The motion: “Geriatric medicine has no future” was bound to stir opinions before a shot had been fired.

The bulk of the audience were geriatricians, with the rest from a range of backgrounds in nursing, therapies, patients' groups, charities and journalism.

Do turkeys vote for Christmas? At the start of the evening, I was expectant but wary. However entertaining the device of a debate, its false dichotomy can obfuscate the real questions, sacrificing constructive dialogue on the altar of entertainment. Perhaps the question would be better posed along the lines of "should geriatric medicine have a future?" and "if so, what kind of geriatric medicine does the NHS need or would we as its practitioners like to see?"; "How can we best ensure that the specialty adapts to secure its future?" and "How can we ensure that it works mainly to promote better care of older people rather than simply to perpetuate itself?" A fascination of the evening would be to see how the four protagonists tackled the same question from a variety of angles.

Proposing the motion, Dawne Garrett, a nurse consultant from Poole Primary Care Trust, Dorset, bravely entered a den where the share of the lions were hospital doctors in this apparently doomed discipline, which as she pointed out was just sixty years old and had nearly 1,000 UK exponents. Perhaps its "vigour and progress had plateaued". In an ageing population, patients increasingly value choice. Health is not just about responding to crises or illness, but about promoting and maintaining complete physical and social wellbeing. Geriatricians are largely lacking from public health, from community, care home or primary care. Nor are they conspicuously involved in new technologies for older people, lobbying, education or information. Patients value an accessible, responsive service, delivered within or close to their own home, including the ability to spend a great deal of time talking through concerns with their clinician, and direct communication via text or personal phone call. A medical model based largely in secondary care, can not meet these needs. When it comes to accessing diagnostics, or the management of long term conditions, GPs maintain that these are core primary care skills. A high-turnover hospital setting does not meet patients' wishes, is depersonalising and does not allow for considered, holistic assessments of their true abilities or needs. The choice agenda might lead to patients themselves rejecting the notion of geriatrics. Compared to less acute, often nurse-led services, consultant geriatricians and hospital teams are an expensive resource. Consultant geriatricians are paid twice as much as nurse consultants but "are we twice as effective?"

Having block by bock demolished the original rationale for the existence of the specialty, Ms Garrett then moved on to its contemporary stronghold - acute hospital care of older people and medical leadership of the multi-disciplinary team. Even here, she argued, team leadership could be provided equally well by others. And the array of service models for hospital based geriatrics does not suggest that there is any proven model for effectiveness. Such models often fail to meet expectations - with, for instance, patients being admitted serially under different consultants, providing poor continuity of care. For all of this, Dawne did admit, in her closing slide that she was really arguing that geriatric medicine had no future in its traditional format.

A little time travel....
Supporting Dawne in her argument was Sheffield's Prof Stuart Parker. In a futuristic "Sci-Fi" presentation he envisaged talking from 2,300 to a holographic projection of himself from 2006. Taking a further "trek" through time, he described the historical origins of the specialty - from the 1601 Poor Relief Act, through to the seminal work of Warren and Exton Smith in the 1940s. The cornerstones of geriatric medicine, at its establishment were the care of the chronic sick and infirm, therapy and rehabilitation and long term care. Yet data from Sheffield shows that there is now specialist medical input into only 27% of teams caring for older patients, 92% of day hospital patients and only 48% of patients with community rehabilitation teams.

Geriatricians are playing an increasing role in the acute medical take, as some organ specialists withdraw. The number of acute admissions is rising, yet the number of specialist elderly care beds is falling. In short, as a specialty we have abandoned long term care, are not widely involved with intermediate care and have next to no involvement in continuing care. The original rationale for our existence is fast disappearing if we actively eschew, or are neither asked nor funded by primary care trusts or local authorities to perform these roles.

