September saw the culmination of twelve months of negotiation and preparation. A workshop organised by the NHS Confederations in partnership with the British Geriatrics Society was held at the Kings’ Fund London. Fifty participants attended and there was a waiting list of about 20 or more for empty spaces. The audience came from a wide variety of backgrounds including general practice, managers of primary care trusts, nurse consultants, directors of social services and community matrons.

Chaired by Dr Jeremy Playfer, speakers included Penny Banks, a Research Fellow from the King’s Fund, Prof Graham Mulley from Leeds, Dr Elizabeth Kendrick, a GP from Durham, Prof John Gladman, then Reader in Geriatric Medicine from Nottingham and Dr Duncan Forsyth, Chair of the Mental Health and Ageing Special Interest Group, now Deputy Chair of the English Council.

Penny Banks, the first speaker, had recently helped edit the King’s Fund Care Services Inquiry published in summer 2005. She described integration as well planned and well organised sets of services and care processes targeted at the multiple needs/problems of an individual client to enable the individual to live as they wish.

The Inquiry investigated whether the current Care System met the care support needs of older people across health, housing and social care. It found that:

• Integrated services were the exception rather than the rule.
• Services provided were regarded as traditional and of varying quality.
• They were identified as being under pressure with gaps in provision and limited prevention work.
• Partnerships were still under development with a lack of overall strategy about managing market development.
• Manpower, staffing and recruitment, ageism and the cost of land and property all add to the challenges of building a cost effective service to meet the high demands of an ageing frail population.

Penny asked the audience whether the re-configuration of PCTs, practice based commissioning, payment by results and the choice agenda, new co-ordination and case management roles and foundation hospitals could be seen as an opportunity or a new challenge. She suggested that successful implementation of integrated care will require early investment with local strategies taking account of local needs. There is no one size fits all.

Comprehensive assessment
Jackie Morris’ presentation was based on the compendium document on comprehensive assessment of frail older people. She described the key ingredients of rehabilitation, with a short explanation of disease, impairment, disability and handicap with an update on the 2001 description of impairments, limitation and restriction. This stresses the importance of body function and structure, activities and participation. She presented a working definition of frailty which when linked in with the single assessment process should identify those patients who need a comprehensive assessment from the multi-disciplinary team.

Community geriatric medicine
Prof Graham Mulley gave an illuminating presentation on community geriatric medicine. He emphasised how important the themes of harmonisation, comprehensiveness as well as the sharing of skills, knowledge, ideas and experience were to the care of older people. He explained that accurate diagnosis, comprehensive assessment and the best of modern medicine are the foundations of good care. He reminded the audience that many social problems are medical problems in disguise.

Graham explained how the Leeds model of Community Geriatric Medicine had arisen as the consequence of concerns about admission avoidance schemes, late referrals, stuttering admissions and readmissions as well as the absence of geriatric medicine from the social work model. This contrasted with the concerns expressed by the community about the erosion of the primacy of the GP, boundaries, problems about hospital notes, staffing levels and skills, audit, governance and the quality of long term care. GPs and the Intermediate care team had experienced problems caring for patients with no information from the hospital.

The Leeds model for 5 PCTS includes six community geriatricians, weekly rounds in selected care homes to see all the intermediate care residents, information sharing, attendance at case reviews, telephone and personal advice, domiciliary visits and tutorials. Rapid access clinics, locality links with wards, were established. Specialist teams in Stroke, COPD and palliation as well as a night sitting were set up. Regular teaching sessions were given in the community to nurses, medical undergraduates, managers, overseas visitors, and specialist registrars.

The benefits of the Leeds model have included:

• The dissemination of notes to the Intermediate care team, GP, clinics and Accident and Emergency
• Standard use of Abbreviated mental test score
• Weight bearing advice on older orthopaedic patients
• Advance statements
• Recommendations for investigations faxed to GPs
• Recommendations for therapy faxed to therapists
• Breaking down the barriers between the hospital and the community

Graham envisages that in the future there will be timely clinical information for all PCT patients, more teaching rounds in care homes, expansion of rapid access clinics, and greater involvement of nurses with an extension of their roles in the community. He sees research and audit being put in place to evaluate and demonstrate the benefits of good practice in an integrated service to the community.

