diagnosis. This is carried out through a process known as Comprehensive Geriatric Assessment. When this is combined with a co-ordinated package of health and social care delivered by a multidisciplinary team, led by a consultant geriatrician, there is evidence that the outcomes for older people with multiple pathologies and functional problems are improved. (1,2)

With the changing demography of the population, the care of older people in hospital and in the community is rightly at the forefront of the new NHS and the modernisation agenda. However, in delivering the change agenda and the hospital access targets, there has been a tendency for the role of geriatricians in caring for older people, and in developing their services, to be ignored or sidelined. This has occurred partly due to the process of commissioning services (reinforced by government policy concerning Long Term Care, Intermediate Care and rehabilitation in general), partly due to the introduction of short term measures producing significant change in the acute management of older people, and also because some consultants in the specialty have become disengaged from those aspects of traditional geriatric medical practice which they find less attractive.

Consequently, the job plan of the individual consultant geriatrician has often developed in line with local commissioners and the wishes of the individual. This has led to a wide variation in consultant geriatric medicine practice across the country and between individuals within the same department. As a result, traditional core skills of a geriatrician are often under-used, and may not even be there to train future generations of geriatricians.

These changes in traditional geriatric practice have centred around three main areas: (a) the involvement of geriatricians in the acute unselected medical take, (b) the involvement of geriatricians in the planning and delivery of services for older people outside of hospital, and (c) the role of geriatricians in delivering sub-specialty services (e.g. stroke, continence, movement disorders, falls, orthogeriatrics) in hospital.

This paper reviews areas of practice of geriatric medicine in light of the results from a recent small survey of consultant and SpR opinion. This paper will consider patterns of work and the development of the consultant geriatrician role in the future.

Possible models

• Consultant geriatricians should become entirely hospital-based without any role in the community, but see their role as being to provide hospital based rehabilitation, sub-specialty services, and to support the management of older people admitted on the acute unselected take.
• Consultant geriatricians should work in a department that accepts corporate responsibility for delivering services for older people in the community and delivers this either by all consultants taking a turn in working in the community on rotation, or all consultants having programmed activities for work in the community in their weekly job plan, or some consultants concentrating on community work while other colleagues work at the "front door".

In relation to the latter suggestion, the role of the consultant geriatrician could change as their career develops from being predominantly hospital based early after appointment (1-10 years) with an increasing emphasis away from acute care towards planning and delivery of community services in later years. This will reflect career development and individual wishes but will preserve the role of the geriatrician in caring for older people outside hospital and in service development. It also recognises the potential limitations of consultants retaining a heavy commitment to the acute emergency take in later years of their career. However, it should be emphasised that the provision in any geographical area of a comprehensive geriatric service will require a balance of roles and responsibilities between all consultants in a department.

Delivery of Emergency Medicine
The number of emergency admissions of patients over 65 is continuing to rise year on year. A high proportion of people requiring urgent care have old-age related needs including falls, stroke, confusion, dementia and multiple pathology, often associated with loss of independence in activities of daily living in the context of complex social support systems. Of the many older people managed through conventional care pathways, those with specific old-age related needs require a timely response by specialist old age services. (3,4)

The process of managing acute medical problems in either A&E or Medical Assessment Units (MAU) has become more urgent and complex due to a number of contributing factors. This includes the requirement that from April 2004, 98% of all patients were to be treated and discharged from A&E within 4 hours. Changes in junior doctors' hours and the European Working Time Directive are fundamentally changing the number of doctors available and the team-based approach previously used for the on-take teams. Some medical specialties have withdrawn, in part, from acute medicine, leaving rota gaps to be filled.