Specialists in the community
Leading off for the opposition was John Gladman - congratulated on his recent appointment as Professor of Older People’s Medicine in Nottingham. He is spending an increasing amount of his clinical time in the community - supporting intermediate care teams and community matrons, reviewing care home residents in conjunction with their GPs and regularly assessing patients in their own homes. He has also recently completed large clinical trials on the effectiveness of intermediate care approaches in Nottingham - with specialist medical input very much part of the model. The role of geriatricians in the acute medical assessment unit is also growing - crucial to making the right decision at the hospital's front end, but also to managing the whole bed pool well.

John argued that geriatric medicine would indeed have no future, so long as no-one suffered falls, strokes, frailty, dementia or delirium, everyone lived to 120 with morbidity compressed to the point that there was no disability in ageing, and all other countries had solved their own problems around medical care for an ageing population. That time is not imminent. With an average of only 5-10 Community Matrons, yet 25 care homes per Primary Care Trust; with inadequate capacity in intermediate care schemes; with the rising tide of acute medical admissions and the number of frail older people in clinical areas throughout the general hospital, it is hard to see how all the unmet need can be managed by alternative new models of care.

Rather than reeling off evidence from clinical trials, John further illustrated his argument with a series of clinical vignettes (which any good geriatrician would recognise from their daily practice), illustrating the complex skills required to turn apparently functional problems into reversible diagnoses and to manage patients with multiple morbidities and non standard presentations. It was the very unexceptional, everyday nature of these cases which made his point so tellingly. Time and again, it was precisely the involvement of a geriatrician which solved (often quickly) problems which had lain unrecognised or untreated by primary care staff, nurses or other hospital specialists. The case histories also demonstrated just how much GPs, community matrons and other hospital specialists actively sought and valued these skills. Our future is secure, but we need to re-invent our role to develop more involvement with the primary care, long term care and long term conditions management in order to maximise our effectiveness in health systems and safeguard our future. We also need to be persistent and active campaigners for better elder care, perhaps echoing the Shavian view that all change is achieved by the "actions of the unreasonable man".

Driving change
Receiving this baton was Prof David Black - also celebrating his recent elevation to a chair. Apposite to John's final remarks, his arguments were based as much on our role as champions, drivers and managers of change for older people’s care as on our clinical role.

The triumphs of the specialty are manifest and we should not be squeamish about proclaiming them. In just over half a century we have secured innumerable gains; getting care out of the workhouse; active rehabilitation, acute assessment and care for all older patients in the district general hospital; the day hospital; medical assessment before long term care; comprehensive specialist geriatric assessment (unequivocally effective); ward based multidisciplinary teams. Moreover, the huge progress made, for instance, in services for falls, stroke, orthopaedic rehabilitation has been driven by our specialty, when largely neglected by others. The National Service Framework has resulted in no small part from our activities and has resulted in an older people’s medical tsar. As a result, tangible progress has been made on a number of key targets - especially in falls, stroke and ageist policies, though there is still much work to be done and no room for complacency. (How many localities, for instance have a truly whole systems approach to falls and fracture prevention, skilled general hospital care for all older patients, or adequate responsiveness and capacity in intermediate care schemes?)

Tellingly, those targets such as person-centred or intermediate care, with less medical input are those against which progress is slower. We are world leaders in falls services and, are still seen as a model from which other countries actively seek to learn. We have also influenced the DoH on other operational issues such as delayed discharge. Our role as campaigners and our influence as change managers, is not to be underestimated. This means actively engaging with change, not only at national level, but also in local health economies - collaborating with other agencies to improve services for older people. Of course, the NHS is in constant flux, the agendae and regulatory frameworks and structures ever influencing the daily workings and strategic direction of our specialty. But this does not negate the value of geriatric medicine and the ever changing climate could be viewed as throwing up new opportunities, new ways of working, rather than threats to our existence. Centrally mandated initiatives to develop the role of specialist nurses or GPs with special interest notwithstanding, others are not queuing up to take up much of our current workload or leadership role.

And the verdict is...
A lively debate from the floor ensued. Perhaps the most telling contribution was by a year four registrar, who said she would dearly love to receive some training in community geriatrics but that acute hospital medicine had completely predominated, leaving her ill-prepared for wider roles as a consultant. At outset, the vote in the hall had been against the motion by a ratio of 3 to 1. After the debate, the motion was defeated even more strongly. It might be argued that the composition of the audience, rather than the strength of the arguments guaranteed this outcome, though all four speakers were equally erudite and compelling.