Long term conditions
Prof John Gladman explained that the lessons learnt from his community service were almost identical to those presented by Prof Mulley. He described the Primary and Continuing Care SIG’s view of a model of care in long term conditions, with the aim of clarifying the wider aspects of the requirements of a service, and hence how these should be integrated (vertically or otherwise).

John reiterated the importance of understanding the concept of frailty in the planning of services for older people: not all older people are frail or need special services, but the most difficult and heavy health and social users usually are. He also emphasised the point that the process of comprehensive geriatric assessment is the process that frail people need to receive to improve their health and well-being. The job of those planning services is to ensure that this happens, and that can only be done when the process is understood.

He pointed out that services for older people are increasingly intended to follow a chronic disease model, which is anticipatory rather than reactive. Nevertheless, models of chronic disease management must include appropriate access to acute care despite the importance of prevention of inappropriate emergency department attendances and hospital admissions. Acute care, in turn, should be configured as a support to chronic disease management, and therefore needs to be fully integrated into it: primary, intermediate and secondary care all need to work together. The community geriatrician is ideally placed to help bring about such integration on a case-by-case basis.

John reminded the audience that many frail people with long-term conditions do not need long term care, because they die of or with them. This means that as people become frail, preparation for end of life care is also important over and above the preparation for life with the condition itself. This aspect of service delivery and planning is easily overlooked but is included in this model.

He finished by emphasising the importance of team work with the understanding that the structure of teams will be influenced by the organisational structures in which staff work. Similarly education, research and development are crucial to the sustainability of services, but if these elements are not planned and integrated into services, then such services will not flourish.

General practice with a special interest
Elizabeth Kendrick, a GP from Durham described her role as a GP with a special interest in older people, explaining how her work is proactive rather than reactive. She covers 14 nursing and residential homes with help and support from a nurse practitioner.

Joint ward rounds and joint practice meetings take place with consultant physicians and old age psychiatrists. Her focus areas have included: falls, palliative care, continence and tissue viability. She had instituted falls assessment and had developed a falls policy, and a falls steering group within the GP quality and outcomes framework. She suggested that one way of improving services for older people was to adapt the quality and outcomes framework nationally within the GP contract, to meet more of the needs of older people.

The proceedings concluded with a presentation by Duncan Forsyth, a consultant geriatrician from Cambridge. He concentrated on the needs of older people with Dementia. Duncan gave an entertaining presentation enlightening the audience with a description of the importance of identifying frequent fliers. He explained that older people with mental and behavioural disorders are more likely to attend A&E regularly and also have more readmissions. He described the case register model, (presented in full in the new consensus document, ”Delirious about Dementia”.

One in five people aged over 80 develop dementia, said Duncan, and 61% of older people have psychiatric illness including depression, delirium and dementia. He talked about how liaison psychiatry had benefited older people and reminded the audience of National Service Framework Standard 7: Older People who have mental health problems have access to integrated health services provided by the NHS and Councils to ensure effective diagnosis, treatment and support for them and their carers. Shared care must be a reality. Joint working should be established.

He emphasised that diagnosis of mental health problems requires expertise and a management strategy. An “at risk register” can be set up by identifying “frequent fliers” and plans for crisis anticipation in addition to crisis management and end of life plans should be set up.

At intervals throughout the day there was a very useful interchange of ideas and discussion. The workshop succeeded in demonstrating the benefits and importance of geriatricians working alongside GPs. Their expertise in the community will contribute to reducing inappropriate emergency admissions, readmissions and admissions to care homes, as well as ensuring that intermediate care works. They should ensure that complex problems are dealt with in depth as well as breadth and that opportunities for cost effective and beneficial treatment are not forgotten.

Jackie Morris
Chairman, BGS Policy Committee