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Community geriatrics is not new. Warren saw patients in care homes. Ferguson Anderson ran combined GP clinics in Rutherglen in the 1950s.

He initiated retirement courses and emphasised the importance of prevention. In Belfast, Adams delivered rehabilitation services to old people living at home using a van which carried a range of therapeutic equipment. In Edinburgh, Williamson developed a system of assessing patients at home before considering hospital admission. The father of community geriatrics was Sheldon, whose book “The social medicine of old age” is a classic. He visited old people in Wolverhampton and made important observations on falls, nutrition and poverty.

However, in recent decades there has been an understandable emphasis on acute hospital care – far better to treat sick old people comprehensively in the early stages of their illness than to try and rehabilitate those who have developed iatrogenic diseases, such as pressure sores and contractures. Most geriatricians in Britain devote much of their time to managing large numbers of ill and disabled old people in hospitals. Beds are often scarce and the idea that closures can continue may seem unimaginable. Yet health analysts and policy makers are convinced that we need even fewer beds.

The arguments include technological innovations (such as minimally invasive hip replacements, further advances in therapeutic radiology), the anticipated benefits of screening and early interventions (e.g. lowering of blood pressure and cholesterol, bone protection, vaccination), the earlier detection and focused treatment of cancers. There are differences internationally in lengths of stay and the range of services in care homes and in people’s own homes. As geriatricians, we must accept that few wards are designed to best meet the needs of many old people, especially those with delirium and physical disabilities. Add to these a range of health care providers, patient choice and convenience, external pressures (such as the European working time directive), centralisation of hyper-acute services and centrally-directed financial pressures to divert care from hospital and to effect earlier discharges, and we can envisage that the style of health services will soon very different.

My initial views on community geriatrics were sceptical. As a profession, we had not been consulted in the move away from hospital. Models for the future configurations of health care omitted mention of old people with complex problems, despite this group forming a large proportion of in-patients. New practices were introduced without evidence for effectiveness. There seemed to be a deliberate plan to exclude doctors from the community model of care (indeed, some PCTs still do not employ geriatricians and there is a tenacious belief that a “social” model of care is preferable to the “medical” model). The development of community services was predicated on questionable assumptions: that elderly care is easy and anyone can do it; that community care will be cheaper. I was concerned that bed closures and the move towards a community model would occur before there were sufficient staff and facilities to ensure that old people and their families would receive timely, comprehensive, high quality care outside hospital.

In Leeds we now have five consultants who do five community sessions each week and two others who work in a nurse-led community unit and who are developing other services, such as community out patient clinics. The work is varied, challenging and enjoyable. We each have our own approach and different initiatives are developing in different parts of the city – e.g. palliative care in nursing homes, closer working with community matrons and nurse consultants. We meet monthly to share ideas and experiences. We act as links between hospital and home – obtaining full patient details, summarising complex cases, clarifying plans for therapy (e.g. details on weight-bearing after fractures), ensuring that rehabilitation aims are clear, mutually agreed and realistic. We do regular rounds in care homes, seeing intermediate care patients and their families as well as permanent residents. We visit patients at home or in other care homes at the request of GPs or intermediate care colleagues.

We also act as sources of information and advice for all members of the team. We are often asked to see patients who are causing concern to colleagues. We give tutorials and informal teachings and are developing guidelines on “red flags” – conditions which may need urgent recognition, diagnosis and intervention. We have developed a community geriatrics undergraduate teaching firm. Research includes work with engineers on hoist design and instruments to identify those at risk of pressure sores.

What are the frustrations and limitations of community work? Pressures on GPs to keep old people out of hospital can mean that some people do not get the right care in the right place at the right time. Reductions in bed numbers can delay admission. Inadequate numbers of ward staff mean that discharge planning is not always as meticulous as it might be and getting full information can be time-consuming. There are delays in getting some investigations done. The time needed to assess people in care homes is much greater than that needed to do a similar evaluation in hospital. Co-ordination with Social Services needs to be improved
The move to the community is bound to accelerate and community geriatrics will become a major element in the repertoire of services that we provide. The challenge is to ensure that this policy enhances rather than threatens the care of sick and frail older people.

Graham Mulley
President-elect