This report addresses part of the remit of the new Health Select Committee Inquiry, with a focus on the specialist medical needs of frail older people and difficulties in recruitment and training of specialists in the face of increasing and diversified service demands.

In relation to the stated remit of the HSC Inquiry, while recognising that a broad group of professionals, volunteers and informal carers are equally important, this submission largely confines itself to issues relating to specialist medical care for older people from the perspective of the British Geriatrics Society whose central concern is excellence in clinical care of frail older people.

A prevailing view in society is that the clinical and functional problems of old age are inevitable and medical intervention has little to offer. The challenge to this notion in the 1940s led to the birth of the specialty of geriatric medicine, whose conception and evolution are described in Appendix 1 of the full version of this document.

• What essential skills does the geriatrician offer?
• Generic specialist skills
• Clinical skills in the detailed medical and functional assessment of older patients with multiple physical and mental problems and correcting that which is treatable.
• Recognising the potential for re-establishing functional independence by the twin approach of targetted medical and nursing treatment and rehabilitation and in many cases leading or at least steering a multi-professional effort on the patient’s behalf

Sub-Specialist skills
The common problems of old age have resulted in increasing specialisation within geriatric medicine, for example in the areas of :

• Mental health (the separate but connected specialty of Old Age Psychiatry)
• Stroke illness (boosted by good evidence that good acute care and coordinated rehabilitation improve functional outcomes)
• Prevention and treatment of falls and fractures (with growing evidence of effective treatment and preventive strategies)
• Advanced neurological disease such as Parkinson’s disease

Readers of this newsletter will know that geriatric medicine is the largest medical specialty in the UK and has a central place in the acute and rehabilitative care of older people with ever increasing demands on its consultant staff. The senior medical workforce of the specialty has increased by nearly 4% per year in the last 13 years to over 1100 in the UK this year.

In the 13 years since the Royal College of Physicians established an annual consultant census, the number of consultants in geriatric medicine has risen from around 650 to over 1100 in the UK. The report to the HSC tries to demonstrate that work demands have increased even more and there is concern about a growing shortfall of consultants. It attempts to quantify the medical workforce shortfall in the specialty of geriatric medicine and draws attention to the reasons for a widening gap between the work demanded of consultant geriatricians and the availability of consultants to do the work.

Based on a requirement of one geriatrician for 35,000 population there is a current shortfall of over 600 whole time equivalent (WTE) consultants in geriatric medicine in the UK (further details in Appendix 2 of the online report).

Hospital doctors provide a 24 hour, seven day a week service. As the largest contributors to emergency medicine, geriatricians and their trainees have been profoundly affected by the restrictions imposed by the implementation of the European Working Time Directive (EWTD). The RCP and BGS have examined this issue in depth and have concluded that it will be impossible with the projected workforce supply to approach legal working hours for between 6 and 8 years (if ever). The calculations upon which this conclusion is based are presented in the full report.

Recruitment and training of specialist registrars
The BGS believes a number of factors are causing difficulties in recruitment and training of Specialist registrars in Geriatric Medicine. Chief among these is the impact of the implementation of the EWTD (manifest as heavy involvement in 24 hour emergency medical care and implementation of shift working). It is having a profound detrimental effect on continuity and quality of patient care and on recruitment of specialist trainees. Quality and quantity of specialist training is reduced by the disruption caused by shifts and the loss of continuous or regular engagement on specialist wards or clinics.

Shifts are also deeply unpopular with registrars and are causing considerable concern in relation to recruitment into hospital medicine in general (more details in Appendix 3 of the online report).

Other factors affecting specialist training and recruitment are disappearance of specialist services such as rehabilitation wards and community hospitals, shortening of the period of medical training requiring earlier selection of specialty (“Modernising Medical Careers”), and competition for trainees with other expanding medical specialties.

Increasing difficulties in recruiting registrars in certain part of the UK have been detected.

Recruitment and retention of consultants
Work pressures have steadily increased due to rapid increase year on year in involvement of geriatricians in emergency care - now over 86% - while other specialties have withdrawn and are continuing to do so. This is added to by an increasing requirement to work on multiple sites.

The direct and indirect consequences of the EWTD are profound and far reaching (Appendix 4 of the online report). For example, the ‘medical’ firm which promotes good communication and continuity of patient care has been severely disrupted by non-availability of junior doctors who are working shifts.

Early retirement
The most recent Consultant Survey by the Federation of Medical Royal Colleges described the age structure of the consultant work-force. In the UK as a whole, 25.7% of male and 11.1% of female consultants (all specialties) were 55 or over and therefore likely to retire over the next 10 years. Despite shortages (and perhaps partly because of them), 78% of male consultants and 22% of females expressed the intention to retire before age 65

Impact of the National Service Framework
The National Service framework for Older People (NSFOP) has been broadly welcomed and emphasises the specialised nature of care of older people. However its development is having a substantial impact on the demand for new skills and increased consultant numbers. A recent survey of this aspect is presented in Appendix 4 of the report which shows an increasing engagement in subspecialties such as stroke, falls, orthopaedic rehabilitation and intermediate care.

All these pressures have led to increasing difficulties in filling consultant posts (50% of appointments committees in geriatric medicine in 2003-4 failed to make an appointment).

International recruitment
Apart from the ethical and moral objections to the Government’s proposed legislation affecting “foreign” doctors, recruiting consultants in elderly care medicine has been largely a non-starter since geriatric medicine is very under-developed as a specialty in countries for whom the attraction of greater financial reward in the UK would be the main incentive for moving.

Twenty-four hour a day workforce
Based upon the daily experience of clinicians managing patients as a result of a crisis at night or at the weekend, some thoughts on the deficiencies in our care workforce ‘out of hours’ are described in Appendix 6 of the online report. It is pointed out that those most likely to be institutionalised or suffer a distressing or unnecessary hospital admission include:

• People whose dementia is associated with time disorientation or a tendency to leave home at night or in their disorientation, make ‘day-time’ calls to relatives at night
• Those with mobility problems who need to get up to the toilet at night and who may fall
• People at the end of their lives, for whom out of hours palliative care support is lacking and who may end their lives in a Casualty Department.

Are there solutions to the shortage of doctors in general and consultants in particular?
The Government and NHS recognise the difficulties facing medical recruitment, particularly in the light of the EWTD and some of the measures to address these issues, are in various stages of development and are outlined in Appendix 7 of the report. Briefly these are:

1. Expansion of UK Medical Schools and creation of new ones
2. “Modernising Medical Careers”, a new generic post-graduate training scheme which will shorten the period from graduation from medical school to becoming a consultant (already commenced and to be fully implemented in 2007)
3. Recruiting consultants from abroad
4. Reducing restrictions on Registrar numbers
5. Skilling up and funding others in the care of vulnerable older people including all aspects of Intermediate Care
6. New ‘across the board’ workforce planning arrangements especially the Older People’s Care Group Workforce team in 2001 (Appendix 10 and 11 of the report). One important initiative was to boost medical care of older people by creating new specialist general practitioner posts focusing on care of older people but for reasons mentioned in Appendix 4 of the report, this initiative has largely failed.

Download the full and referenced version of this report.

Alistair Main
Chairman of the BGS Workforce Group