The evolution of Geriatric Medicine in the UK: Are there any lessons for Taiwan?

1. The evolution of Geriatric Medicine in the UK: Are there any lessons for Taiwan? 12th January 2008 Dr David Oliver Reading University and Royal Berkshire Hospital Secretary, British Geriatrics Society

2. Outline • I: How Geriatrics and BGS started in the UK • II: Evolution 1947 to 1977 • III: Key developments from 1977-2007 • IV: The state of UK geriatrics and the BGS 2007 • V: Obstacles & threats to our future • VI: Why we need geriatrics and how to convince others? • VII: Why the UK doesn’t have all the answers – our services are far from perfect! • VIII: Possible lessons for Taiwan • From our successes in the UK • And our mistakes!

3. I: How Geriatrics Started in the UK And the role of the BGS (founded 1947)

4. Ignatz Leo Nascher (1863-1944 USA) • Invented term “geriatrics” • Two ancient Greek words • “Geras” (Old-Age) • “Iatricos” (Relating to the physician) • “There should be a separate speciality to deal with problems of senility” • Although conceived and named in US, geriatrics was first fully practiced in UK..

5. British Geriatrics Society Compendium www.bgs.org.uk • “that branch of internal medicine which deals with the prevention, diagnosis and treatment of diseases specific to old age”.

6. Marjory Warren – “the mother of British Geriatrics”

7. Marjory Warren • Medical director West Middlesex Hospital • Responsible for 714 bed poor law workhouse infirmary when it merged with the hospital • Patients described as “Incontinent, seizures, dementia, bed ridden, elderly sick, unmoved muscles” • “For proper care, they require the full facilities of the general hospital” • Created specialised geriatric assessment unit – the first in the UK • Systematically assessed neglected, bedridden patients • Determined capacity to improve • Re-mobilised most. & returned many to own homes • Pioneer of discharge planning (a revolutionary idea!!) • And Comprehensive Geriatric Assessment

8. Marjory Warren • Reduced beds from 714 to 240 and increased turnover 300%! • Spare beds then used for TB/Chest Medicine • Gifted advocate, innovator educator, mentor and teacher • Attracted interest from health minister when discharge rate reached 25%”! • Published 27 papers in the 1940s and 50s on rehabilitation and assessment of frail older people • Most famously… • Warren MW. Care of chronic sick. A case for treating chronic sick in blocks in a general hospital. BMJ 1943;ii:822–3. BMJ 1943 • Warren MW. Care of the chronic aged sick. Lancet 1946;i:841–3.

9. .Warren’s classification of the chronic aged sick 1946 Lancet • “Chronic up-patients” (that is, out of bed). • “Chronic continent bedridden patients.” • “Chronic incontinent patients.” • “Senile, quietly confused, but not noisy or annoying others.” • “Senile dements”—”requiring segregation from other patients.”

10. MD Thesis, The care of the elderly, N.H.Nisbet ‘Dr Warren’s routine was carefully studied, the method of admission, examination, diagnosis and treatment, the return home or transfer to Home or hostel, the careful follow-up, the close contact maintained with the relatives, the help obtained from almoner, physiotherapists, OTs and chiropodist. The metamorphosis of an utterly hopeless helpless patient into an active, energetic and everlastingly grateful one was observed again and again.’

11. Wasn’t Warren really pioneering…..Comprehensive Geriatric Assessment? • “a multi-dimensional, interdisciplinary, diagnostic process to determine the medical, psychological and functional capabilities of a frail older person in order to develop a co-ordinated and integrated plan for treatment and long term follow up” • Stuck et al Lancet 1994 • “Applying CGA especially to patients with frailty, functional impairment and multiple long term conditions is what best defines what we do as geriatricians” • Rockwood K Age Ageing 2004

