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Editorials

Future directions for geriatric medicine

BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7228.133 (Published 15 January 2000) Cite this as: BMJ 2000;320:133

Geriatricians must move with their patients into the community

  1. John Young (Youngj{at}bhtwise.mhs.compuserve.com), professor,
  2. Ian Philp, director
  1. Sheffield Institute for Studies on Ageing, Northern General Hospital, Sheffield S5 7AU

    Less than 50 years ago the plight of sick older people in the United Kingdom was pitiful. Chronically sick old people were left to languish bedridden in the most miserable of circumstances. The specialty of geriatric medicine developed in the 1950s as a response to the particular health needs of frail older people.1 Timely response to crises, comprehensive assessment of needs, multidisciplinary management focused on reducing disability, and helping older people to remain at home while recognising the needs of family carers became the underlying principles. These elements have become accepted and implemented in many countries, with convincing evidence of effectiveness.2 Britain is still unique, however, in the extent to which geriatricians work in the acute hospital sector, and a major triumph of elderly care medicine has been the unquestioned access of acutely ill older people to district general hospitals. With these successes it is therefore surprising that geriatric medicine is now indecisively poised at something of a crossroads.

    The steady increase in consultant posts in geriatric medicine has disguised an insidious shift in clinical responsibilities from frail elderly to adult medicine to bridge the “gap” which has emerged as general physicians have gradually withdrawn into their medical specialties. Moreover, increasing emergency admissions but reduced numbers of acute beds have driven down lengths of stay3 and created a new intensity of working in which opportunities for recovery and rehabilitation have become jeopardised.4 More recently, new community care initiatives have started to take shape within the NHS and are making fresh demands on overcommitted elderly care services. How should geriatric medicine respond to these pressures during the next 10 years?

    Firstly, we must ensure that the “best practice” of stroke rehabilitation units and orthogeriatric liaison in its several guises becomes more widely implemented. Geriatricians have taken the lead for both services in the past and will need to continue to do so in the future. Secondly, and more controversially, geriatricians will need to follow their patients into the community because effective community rehabilitation is the remedy to the smaller and more intensive district general hospital. Local partnership arrangements negotiated and delivered through primary care groups should provide the mechanism.

    Some will argue that the underpinning principles of community rehabilitation—that older people are reluctant to be in hospital and that “intermediate care” services are equally effective but less costly5—are unsubstantiated and an embarrassment to the notion of an evidence based health policy. Nevertheless, the policies of a primary care led NHS and of joint working with social services are their own momentum. 3 6 If rehabilitation in the community is to be implemented effectively then geriatricians must be actively involved. In some areas the function of community elderly care will be discharged by a community geriatrician,7 but at present there is no training programme for such a post. The notion that all trainee geriatricians should spend time in primary care also needs to be seriously embraced.

    The training needs of general physicians and geriatricians should also become more closely intertwined. Modern medicine is complex and multiskilled, and interspecialty collaboration can be expected to improve outcomes for older people. Syncope, neurovascular, and diabetic clinics have potential for partnerships between physicians and geriatricians. Such working needs to be supported and nurtured by specialty training programmes.

    In the past all geriatricians undertook similar duties, with resources and patients divided equally to cover the three core functions of acute care, rehabilitation, and long stay work. In future, departments of geriatric medicine will be called on to provide emergency care, specialist rehabilitation, community outreach support, and subspeciality collaborative clinics. Individual geriatricians, however, will no longer be expected to work in all these areas. Instead they are likely to cover one or two general areas—and these might change over a consultant career.

    The demographic transition of the 20th century has extended to the developing world and is being celebrated by the International Year of Older Persons.8 Health services everywhere will need to respond creatively to address the needs of older people as a priority. Britain pioneered the development of geriatric medicine, which has established a prominent role within our hospital services. The specialty must now adapt to contemporary pressures to expand its influence on the care of older people both within hospitals and without. Failure to respond to this challenge will mean that a only few fortunate older people will receive high quality care in specialist units. The others will be undertreated or overtreated for their acute needs, have their opportunities for rehabilitation cut short, and end their lives in substandard institutional care facilities—just like 50 years ago.

    References

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    View Abstract