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Anyone who has followed the pattern of job descriptions for consultant posts advertised in the last few years will have noticed that a substantial number require an interest in Intermediate Care or Community Geriatrics.

We are also informed that many established consultants have negotiated job plans that include various clinical duties in the community setting. This trend began several years ago but the line is becoming steeper. Of course, there is nothing new about the concept of community geriatrics, and some excellent services have been in place for many years in, for example, parts of Wales and East Anglia. However, it was the managerial shift towards the idea of Intermediate Care across the UK (except Scotland) that nudged, or in some cases threw, the centre of gravity of medical and therapy services for frail older people in the community direction. These changes needed to be reflected in the higher training curriculum for geriatric medicine so the SAC incorporated a better defined set of learning objectives, teaching and learning methods and assessments for “Intermediate Care and Community Practice” in the last two revisions of the curriculum, including the current version that has been approved by Postgraduate Medical Education and Training Board (PMETB).

Community Geriatrics in the approved curriculum
Trainees and trainers should note that this nationally (UK) approved curriculum is the standard against which progress will be assessed at ARCP and in the run up to CCT, so any locally produced curricula for Intermediate Care / Community Geriatrics must be consistent with the UK curriculum and must equal or exceed it for content and delivery. A good example of a local curriculum that achieves this is in use in Wales where colleagues have taken full advantage of well-developed community services to set up exemplary training for their registrars.

In the approved curriculum, it was necessary to use sufficiently general terms to allow training in Intermediate Care / Community Geriatrics in various parts of the UK to take on a local flavour. The reason for this is that there are wider variations in service models for community care than for, for example, acute care or falls services. The structures and means will naturally be very different in sparsely populated rural areas, compared with inner city boroughs. As an SAC, we are therefore encouraging programme directors and their training committees to interpret the curriculum in ways that can deliver the training within the local environment. For example, some training programmes no longer have any access to day hospitals, but the work normally done in day hospitals is carried out through alternative systems. So, in the next version of the curriculum, we will be making that degree of flexibility for community training clearer. Examples of the media through which the curricular requirements can be delivered will include training and experience in a mix of some, but not necessarily all, of working with a community geriatrician and other community-based professionals, community hospital, step-down rehabilitation unit, day hospital, community clinic, working directly with primary care, community assessment and rehabilitation team, supported discharge team, hospital-at-home, home-from-hospital, community team in the acute hospital, rapid reaction team, domiciliary consultation, community monitoring, telemedicine, other electronic consultations, working with assistive device and monitoring technology specialists, and working alongside other agencies such as social services staff or voluntary sector workers; this is not an exhaustive list.

Intermediate Care and Community Practice as a special interest
There has been an evolving tradition of consultants having special interests within geriatric medicine, including well established fields such as falls, ortho-geriatric services and continence. Until now, a trainee wishing to have such a special interest would, by arrangement with their supervisors and programme director, spend more time in an appropriate department, read around the subject and attend relevant training events in a relatively unstructured approach to deliver an amplified version of that topic in the basic curriculum. We have agreed with PMETB that this is a legitimate approach for the time being, but that in future the curricula for special interests will need to be written to the required standard, with an agreed valid suite of assessments. How special interests will be accredited and certified in future is not yet clear, though it is unlikely that they will follow stroke medicine into sub-CCT format. These developments will clearly apply to Intermediate Care / Community Geriatrics since that is emerging as a marketable special interest and is receiving a lot of attention from trainees. Therefore a special interest curricular “grid” for community training has been generated, in conjunction with colleagues who are expert in that field, to be presented to PMETB along with other special interest grids in future versions of the curriculum. Such special interest grids are not yet extant in the approved published curriculum. In the meantime, trainees who wish to acquire the additional knowledge, experience, insights and skills for community practice should take every opportunity available to gain those attributes in a local context, over and above the level expected in the approved curriculum, and if necessary they should arrange to visit areas that run alternative community care models to broaden their understanding. Programme directors should do all that is possible and reasonable to foster training in community practice, as this will become an increasingly common professional destination for their trainees.

Steve Allen
Chairman SAC geriatric Medicine

BGS Newsletter, Oct 2008
Issue 18 ISSN 1748-6343 18