12. Some other early pioneers…

13. N Exton-Smith (Lancet 1949) • Advocated “the speciality of Geriatric Medicine for medical management, rehabilitation and long term care of older people.” • UCH (1st geriatric unit in London teaching hospital) • Worked with Lord Amulree (later civil servant) • First English Professor of Geriatric Medicine • Worked with Doreen Norton, the first professor of gerontological nursing (Norton Scale) • Earlier discharges created beds for other specialities and high profile attracted students and interest from government • Founded first memory clinic • Pioneered early ripple mattresses • Research interests in previously neglected clinical areas

14. Others Pioneers e.g. • Joseph Sheldon • 11% older people housebound • First described community geriatrics • Advocated community physio, home adaptations • Foot-care, continence etc to maintain independence • George Adams. • First Professor of Geriatrics in Belfast. • First to teach geriatrics to undergraduates • Studied Warren’s work and followed her model to “improve the human wreckage and overcrowded wards” in workhouse infirmaries • Opened first purpose built geriatric rehab unit • Published in stroke and rehabilitation

15. Others e.g. • Lionel Cosin • General surgeon (war casualties) • Originator of the geriatric day hospital (Oxford) 1957 • Pioneer of orthogeriatrics and rehabilitation.. • Responsibility for 300 “chronic sick” beds. • Admitted patients thought to require “permanent care” after hip fracture • Operated then started early rehabilitation with the help of a physiotherapist, and many were discharged. • Bobby Irvine • Worked in Hastings with orthopaedic surgeon (who recognised his own lack of specialist knowledge) • Established world famous orthogeriatric unit widely studied as an example • Operated on even the frailest patients • Mobilised them • “The first step in rehabilitation is the first step”

16. Original Aims of the BGS 1947 • Meeting of small number of pioneering practitioners convened by Dr Trevor Howell (former GP and now medical director of Chelsea Pensioners Home –i.e. war veterans) • “the relief of suffering and distress amongst the aged and infirm by the improvement of standards of medical care for such persons, the holding of meetings and the publication and distribution of the results of research “

17. Early influence of BGS (Barton and Mulley 2003) • “This meeting was to begin a revolution in the delivery of elderly care services. • These pioneers persuaded the Minister of Health to appoint more geriatricians as part of the hospital consultant expansion of the new NHS. • Following Marjory Warren’s example, frail or disabled patients were to be under the care of a geriatrician and comprehensively assessed by an interdisciplinary team. • Those who recovered were discharged home • Those who were frail but did not require 24 hour nursing care went to long stay annexes. • Patients previously thought to be "senile" or disabled were reassessed, and often found to have modifiable organic disease; many could be rehabilitated. • As more older patients returned home, there was more space on the wards, which were repainted and upgraded.”

18. Lessons from this pioneering phase

19. Adoption of change in systems (After Gladwell M The Tipping Point) Tip KOLs Enthusiasts Chasm

20. Lessons for Taiwan?… • Pioneers and Innovators • From variety of clinical backgrounds (just as in Taiwan) – commitment and interest is what counts • Challenging assumptions (“that’s the way we’ve always done things) • Challenging ageism/therapeutic nihilism • Publishing and publicising • Developing evidence base • Mentorship, teaching, role models • Spreading good practice to other units by example and training

21. Lessons for Taiwan? • Showing the benefits of geriatrics to the whole system • Once people see what you can do they can be “won over” and usually want more • Getting politicians and civil servants on board • Alliances with other professions and organisations (strength in numbers) • Put the patients first in your arguments….(not the profession)

22. II: How geriatrics evolved in the UK from 1947 to 1977

23. The “Geriatric Giants” – (just what Warren described 30 years earlier) Adapted from Isaacs B* The Challenge of Ageing 1982. * Pioneer of stroke units Immobility Confusion Pressure sores Geriatric Giants Falls Vision Hearing Depression Incontinence

24. The 1960s and 1970s: expansion • Improvements in medical care of patients managed on geriatric units. • Rapid increase geriatrician appointments. • 4 geriatricians in 1947. 335 by 1977 • Academic departments established. • First UK Professor 1965 Glasgow. (William Ferguson-Anderson)

25. But not all good. Still opposition.. • Many general physicians questioned need for separate specialty • Considered inferior specialty for third rate doctors who could not “make the grade” elsewhere. • Negative, disdainful attitudes from doctors in training • Medical students generally not inspired by the image of geriatrics.

