| BGS
Newsletter Online |
| Letters to the Editor (Sept 2009) |
| Email your comments Prof Arup Banerjee on "Geriatric Care in India" Geriatric Care in India I congratulate Neela Patel for her comprehensive review of Geriatric practice in India (BGS Newsletter, July 2009). I would like to make a few comments on the subject. She is absolutely right when she talks about the projected figures signifying a substantial increase in the elderly population in India over the next 3-4 decades. In fact, a similar increase in numbers of older people will be evident in many other countries in Asia and in Latin America. Sadly, many of these countries (India included) are not preparing themselves to meet the challenge. Lessons could be learnt from the West, where such a population ‘explosion’ has already taken place and not all measures taken have been terribly useful. Hence, we can advise those ‘new’ countries in this game on what is more likely to work or not work. Virtually all British textbooks in Geriatric Medicine carry a chapter on International Geriatrics but that doesn’t go far enough as most doctors in countries like India don’t, as a rule, read books on Geriatric Medicine. The BGS, during its Jubilee Year celebration in 1997, honoured a number of eminent geriatricians and gerontologists from all the continents, including some from India. Prof V S Natarajan of Chennai (Madras) was honoured with the BGS Jubilee Medal as the pioneer of geriatrics training and research in India. Sadly, training in geriatric medicine or nursing or rehabilitation still remains rudimentary and often, any kind of ‘assessment’ of disabled older people in care homes is resisted by the business-minded owners of such institutions. I distinctly remember being approached by a geriatrician from Pune, whose efforts to assess and diagnose older people in her clinic were thwarted with ‘threats’. Although Neela has mentioned a few publications, there is a quarterly journal published by the Indian Gerontological Association based at Jaipur, Rajasthan, called, ‘’Indian Journal of Gerontolgy”, edited by Professor K L Sharma, a philosopher himself. As one of the past Presidents of the BGS, I was invited to be one of its Consulting Editors. One of its special recent issues covered ‘Elder Abuse and Neglect’. The Open University based at Milton Keynes is currently running a research project looking into ‘The Contribution of the South Asian Doctors to British Geriatric Medicine’. I wonder whether any South Asian Researcher would undertake a similar study on the standard of knowledge-based care of the elderly in the Indian subcontinent! My suggestion would be for the BGS to look outwards a little; perhaps to set up an ‘’overseas‘’ committee and to liaise with those professionals in the Indian subcontinent, with ‘interest’ in elder care, with exchange visits, working with voluntary bodies and NGOs. There is no reason why some of the academic departments in this country could not establish a link with Universities in India keen on developing any research/training programme in Geriatric Medicine. The DGM might be another option to explore. Prof Arup K Banerjee OBE FRCP Editor’s reply: Thank you for your comments. The BGS did, in fact, attempt to explore the establishment of an “overseas group” during Professor Peter Crome’s presidency. We invited overseas delegates to attend a meeting at two of our Scientific Conferences, to explore the scope and logistics of running such a group, but attendance at the meeting, despite a fairly large number of overseas delegates attending the Scientific Meetings, was poor. With regard to an outreach programme, we have had some success in this area - in Taiwan, for instance. It is our finding that these programmes need to be driven by people in the country concerned. - David Never Mind the Name, Where is Geriatric Medicine Going? In the beginning, there were assessment units, rehabilitation services, long-stay NHS wards, local authority residential homes (often in “poor law” institutions), and a few private and voluntary “homes,” certainly in Scotland - but not enough beds anywhere. To ensure the appropriate placement of patients, Dr Rudd, Southampton, invented the pre-admission home assessment visit by a senior physician in geriatric medicine, accompanied by a hospital-based Almoner, the predecessor of the social worker. This holistic approach allowed assessment of the patient’s physical, mental, social and economic problems. A decision could be made regarding early hospital admission for investigation and treatment, a more leisurely arranged admission for rehabilitation, attendance at a Day Hospital, continued treatment at home or referral to the local authority welfare officer, another predecessor of the social worker. This service was extended to inter-unit consultations to older patients in medical, surgical and orthopaedic units in an attempt to get the right patient, in the right place, at the right time. Following assessment, treatment and rehabilitation, appropriate arrangements were made for discharge or transfer to a long-stay unit within the geriatric service. Physical and mental stimulation were continued and, in Angus, the record for slow-stream rehabilitation was won by a lady who became fit enough for residential care, two years after sustaining a severe stroke. Later, a small number of units offered General Practitioners “open access” to Assessment Units, but up to 25% of patients admitted would have been treated as an out-patient or referred to another service if there had been a pre-admission assessment visit...thus the “inappropriate admission” was invented. Geriatric services continued to develop throughout the United (?) Kingdom; more choice of facilities appeared in the community, but poor standards of care were reported in a small number of long-stay units for older people and younger folk with learning disabilities. The answer was to close these units and Care in the Community was invented. No one would languish evermore in an NHS long-stay unit – they would languish in a Care Home, that would provide residential care, nursing care or both. The Care Commission in Scotland replaced Local Authorities who had been responsible for standards of care, and on the seventh day, they rested. But where has geriatric medicine been during all these changes. Do we prevent inappropriate admissions? Do we assist early supported discharge? Do we provide slow-stream rehabilitation? Do we contribute to the assessment, treatment and rehabilitation of care home residents? Do we wonder if the European Working Time Directives may have an adverse effect on patient care. Do we know who is looking after our patients “Out-of hours” (OOH!)? Do we participate in assessments of older people with co-morbidity who attend Accident and Emergency Department? Or is Geriatric Medicine moving towards Acute Medicine of Old Age and specialisation? Or am I out of touch with reality? Help! Dr Elizabeth Cohen Editor's reply: Thank you for your letter which raises so many important issues. I believe we need a full response and debate in a future issue of the newsletter. You don't say, but I am guessing that you have long experience in the NHS and have seen all manner of changes to services. I cannot answer for the whole Society but my h'aporth is that we can define what we do as geriatricians by the failings in elderly care perpetrated by those with no geriatrics training, or how little interest these people sometimes show, often "not knowing what they don't know". We are advocates for older people with complex needs, functional impairment, syndromes of ageing. We understand that those same people need comprehensive assessment. We know (the biggest lesson of geriatric medicine) that functional problems have reversible diagnoses, and that even when we cannot reverse them there is plenty we can do to optimise the lives of frail older people. In the light of these principles, we have a major role to play. I think that this role is equally valid whether we play it in acute hospitals, intermediate care units or primary care. Organisational changes in the NHS have altered the ways in which we work. Long stay wards were always doomed once the Community Care Act came into force. Our growing involvement in acute medical care happened by stealth, though may not be a bad thing if we can ensure better care for older patients admitted acutely. There are now pockets of community geriatrics and involvement in long term care, care home medicine and chronic disease management, but we have to be sufficiently powerful advocates for our speciality to ensure that PCTs want to pay for our services. As Shaw said, "All change is achieved by the actions of the unreasonable man. - David BGS Newsletter, September 2009 |