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Opinion

Resolving the health and social care crisis requires a focus on care for older people

BMJ 2023; 380 doi: https://doi.org/10.1136/bmj.p97 (Published 13 January 2023) Cite this as: BMJ 2023;380:p97

Rapid Response:

How can medical schools help in this ‘crisis of care’? Re: Resolving the health and social care crisis requires a focus on care for older people

Dear Editor,

Legislation and strategic planning for the care of older people is not futureproof unless we have trainees poised and equipped to work in these care models. There is a national shortage of geriatricians [1], with just 1 consultant geriatrician per 8031 patients aged over 65 in the UK [2]. This ratio is set to deteriorate further; the ageing population will increase the denominator, whilst there is little to no projected increase in the numerator. Governing bodies attempt to address workforce shortages by funding more medical school places [3], yet over 60% of junior doctors choose not to enter specialty training post-foundation [4].

Furthermore the British Medical Association (BMA) are balloting junior doctors on strike action in the context of a workforce feeling undervalued and demoralised [5]. Therefore recruitment and retention may yet worsen still – indeed a recent survey found that 40% of junior doctors are actively seeking work outside of the NHS [6]. We are balanced on a knife-edge, facing the very imminent reality that we have insufficient specialty workforce to care for an ageing population unless drastic changes are made to medical education and training.

It is imperative we look ahead to tomorrow’s doctors, making alterations now to optimise the future workforce to care for older people with complex needs. In the immediate-term, institutions must intervene to mitigate for the impact of this crisis on medical students’ experience of older peoples’ healthcare. With very high incidence of delayed discharges and ‘corridor medicine’, students are being exposed to large volumes of patients in whom iatrogenic harm is prevalent, with high rates of delirium and deconditioning resulting from prolonged hospitalisation [7]. Arguably, learning cannot be achieved in an environment where optimal care cannot be modelled, and patient care is frequently compromised. Indeed, student attitudes towards older patients have been shown to deteriorate during clinical placement years [8], but can be improved with positive role-modelling [9,10].

In their recommended undergraduate curriculum, the British Geriatrics Society advocate for exposure across a variety of settings and disciplines, to aid students in their understanding of the clinical and social variety of ageing, frailty, and medicine in older people [11]. We are at a key juncture, where innovative services such as virtual wards and Hospital at Home are being widely and rapidly implemented across the country, and new opportunities for training should be integrated from the outset, and continued long-term. We must take this opportunity to identify and effect positive experiences for students and trainees in geriatric medicine, recognising that students who receive higher quality undergraduate education in geriatrics are more likely to consider a career as a geriatrician [12,13].

Once we have generated skilled graduates enthused about the care of older people, focus needs to be maintained in retaining them in the workforce. This will likely be achieved by making specialist training more attractive and expanding alternative workforce development, such as SAS (speciality and associate specialist) and LE (locally employed) posts. If current trends continue SAS and LE doctors will be the largest group of doctors on the register by 2030 [14], and this diversity of pathways through medicine must, in turn, be reflected to undergraduates.

Gordon and Dhesi highlight the precarious, system-level decompensation that has caused harm [15]. We are undoubtedly therefore at a critical tipping point. Successfully educating and inspiring healthcare professionals in the care of older patients is paramount. Intervention, underpinned by robust pedagogical evidence, coupled with expert guidance and meaningful action is required to skill a workforce in the complexities of caring for older people.

References
1. British Geriatrics Society, Arora A, Greenbrook S. The Geriatric Medicine Workforce 2022., 2022.
2. Royal College of Physicians. RCP warns the UK is facing a crisis in care for older people. 2022.
3. O’Dowd A. Funding boost aims to expand England’s medical school places. BMJ 2021;374:n1998.
4. Moberly T, Stahl-Timmins W. More doctors are taking a break from training after foundation programme. BMJ 2019;364, DOI: 10.1136/BMJ.L842.
5. Lock FK, Carrieri D. Factors affecting the UK junior doctor workforce retention crisis: an integrative review. BMJ Open 2022;12:59397.
6. British Medical Association. Four in ten junior doctors plan to leave the NHS as soon as they can find another job, BMA council chair reveals in New Year’s message. 2022.
7. British Geriatrics Society, Royal College of Physicians London, Royal College of Physicians Edinburgh. Protecting the rights of older people to health and social care. 2023.
8. McCarthy F, Winter R, Levett T. An exploration of medical student attitudes towards older persons and frailty during undergraduate training. Eur Geriatr Med 2021;12:347–53.
9. Nimmons D, Pattison T, O’neill P. Medical student attitudes and concepts of frailty and delirium. Eur Geriatr Med 1999;9, DOI: 10.1007/s41999-017-0018-y.
10. Meiboom A, Diedrich C, Vries H De et al. The hidden curriculum of the medical care for elderly patients in medical education: a qualitative study. Gerontol Geriatr Educ 2015;36:30–44.
11. Pearson GM, Winter R, Blundell A et al. Updating the British Geriatrics Society Recommended Undergraduate Curriculum in Geriatric Medicine: A curriculum mapping and nominal group technique study. Age Ageing.
12. World Health Organization Department of Ageing and Life Course, International Federation of Medical Student Associations. Teaching Geriatrics in Medical Education II. Geneva, 2007.
13. Meiboom AA, De Vries H, Hertogh CMPM et al. Why medical students do not choose a career in geriatrics: a systematic review. BMC Med Educ 2015;15, DOI: 10.1186/S12909-015-0384-4.
14. General Medical Council. The State of Medical Education and Practice in the UK: The Workforce Report 2022. London, 2022.
15. Gordon AL, Dhesi J. Resolving the health and social care crisis requires a focus on care for older people. , DOI: 10.1136/bmj.p97.

Competing interests: EJH is Academic Vice President of the British Geriatrics Society (BGS), and RW is a past trainee representative on the BGS Education and Training Committee. All authors wrote the recent update of the BGS recommended undergraduate curriculum in geriatric medicine (in press).

23 January 2023
Grace ME Pearson
Clinical Research Fellow
Dr Rebecca Winter, Dr Emily J Henderson
Bristol Medical School (Population Health Sciences)
Ageing & Movement Research Group, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU