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Use of community hospitals for assessment of complex needs; Use of community hospitals for step up and step down facilities (Dr G Greveson)
On the Society’s relationship with the pharmaceutical industry (Dr Leeming) and (Dr P Diggory and D Griffith)
The BGS Strapline
On Urgent Care Reform - to Professor Ian Philp:
Use of community hospitals for assessment of complex needs; Use of community hospitals for step up and step down facilities
With appropriate criteria and screening, community hospitals are very useful for providing step-down and possibly step-up care. However, it may be more appropriate to develop these services in a more homely residential environment, such as a care home (with appropriate health care input). Community hospitals are well placed (if appropriately staffed) to provide ‘cold’ assessment of patients with complex needs. I have mixed feelings about the use of community hospitals for assessment of complex needs in the acute or semi-acute situation, although I accept that it could be very appropriate in some localities and circumstances. My main concern is that such patients must have timely access to specialist opinion and diagnostic services, maybe via experienced nurse practitioners.
My own experience is that it is often difficult to tell from a patient’s presentation if they require more extensive services than a community hospital can provide. Without ready access to specialist opinion and diagnostic facilities, patients may receive unsuitable management, sometimes with potentially devastating outcomes.
My comments are based on
• c 10years experience with a community based interdisciplinary assessment and rehabilitation team (Newcastle)
• c 4-5 years experience with a residential community rehabilitation service providing step up and step down intermediate care in a local authority residential home (Newcastle)
• c 6 months experience with a multidisciplinary intermediate care assessment team based in an acute hospital adjacent to the A&E department (Ashington, Northumberland) linked to intermediate care services (such as rapid response nursing service in the community or a rehabilitation ward in a community hospital).
In these services I have encountered ‘exacerbation of arthritis’ that turned out to be bone metastases, fallers with sub-dural haematomas, ‘not coping’ (anything from a brain metastasis to hypoxia to heart failure), someone with acute renal failure due to a drug reaction and so on.
Interestingly, not all such patients require admission to an acute bed. With good knowledge of services and alternative facilities ranging from rapid response nursing services, ready access to basic and more sophisticated investigational facilities together with senior medical input means that it may be possible to institute an appropriate management plan that is acceptable to patients and may avoid acute hospital admission.
Key elements of a successful assessment and intermediate care service include:
Ready access to diagnostic facilities
In all cases I have found it important to have easy access to investigations and appropriate medical specialists to ensure that patients receive the appropriate diagnosis and management. In Newcastle that was achieved by ready access to a geriatric day hospital on an acute hospital site and good arrangements for out of hours medical input from a GP practice.
Guidance on referral criteria and referral pathways
This does not just mean production of a written referral checklist in isolation. It requires good knowledge of the range of services available in primary and secondary care and from social services. It requires significant dialogue (and often debate) with potential referrers and other crucial providers such as the ambulance service. It demands constructive feedback to educate referrers who refer inappropriately and to reinforce appropriate referrals.
Skilled and knowledgeable team members
As well as expertise related to individual disciplines, team members working in such services need to be aware of when, how, and how urgently, to request input from medics (whether GPs or specialists). This requires careful in-service training and monitoring.
Robust medical cover arrangements
Geriatricians need to be readily available to provide advice if not direct input to ensure patients receive appropriate management in a timely manner. It is very important that doctors involved in such services are seen as accessible and supportive so that they are called when team members are uncertain or worried about a patient.
Excellent networks
As there is a growing range of services that referrers can access for patients with complex needs, it is very important that the various services work closely together and understand the remit, expertise, strengths and limitations of all the services in an intermediate care network. It is particularly important to have links to old age psychiatry services.
Gabrielle Greveson FRCP, Ed D
Consultant Physician and Honorary Senior Clinical Lecturer
Elderly Medicine
Wansbeck General Hospital
Woodhorn Lane
Ashington
Northumberland NE63 9JJ
August 2006
On the Society’s relationship with the pharmaceutical industry:
Dear Dr Beaumont
We agree with the position you have stated with regard to relations with the pharmaceutical industry. There is ample evidence of the deleterious effect of getting too close to the industry. (See for instance the BMJ of 31 May 2003 and the "No Free Lunch" campaign). The pharmaceutical industry would of course like us to be very dependent on them for funding as this would increase their influence still further, with adverse consequences for patients and for the NHS as a whole. Anything which takes us further in the direction of reliance on the industry should be strongly resisted and indeed we should be seeking to draw back from our present close links. Some of us feel that doctors earn sufficient to be able to bear the full cost of meetings without any industry sponsorship but we realise that at present this is likely to be a step too far for most people. It would, however, be an excellent example for the BGS to set for the rest of our colleagues.
Yours sincerely
David Griffith and Paul Diggory
Consultant Physicians
Care of Older People
On the Society’s relationship with the pharmaceutical industry:
Dear Dave
The contribution by Dave Beaumont “for the prosecution” – on the Society’s relationship with the pharmaceutical industry featured in the July Newsletter - is absolutely excellent, and should be lauded as a landmark contribution to this debate which has raged at least since I joined the BGS in 1960.
In my view the Society should adopt in entirety the principles he sets out for governing relationships with the pharmaceutical industry. His points are not anti the industry, but embody just the right stance to allow mutual relationships to develop in an ethical and constructive manner. To water down his remarks would detract from the dignity and standing of both the BGS and the industry, and would not be worthy of the high scientific and ethical standards professed by both bodies.
Dr J T Leeming
Manchester
On the Society’s strapline:
Dear Dr Beaumont
Apropos your note on developing a new strapline for the BGS logo, you may be interested to know that the first one - ‘For the health of the aged’ - was the brainchild of Saatchi and Saatchi. In the mid-1980’s, during discussion on the perennial issue of the Society’s name, the BGS Executive Committee was informed that Saatchi and Saatchi were offering a one hour free consultation to charities (perhaps they still do). So Robert Kandt, BGS Administrative Director at the time, and I went along to their premises to get the view of two of their experts on problems associated with the name ‘Geriatrics Society’, its pejorative context and being perceived as a society for old people.
Their advice was to keep the name (which I am sure was sensible since ‘geriatrics’ was becoming recognised world wide) - but to add a sub-title, “for the health of the aged”. This was changed in the 1990s to “For health in old age”.
Good luck in updating it.
Yours sincerely
Professor John Brocklehurst
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