26. Key themes of this expansion phase (Barton and Mulley 2003) • Awareness of atypical/ non-specific presentation of acute illness in old age. • Whole person approach to older people with co-morbidity and complex disability. • MDT team working and CGA • Central importance of rehab. • Recognition of caregivers’ stress; respite care. • The teaching of geriatric medicine to medical undergraduates.

27. 3 models of practice by the 1970s (fuller discussion of pros and cons in BGS compendium at www.bgs.org.uk) • (1) Traditional or needs based, where geriatricians take selected referrals from other consultants, with a view to rehabilitation, or, if appropriate, placement in long term care. • (2) Age defined care (regardless of patients’ needs) based on an arbitrary age cut off (usually 75 years and over). (e.g. Bagnall et al) • (3) Geriatric services fully integrated with general medicine. (e.g. Grimley Evans et al) • Advantages and disadvantages to each…

28. Recommendations of Royal College Physicians (1977) working party on medical care of the elderly(Note how little things have changed 30 years on!) • General medical and geriatric facilities to be integrated. • Posts for general physicians with an interest in geriatrics • Multidisciplinary approach to elderly care. • Undergrad/postgrad training in elderly care for every doctor. • Elderly medicine to become component of MRCP syllabus. • Increased involvement of general practitioners in the medicine of old age. • Local authority residential care review. • Review of elderly mental health services.

29. III: Key developments 1977-2007

30. MDT case conference. Geriatric day hospital. Domiciliary visits requested by GP Community geriatrics. Outreach clinics in general practitioner surgeries. Old age psychiatry. Ortho-geriatric liaison. Stroke rehabilitation units and services. Specialty clinics—for example, falls, parkinsonism, stroke. Rapid assessment clinics. But Geriatrics more and more hospital based Only 14% consultants with dedicated community or long stay care involvement And increasingly involved in acute general internal medicine Stroke becoming a separate speciality with more acute focus Key Services pioneered before 1977 and expanded 1977-2007

31. Current NHS structure58.5 M Pop£ 70 billion expenditure (£8 b drugs, £6 b IT)1 M employees. 35,000 GPs. 34,000 hospital consultants, 350,000 nurses Performance targets and “star ratings” for Primary and Secondary Care. Quality and Outcomes Framework (QOF) in GP contract Regulation of Quality By HealthCare Commission, complaints procedure, National Patient Safety Agency Local Social Services. Provide assessment, home care and long term residential/nursing care (means tested). Funding through local tax (20%) and national government. Elected local political leaders. Regulation by National Commission for Social Care and Inspection (CSCI)

32. Total UK health expenditure

33. Health expenditure(developed nations)

34. Key developments (general) • Structural re-organisations of the NHS focus on efficiency, performance and reducing inequality • Increase in spending to 8.8% GDP by 2006 • Introduction of “internal market” and “purchaser-provider split” between primary and secondary care • Primary care now receives 70% of resource and commissions services from hospitals • NHS Plan with performance targets for hospitals (efficiency, access, waiting times etc) • Quality and Outcomes Framework (QOF) for GP contract with incentives to hit targets for screening, prevention, long term conditions • Growing involvement of private sector in building hospitals and providing elective treatment • Shortening and re-structuring of postgraduate medical training • Overhaul of medical research funding and performance assessment

35. Evolution of Policy Since 1990 • For Older People, key themes have been: • Transfer of responsibility (1990 Community Care Act) to local government for social care and closure of NHS Long-stay beds • Shifting balance back towards primary care • Reducing “inappropriate hospital bed use” • Better management of long term conditions • Social Vs Medical Care (and funding) • Quality and inspection • More integrated working between primary and secondary care and social services • Resource allocation/rationing • (Policies and guidelines for older people/mental health tend to have come with few resources)