The Royal College of Physicians (London) (RCPL) has proposed the appointment of acute physicians to manage patients in Medical Assessment Units who eventually may provide much of the first 48 hours of patient management. (5) Current proposals for sub-specialty qualification in Acute Medicine envisage an appointee having a CCST in G(I)M and an extra year in acute medicine, mostly built around skills in managing the very sick patient. Anecdotally a number of trainees in geriatric medicine have been appointed to acute physician jobs running AMU's in District General Hospitals.
It has been proposed by both the BGS and the National Director of Older People's Services, that the management of older people in the emergency department could be improved by the routine involvement of specialists and their teams trained in the care of older people (either consultants in geriatric medicine, nurse consultants or nurse specialists). (3,6)

This would ensure that:

• The processes needed to search for reversible cause of ill health or loss of function in older people can be started without delay.
• Older people who need hospital admission, do not enter admission avoidance schemes.
• Older people who would not benefit from being admitted to an acute hospital bed can be directed appropriately either back home (with or without additional support) or to residential Intermediate Care. In either case the diagnostic and therapeutic processes can continue once the patient has seen an older person's specialist in the emergency department.

A BGS Working Party in 2003 developed the theme of opportunities for streaming to support reform of Emergency Care Services. (7) It suggested a number of detailed systems to:

• manage crisis in the community and at home
• manage crisis at the front door of the hospital
• manage post acute care

The RCPL in October 2003 recommended daily input to admission units with an input to the Post Take Ward Round by consultant geriatricians and others whom form the medicine for the elderly teams. (8).

Delivery of Care in the Community
A key strand to delivering both the National Plan capacity in hospitals and the National Older Peoples Service Framework (9) has been the development of Intermediate Care. In many areas the development of Intermediate Care has been patchy and fragmented and is yet to make a significant contribution to the overall pattern of care. The Academy of the Royal Colleges Medical Aspects of Intermediate Care document (10) identified a lack of specialist medical input as being one of the reasons Intermediate Care has not developed in the way originally envisaged.

The document suggested specific geriatrician time needed to be identified for Intermediate Care and encouraged geriatricians to consider career progression so that people could do less acute work and more community work later in their career. The report also encouraged the development of GPs with a specialist interest as being one route to improve medical input to services in the community. This is being increasingly developed by the Department of Health (11) and it is hoped that shortly, 300 GPs with a specialist interest will be appointed across England to support the development of community geriatric services

One criticism levelled at geriatricians has been that they have withdrawn from supporting the long-term care and continuing care of the most frail. A report of the Royal College of Physicians (London) (12) in 2000 identified deficiencies in the care of frail older people, particularly those in institutional care, and made recommendations regarding the re-engagement of geriatric medicine and Primary Care in finding a solution to the problems. The report envisaged specialist medical time being available for that process. As of 2004 this remains an unmet need within the community.

Delivery of the sub-specialties
While the reforming emergency care agenda has pulled geriatricians and geriatric medicine increasingly (and often appropriately) into supporting emergency and urgent work, other drivers, in particular the National Service Framework for Older People, have made increasing demands.

The work on Falls Services and Stroke Services (standards 5 and 6 of the National Service Framework) are increasingly taking up clinical time. Indeed, some geriatricians increasingly spend the majority of their time in these sub-specialisms while dropping either acute and/or geriatric medicine from their job plans. The NSF milestones for falls will be particularly challenging and demanding on geriatric medicine services. The development of stroke medicine as a recognised sub specialty may also divert specialist geriatric time in due course. Little time is now available for either prevention or health promotion.

This document concentrates on the service commitments of geriatricians. Those with academic commitments find the provision of teaching and research, as well as service delivery, to be an additional challenge, yet vital to the future health of the specialty.
Current Views of Geriatricians in England and Wales
For results of our survey, see box below. The response rate for this survey is relatively low and as a consequence there may be selection bias in those responses received. However it is sufficiently large to deduce that:

• there is currently a large commitment to acute and emergency work by consultants
• although many consultants are currently happy with their present job plan there is no desire to do more acute work than is being done now
• there is a clear interest in increasing the commitment to specialist services such as strokes and falls, but only 15-20% of respondents are interested in developing community services
• the desire is to move to jobs containing more specialist geriatric work or community work now rather than necessarily waiting for 5 years
• a large majority believe that there should be clear career pathways for geriatricians to do less acute work and more community-based work later in their careers. Overwhelming support for this should mean it is seen as a positive career move.
• although there is no desire to do more acute work, the majority believe that the current amount that is being done should continue. A significant minority (47% of consultants) believe that we should be reducing the amount of acute work now.
• currently SpRs see community work as being of least interest to them at this stage of their careers.