Having attempted to report the debate impartially, I will admit that my own views are partial - and bound to stir some correspondence! It is clear that even within the general hospital, there is great unmet need in frail complex older patients on the acute take and in all clinical areas. Patients for whom outcomes are improved by specialist medical and multidisciplinary input - and who are rarely well catered-for by single organ specialists in non-dedicated wards, unless they take a particular interest in "joined up" care. Most adult physicians and surgeons are more than happy for us to take a healthy proportion of such patients off their hands. And experience dictates that once regular geriatric input has been provided, its withdrawal causes great dissatisfaction. We may have a "soft" skill, not so visible as procedural ones such as those provided in the endoscopy suite or catheter lab, but it is a real and complex one. And as John Gladman illustrated, it can best be defined by the way in which others fail to address the problems of older people.

We would not make a tacit assumption about any other specialty, that several years of higher specialist training and a career spent exclusively in this area conferred no extra benefit to diagnosis or management. Assertions by General Practitioners that managing chronic illness in older people is a core activity for them are justifiable. However, there is a shortage of properly accredited GPs with a Special Interest available. And the latest QOF for the GMS contract contains lamentably few incentives around older people’s care - for instance nothing on fall or fracture prevention. Intermediate care teams, General Practitioners and community matrons among others clearly value and seek our input. With regard to leadership of multidisciplinary teams, of course, senior nurses or therapists may be equally skilled in overseeing rehabilitation or discharge planning, if they have continued to be ward based clinicians. However, as doctors we have a unique and rigorous focus on turning apparently functional problems into reversible diagnoses.

As Prof Black argued, our role in campaigning for and shaping change at local and national level - often in previously neglected areas of clinical practice is not to be underestimated, nor the gains made as result. But we need to be constantly aware of the shifting agenda and adapt our role and influence accordingly. For instance, the targets for case management in long term conditions and the implications of the draft White Paper with an even greater emphasis on alternatives to hospital admission and the use of community hospitals may alter the way we practice and the policy priorities of our society.

With regard to choice, of course services should be more patient-centred, but it strikes me that for many of the frail and vulnerable older people we look after, it is advocacy, non ageist treatment and a proper assessment and management plan which they require most. It is also unhelpful to assert that nurses have superior skills in holistic care, empathy or communication when compared to senior geriatricians. Simply asserting this mantra does not make it automatically true and is as patronising as a claim that only doctors can lead a multidisciplinary team. There will have to be massive recruitment and training of existing nurses into nurse consultant or community matron roles to compensate for the roles currently played by specialist geriatricians, should the latter disappear. To deny older people a rigorous assessment by a specialist clinician is inherently ageist.

The working practices and role of modern day geriatrics may have evolved from Marjory Warren's original "mission statement", but all medical specialties (and indeed the role of nurses and GPs) have evolved beyond recognition in the past 50 years, without being seen to be doomed. In the end, I was left feeling that both Dawne Garrett and Stuart Parker were really arguing that geriatric medicine had no future - as initially envisaged and practiced. Despite the push in the NHS plan to devolve services to the community, there appears no imminent danger of need drying up for our skills in the general hospital. At the same time, we need to revisit our historical roots and claim proactively and vigorously, a greater role in primary, intermediate and long term care, rather than waiting for a call which may never come. Our greatest potential threat is that primary care may decide not to invest in our services, however eager we are to be on board. We may be seen to be an expensive resource and one which could largely be supplanted by other professional roles. Our greatest opportunity is the knowledge that getting the care of older people right is key to the whole health and social care system. So we need to engage actively and early with new agendae. I will leave the last words to John Gladman , "I have seen the future, and it looks wonderful"

Correspondence to the Newsletter on this debate would be welcome.

David Oliver
Senior Lecturer, University of Reading,
Consultant Physician Royal Berkshire Hospital,
Hon Dep Sec
British Geriatrics Society