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Long term conditions are the main reasons for multiple pathology, and multiple pathology is the main explanation for non-specific presentations of disease that typify geriatric medicine.

These conditions include the geriatric giants of immobility, instability and intellectual impairment.

Long term conditions are managed principally in primary care settings, yet much acute hospital work can be seen as episodes of exacerbations of long term conditions rather than de novo acute, self limiting conditions. Hospital care and community care are part of the same process of managing long term conditions.

Secondary care services are able to develop specialist areas of expertise, for example, in stroke, Parkinson’s disease and in falls. This expertise is required both for those who are acutely unwell and also for those in the stable phases of their long term conditions.
It follows that promoting community geriatricians in support of this process is required, including:

• training of geriatricians for this role
• supporting the CPD for geriatricians in this role
• taking a lead on the multi-disciplinary education and training of staff involved in these services and identifying the R&D needs in this process

Policy developments strengthening primary care provide the specialty of geriatric medicine an opportunity to review and strengthen its partnership with primary care. The Department of Health has promulgated a three level model for the management of long term conditions: self management, disease management and case management for those with complex and multiple conditions. It is to this latter group that geriatricians have most to offer, backed up by the evidence-based practice of comprehensive geriatric assessment.

The BGS Primary and Continuing Care SIG offer a model of care for frail older people, and this is intended to be useful for the effective implementation of services for such people, including case management (Figure 1).

Fundamental to any system managing long term conditions is the requirement of the patient to access appropriate types of treatment, delivered in a flexible and collaborative fashion wherever the patient lives. These should include:

• Acute treatment
• Comprehensive assessment and review
• Rehabilitation and re-enablement
• Palliative care and end of life care

Elements that underpin sound service implementation include teaching, training, governance and research.

A considerable number of frail complex older people suffering from long term conditions live in care homes and in some areas account for a disproportionate number of admissions to acute hospitals. A case management system such as has been demonstrated to be effective in the United States could be used in the United Kingdom.

The role of the geriatrician should include:

• Participation in the management of older people with multiple long-term conditions, as well as common conditions in older people affecting their function such as Parkinson’s disease
• Providing advice at times of transition, recognising the limitations of active intervention and the importance of palliation
• Providing specialist clinical support to primary care in the management of frail older people especially at the time of a health crisis
• Providing professional support for assessment processes used on older people, in particular the assessment for NHS continuing healthcare and NHS funded nursing care
• Leadership of clinical governance arrangements for services outside the hospital.
• Nurturing the multidisciplinary team in the primary care sector, including teaching
• Leading and facilitating the R&D in services for long term conditions.

This article represents a summary of a document which was revised by the BGS Primary and Continuing Care SIG this year, with particular contributions by Prof John Gladman, Dr Ian Donald, Dr Willie Primrose and Dr Chris Turnbull. The full document can be downloaded from the BGS website www.bgs.org.uk (Select Publications / Reference.

BGS Newsletter, November 2009
Issue 24 ISSN 1748-634000 24