Service Models Finbarr Martin, Geriatrician Guys & St Thomas’ Hospital and King’s College London

1. Beyond the geriatric giants: moving from elderly care to evidence-based medicine for the older person. Conference to honour the career of Professor Peter Crome Keele, March 21st 2013 Service Models Finbarr Martin, Geriatrician Guys & St Thomas’ Hospital and King’s College London

2. Medicine - No Country for Old Men ! “We realize that for all practical purposes the lives of the aged are useless, that they are often a burden to themselves, their family and the community at large. Their appearance is generally unesthetic, their actions objectionable, their very existence often an incubus to those who in their humanity or duty take upon themselves the care of the aged.” Nascher IL. Geriatrics: the disease of old age and their treatment. Philadelphia: P Blakiston's Son & Co, 1914.

3. A surgeon rides to the rescue Marjory Warren (1897 – 1960) at Isleworth Infirmary 1935 took over an adjacent workhouse to form the West Middlesex County Hospital. Systematically reviewed several hundred inmates Classified into 5 groups Adapted from Barton A and Mulley GP, 2003

4. Her achievementsWarren MW A case for treating chronic sick in blocks in a general hospital. BMJ 1943.Warren MW . Care of the chronic aged sick. Lancet 1946 discharged many patients by providing rehabilitation and appropriate equipment. Upgraded wards, improved patient and staff morale Advocated creating a medical specialty of geriatrics providing special geriatric units in general hospitals teaching medical students about the care of elderly people, by senior doctors with specialist interest in geriatrics.

5. Early experience at St Pancras, London Lancet, 1951

6. Look at the age in 1950

7. Progressive patient care – first model designed to optimise use of acute beds Lancet, 1962 30 beds, pre-discharge 32 beds, long stay 106 beds, post acute +rehab 22 beds LOS mean 10 days

8. Two models emerged in 1970s Age defined model (Sunderland) (O'Brien TD et al , No apology for geriatrics. BMJ 1973;i:277–80) Became predominant model till 1990 as old hospitals closed and DGHs absorbed older medical patients Integrated model (Newcastle) (Grimley Evans J Integration of geriatric with general medical services in Newcastle. Lancet 1983;i:1430–3) Recommended by RCPL in 1977 Reduced beds and reduced doctors’ hours galvanised this Withdrawal from rehab and long stay as consequence

9. Where are we now? People aged 65+ are ~ 17 % of the population And use 65% of acute hospital bed-days >50% of the patients having surgery, (>major) ================================= More older people Older people are older And older people are different

10. older people are older ( rectangularisation to elongation of age distribution) Around 18% of all deaths were before 65 in 2006 –same proportion as in 1991 Source: mortality.org, originally ONS 10

11. As a result………… Most older people now live long enough To have several long-term conditions (+ multiple medications) eg Respiratory, cardiac, diabetes to develop sensory impairment, sarcopenia, inflammaging Many also develop dementia, osteoporosis, cataracts etc homeostatic dysregulation Resulting in frailty and “geriatric syndromes”

12. People with long-term conditions have high health service use, especially hospitals (69% total spend). Limiting LTC Non limiting LTC percentages No LTC Older people GP consults Practice nurse Outpatients Inpatients Type of Service used Source: 2005 Household Survey 12

13. And older people vary Genetics inc chance changes in development Maternal and early life factors Society and Lifestyle etc Events and illnesses and chance Frailty Specific diseases Spectrum of health and capacity

14. Frailty “summarises” prediction of outcomes Rockwood and Mitniski A J Gerontol 2007

15. Implications for health care (Tinetti Am Med J 2004)

16. Age attuning health services Expect older people with problems Identify frailty and geriatric syndromes routinely Use comprehensive geriatric assessment (CGA) Predict “complications” Use experts judiciously Up-skill general services Promote multidisciplinary clinical practice and clinical governance Better care is often cheaper care in the end, so NHS must get better to survive economically

17. The scope of geriatric medicine Acute and episodic illness Post acute recovery and rehabilitation Long term management of diseases and frailty Support for people living with high dependency End of life care

18. Acute and episodic illness Interface geriatrics - between community and hospital in response to acute clinical change support Emergency Departments liaison with intermediate care (IC) Provide part of the acute medical admission service proactive case finding in acute medicine CGA approach with selected patients Support hospital approach to age attuning all services design and delivery of services leadership in quality improvement with geriatric syndromes Support education and training of the workforce

19. Implications for SurgeryNCEPOD Report 2010 • >1000 deaths of surgical patients 80+ years • Report highlights suboptimal management of common post-operative complications • Gap between policies, guidelines and clinical practice. • Assessment and clinical skills were too narrow • Likely events not anticipated or responded to • Interdisciplinary collaboration sporadic

20. Systematic responses 1 Proactive support for frail older people having surgery developing risk assessment in surgical services pre-op CGA for selected high risk patients ongoing medical input to peri- & post-operative care

21. Eg. Local proactive joint care - example from GSTT: Proactive care of Older People having surgery -“POPS” Surgical Outpatients/PAC Proactive referral of patients aged 65+ Screen to identify risk Including “medically unfit for surgery” Pre-operative CGA Consultant Clinical Nurse Specialist Occupational therapist Physiotherapy Social worker Patient education Post Discharge Intermediate Care Links with primary care/ social care Specialist clinic follow up (falls etc) Preadmission Liaison Surgical team Anaesthetists GP and Community services Patient Hospital Admission Post-op consultant geriatrician and specialist nurse interventions Therapy liaison Discharge planning

22. Provide shared care for patients with fragility fractures Co-design and supervise the hip fracture clinical pathway Provide daily medical care to selected patients Share clinical governance responsibility to achieve the best practice standards of care and secondary prevention

23. Eg Fracture servicesNational inter-disciplinary collaboration The Blue Book and the NHFD

24. Post acute recovery and rehabilitation Design and quality assure post acute care pathways assist clinical systems to identify inpatients’ ongoing needs specialist input to bed based or domiciliary IC services (EVIDENCE?) Provide “hot clinics” for CGA and other key conditions Link to A&E, acute admission units and community assessment in a whole system approach to urgent care Link with community based services to optimise recovery, ameliorate frailty and target secondary prevention (EVIDENCE PATCHY AND NARROW)

25. Long term conditions and Frailty Estimating potential benefit is complex Attributing risk in context of co-morbidity Effects on LE, independence and quality of life Estimating risks and burdens is complex Factoring in frailty So geriatrician- primary care co-working is needed So far, relatively evidence free zone

26. Support for people living with high dependency CGA for older people at transitions of dependency diagnostic input prior to institutional care design and delivery of pathways for frequent hospital attendees (LOTS OF INITIATIVES, LITTLE EVIDENCE) Specialist support for care home residents

27. End of life care - recognition Trajectories in the final 12 months of life

28. Summary Its not just about our wards anymore Its still about diagnosis but through CGA Its more about frailty more than age Its about getting it structured and simple and reliable It will be about new therapies for frailty etc Geriatrics is coming of age