Workforce Position
Based on the Consultant Physicians Working with Patients - 3rd Edition, Royal College of Physicians (London) (13):

There were 1037 (999 WTE) consultants in Geriatric Medicine in the UK in late 2002, which represents one WTE per 55,000 of the UK population. Compared with 761 in 1997, this represents an average annual increase of 55 (or approximately 7%) and approximately 25% expansion since 1993.

The British Geriatrics Society has recommended that to care for the older population aged > 65yr there should be 1 WTE geriatrician per 50,000 of the population (1 WTE for 4000 people >75yr).

However, this does not take account of the increasing involvement of geriatricians in unselected acute medicine (30% of consultants in 1995 rising to 88.6%) in 2002. Previously estimated by the BGS to equate to 1 WTE per 35,000 of the population, this 'non-geriatric' work has recently been more accurately estimated to account for 7.8 hours (approximately 2 Programme Activities) per week. Therefore, where geriatricians participate in acute medical takes equably with other acute medical specialties, 20% more consultants (one per 250,000 population) would be required if current work in the specialty is to be maintained, giving an estimate of 1 WTE consultant per 40,000.
The 2002 RCP (London) consultant census also indicates that consultant geriatricians currently exceed the European Working Time Directive maximum of 48 hours by 7.8 hours. As a consequence the Federation of Royal Colleges has estimated that an additional 210 consultant geriatricians are required in the UK, representing a 20% increase and an additional 1 WTE per 250,000 of the population.

Sub-specialty service developments in hospital and community-based service developments for older people will also require additional manpower. These include additional work associated with implementation of the National Service Framework for Older People, development and expansion of the existing sub specialties of geriatric medicine (such as stroke, continence, falls and orthogeriatrics) in all District General Hospitals, and new services include Intermediate Care, complex assessment, and community based work in nursing and residential homes.

It should also be noted that many newly appointed consultants in geriatric medicine are women. This is a welcome trend but it needs to be recognised that many of the new appointees, both male and female, will wish to undertake flexible/part time working for a significant part of their career.

Although there has been a recent expansion in NTN's for trainees, in some parts of the country in England, these are proving hard to fill. Currently the national vacancy rate is 8%. This is an important issue which may limit consultant expansion in the specialty in the future.

Recommendations
Older people who need it, should have access to specialist geriatric input in a way and setting that suits their needs.

The primary focus of every department of geriatric medicine should be the management of frail older people and assisting in the delivery of high quality care to this vulnerable group where-ever they might be.

Geriatric departments need a balance between the acute management of older people in the first 24 hours and other aspects of a comprehensive service including rehabilitation. This needs to be reflected in the job plans of consultants in the specialty which should (a) take account of the other core aspects of geriatric practice in the community and (b) recognise the value of the sub-specialties of geriatric medicine and their value to the care of older people in both primary and secondary care.

Specialist geriatric input is central to the work of A&E departments and in particular, the growing importance of Medical Assessment Units. The daily input into post take ward rounds by either consultant geriatricians or Specialist Nurses from the medicine for elderly team should be an objective for all acute Trusts. Geriatricians in the role of Acute Physician or Physician to the Medical Assessment Unit require a significant geriatric medicine component in the rest of their job plan. The Royal College of Physicians (London) should insist that all other doctors training for, or applying for, such posts should receive a minimum of 6 months training in geriatric medicine, and be capable of demonstrating ability in core competencies once complete.

Chronic disease management and intermediate care (underpinned by comprehensive geriatric assessment) are important community developments that require the involvement of geriatricians for both the development and delivery of these services. This is important both to ensure that the services deliver the expected improvements in care and to make sure that older people who need a specialist medical opinion or hospital admission as part of their management have these needs met. This will require a greater emphasis on implementation of the new training curriculum.

While a small proportion of CCST holders will take up posts with a significant community content for their first post, the British Geriatrics Society and the Royal College of Physicians (L) should actively encourage Trusts and individuals to consider a career progression for geriatricians, allowing them to spend a greater proportion of their time in specialist services or community activities in the later part of their careers.

The importance of comprehensive geriatric assessment and the management of the frail older person in the community and Intermediate Care should be constantly emphasised. This will require a greater emphasis on implementation of the new training curriculum.

England Council

This summarises the overall results from a questionnaire sent to all BGS consultant and SpR members in January 2004. We believe it went to 810 Consultants and 293 SpR’s. It has been completed by 223 consultants and 84 SpR’s in geriatric medicine.

Current Views of Geriatricians in England and Wales

Question A: (Consultants only) Very approximately how much clinical time is spent on these four activities?:
Emergency Care 34 %; General geriatric work including rehabilitation assessment 34%; Specialist services (stroke, Parkinson’s, falls, geriatric orthopaedics) 20%; Community based work (community hospital, Intermediate Care supporting community teams etc) 12%

Question B: (Consultants only) If you could change your job today, would you prefer to do more of one of these areas or leave your job unchanged?:
Emergency Care 3%; General geriatric work 15%; Specialist services 33%; Community based work 14%; Unchanged 35%

Question C: (Consultants only) If you could plan a job change in 5 – 10 years, would you prefer to do more?:
Emergency Care 2%; General geriatric work 13%; Specialist services 36%; Community based work 21%; Unchanged or retired 29%

Question D: (Consultants and SpR’s) Should the BGS be examining the option of career progression for geriatricians with less acute and more community based work later in a career? Yes 80%; No 20%

Question E: (Consultants and SpR’s) Should we be reducing our input to acute take medicine now? Consultant Yes 47%; No 53%. SpR’s Yes 27%; No 73%

Question F: (For SpR’s only) Realistically most jobs can only contain three of the four components above. All being equal, which one currently holds the least interest for you?
Emergency Care 27%; General geriatric work 2%; Specialist services 11%; Community based work 60%

References:
1. Geriatric Medicine in Consultant Physicians Working for Patients Second Edition Royal College of Physicians London 2001

2. Stuck A SuiAL Wieland GD,Adams J, Rubensein LZ. Comprehensive Geriatric Assessment: A Meta Analysis of Controlled Trials. Lancet 1993;342:1032-1036

3. Urgent Care in Older People, Statement from the National Director of Older Peoples Services. Department of Health 2003

4. The Older Patient in the Accident Emergency Department. Joint statement of the British Geriatrics Society, the British Association of Accident and Emergency Medicine, and the Royal College of Nursing. British Geriatrics Society Compendium Document C2.2000

5. Acute Medicine. Draft Report. Royal College of Physicians, London 2004.

6. Older Person in the Accident and Emergency Department (Addendum to reference 4) The Role of Specialist in the Care of Older People. The Joint Statement by the British Geriatrics Society, the British Association of Emergency Medicine and the Royal College of Nursing. BGS London 2004.

7. Developing Intermediate Care to support reform of the Emergency Care Services. Support of the Intermediate Care working group 2003. British Geriatrics Society London 2003.

8. Emergency Medical Admissions: New Recommendations. RCP London College Commentary September/October 2003.

9. National Service Framework for Older People. Department of Health London 2001.

10. Medical Aspects of Intermediate Care. Report of a working party. Federation of the Medical Royal Colleges London 2002.

11. Department of Health: Practitioners with Special Interest
http://www.doh.gov.uk/pricare/gp-specialinterests/

12. Health and Care of Older People in Care Homes. Working party report. Royal College of Physicians London 2000.

13. Consultant Physicians Working with Patients – 3rd Edition. Royal College of Physicians (London) in press.