37. NSF for Older People 2001 (Clear targets but no real money or penalties) • 1:Rooting out age discrimination • 2:Promoting person-centred care (including a single assessment process for care records) • 3:Intermediate care • 4:General hospital care • 5:Stroke services • 6:Falls and Bone Health services • 7:Mental health in older people • 8:Promoting health and active life in old age

38. Progress against initial NSF • Increase in provision of complex social care at home • More stroke units • More falls clinics and services • More Intermediate Care places • Less overt age discrimination • “Spin off” benefits for older people from other targets • But services still not “fit for purpose” or “age-proof” • Breaches of Dignity and deep-seated negative attitudes to older people still common • Skills, training and knowledge lacking • General hospital care just as problematic • Very few people actually receiving appropriate falls and OP treatment • Many people still not getting to stroke units • Single assessment process rarely implemented

40. “ A new ambition” 10 programmes under 3 themes • Dignity In Care • Dignity in care • Dignity at the end of life • Joined Up Care • Stroke Services • Falls and Bone Health • Mental Health in Old Age • Complex Needs • Urgent Care • Care Records • Healthy Ageing • Healthy Ageing • Independence, Well Being and Choice

41. More than an ambition? • No dedicated money • No “must do” targets • Many competing priorities in the “hierarchy” • Little in the GP contract to incentivise them • Still ageist attitudes in the system • Focus on short term gains, not long term planning • “Box-ticking” approach rather than real change?

42. Lessons for Taiwan? • As the speciality grows you can begin to sub-specialise and expand range of services and outreach into other settings • You must expect negative perceptions and attacks and work hard to improve the “image” of geriatrics and “sell” it to potential recruits and to colleagues in other specialities • You need to think about the model of service delivery (needs, age, integrated etc) and how it fits with existing local services/facilities • Be careful about being sucked into general internal medicine so much that you neglect the frail and the long-term

43. Lessons for Taiwan • Pointless to have service frameworks and targets with no money, no incentives, non infrastructure • Other incentives in the system (some “perverse”) may fight against what you are trying to achieve – you need to battle this • No good having “Rolls Royce” services if only a small percentage of people receive them • Prevention and primary care matter • “Softer” gains around attitudes and care are harder to achieve but vital to the patients’ experience

44. IV: UK geriatrics and the BGS in 2007 Where are we now?

45. BGS…(for full range of our activities please join or use www.bgs.org.uk) • Geriatric Medicine is now the second biggest hospital-based speciality in the UK • BGS membership 2007 • 2,500 • 589 trainees, • 1,200 consultants • 310 overseas • 150 allied professionals

46. Roles of BGS • Bi-ennial scientific meetings (600 delegates) • Age and Ageing (700 submissions per annum) • Sections (e.g. falls&bone, stroke, continence, prescribing) • Education and training • Continuing Professional Development • Academic and Research (including grants and fellowships) • Policy – produces compendium of good practice • National Audits • Advice/input to government and medical colleges! • Campaigning, influencing and highlighting issues • www.bgs.org.uk

47. How healthy is geriatrics in the UK now? • Strength in numbers? • Growing evidence-base for what we do • Ageing population • Frailty, long term conditions are crucial • Other physicians don’t all want complex, frail older patients • Current GP performance framework does not incentivise them to look after these patients • Getting care of older people right will surely help every part of the system • So the future looks good surely?

48. Not so simple….

49. V: The obstacles in our way Threats, challenges or opportunities?

50. Threat 1:Systems reform • DH want old people out of hospital and in “community” • (But to what alternative services?) • But UK geriatrics has become largely hospital-based • So now we must persuade primary care organisations to buy our services or take over the running of some “intermediate care” • Many aren’t interested – despite the evidence-base for CGA etc • There is little in the GP performance framework about geriatrics • But a perception from some GPs that geriatrics is “easy” and its “what GPs do anyway” .It doesn’t need specialist training or a separate speciality