Evidence submitted by the British Geriatrics
Society (WP 35)
THE BRITISH
GERIATRICS SOCIETY
The British Geriatrics Society (BGS) is the
only professional association, in the United Kingdom, for doctors
practising geriatric medicine. The 2,200 members worldwide are
consultants in geriatric medicine, the psychiatry of old age,
public health medicine, general practitioners, and scientists
engaged in the research of age-related disease. The Society offers
specialist medical expertise in the whole range of health care
needs of older people, from acute hospital care to high quality
long-term care in the community.
GERIATRIC MEDICINE
Geriatric Medicine (Geriatrics) is that branch
of general medicine concerned with the clinical, preventive, remedial
and social aspects of illness of older people. Their high morbidity
rates, different patterns of disease presentation, slower response
to treatment and requirements for social support, call for special
medical skills. The purpose is to restore an ill and disabled
person to a level of maximum ability and, wherever possible, return
the person to an independent life at home.
The Society welcomes the opportunity to contribute
to this debate and would comment on particular questions as follows:
1. In considering future demand, how should
the effects of the following be taken into account:
— recent policy announcements, including
Commissioning a patient-led NHS;
— technological change; and
1.3.1 While Commissioning a patient-led
NHS may ensure that older people with intact cognition will be
heard the same cannot be said for the frail older person being
admitted to hospital who can often suffer from Dementia and or
Delirium. They require specialist care.
1.3.2 The Society stresses the importance
of a broad group of professionals required to provide care for
older people. The key skill of the speciality is a multi-disciplinary
team approach delivering a comprehensive assessment to frail older
people. The Society recognises the importance of many models of
care but believes a medical assessment and treatment model has
its place in a multi-faceted continuum of care. This report focuses
on the challenges of training, recruitment and retention of specialists
in geriatric medicine in the UK as well as highlighting the issues
responsible for a shortage of specialists required for an expanding
population of older citizens.
1.3.3 The National Service Framework for
Older People1 came into force in England in March 2001. It espouses
eight Standards to be applied to the Care of Older People and
has been broadly welcomed by geriatricians, emphasising as it
does the specialty nature of medical care of older people, particularly
in the areas of:
— Better acute hospital care for older
people.
— Falls and fractures (and their prevention
as well as treatment).
— Stroke (treatment and prevention—with
good evidence that well coordinated stroke care saves lives and
reduces disability). The inclusion of stroke mortality as a nationally
required outcome measure by which hospital trusts are judged has
had an impact in creating new consultant posts specialising in
stroke.
— Intermediate Care and rehabilitation.
— Mental Health (not strictly the remit
of this report but recognising the combined physical and mental
health problems in frail older people).
1.3.4 Although still in its infancy as a
formal part of health and social care, Intermediate Care (as part
of the NSFOP for England) is now a reality with investment in
both hospital and community based services evident. In 2002, a
year after the launch of the NSFOP, the BGS surveyed 153 lead
consultants (with excellent 75% response rate). It examined geriatricians'
involvement with NSF developments. In general, good early progress
was reported in implementing the NSF. However there are substantial
implications for demands on consultant time with consultant geriatricians
providing leadership for "specialty led multidisciplinary
teams" and involvement in:
— Acute medical Care with a high proportion
of medical emergencies occurring in frail older people.
— Specialist clinical leadership in
management of Stroke and Falls.
— Comprehensive assessment of older
peoples in various settings.
— Specialist input into intermediate
care whose main aim is reduce the need for acute hospital care.
— Planning activities for NSF developments.
1.3.5 In the five years since its inception
the NSFOP has had a significant impact on demands for the specialist
expertise of geriatricians and a number of new posts have been
created or adapted to fulfil the needs to service the NSFOP.
1.3.6 The recent changes to the General
Practitioner contract have led to older people facing major obstacles
when seeking help in a crisis.
1.3.7 The consequences are both immediate
and far-reaching for vulnerable older people and those informal
carers on whom they depend. The immediate crisis may result in
an unwanted or unnecessary hospital admission in which the crisis
is worsened by its late discovery the next day which may eventually
lead to inappropriate premature institutional care.
1.3.8 Increasing demands are being made
on geriatricians. As a result, the Society has for many years
been putting the case for more geriatricians. In July 1998, the
BGS published its recommendations for the provision of consultant
geriatricians which were then recalculated. They calculated that
an expansion from 764 consultants to 1,700 in England and Wales
would be required by 2005 taking into account the needs of patients
aged 75 and over, the requirements of academic staff within the
speciality and the wider pressures being placed on the speciality.
The latest Consultant Census carried out by the RCP in 2004 enumerated
only 1,075 WTE in the UK and for England and Wales 913, well short
of the original target of 1,332. For reasons described below
a large shortfall is likely for many years.
1.3.9 Difficulties in filling consultant
posts—Despite being the largest medical specialty in the
UK, the RCP surveys (annually since 1993), have indicated a lower
growth in posts in geriatric medicine (3.9% per annum) compared
with the average for medical specialties of 6.5% per annum. In
the last year, despite Geriatric Medicine being the largest medical
specialty, expansion in Geriatric posts (12 between 2003 and 2004)
is less than in other acute specialties (eg Cardiology up by 28
posts, respiratory Medicine 26, gastroenterology 25 and Endocrinology
and Diabetes 20).
1.3.10 Increased demand has outstripped
supply in all acute medical specialties, a situation which has
deteriorated over the last few years. Taking all medical specialties,
the RCP survey in 2004 noted that 36% of Advisory Appointments
Committees failed to make an appointment, with especially high
failure to appoint in acute/general medicine (56%), geriatrics
(50%), rehabilitation medicine (47%) and Palliative care (44%).
1.3.11 The problem for geriatric medicine
has been compounded by:
— The parallel (and faster) expansion
in other specialties (notably cardiology, gastroenterology and
respiratory medicine), attracting trainees away from geriatrics.
— A trend (unquantified) for consultants
to move "sideways" into more attractive vacant posts.
— The danger of unfilled posts being
withdrawn.
— An increasing number of consultants
who wish to work part-time (41.5% of SpRs in the 2004 survey were
women). Likewise the number of part-time trainees is increasing,
which lengthens their training period.
— An eight to 10 year hiatus between
the current recruitment rate of doctors and the expected increase
in medical school output.
— Geriatric (Old Age) Medicine is the
largest medical specialty in the UK and has a central place in
the acute and rehabilitative care of older people with ever increasing
demands on its consultant staff. The senior medical workforce
of the specialty has increased by nearly 4% per year in the last
13 years to over 1,100 in the UK this year.
— In the 13 years since the Royal College
of Physicians established an annual consultant census, the number
of consultants in geriatric medicine has risen from around 650
to over 1,100 in the UK. As this paper will demonstrate, the work
demands have increased even more and there is concern about a
growing shortfall of consultants.
— This report attempts to quantify
the medical workforce shortfall in the specialty of geriatric
medicine and draws attention to the reasons for a widening gap
between the work demanded of consultant geriatricians and the
availability of consultants to do the work.
— Based on a requirement of one geriatrician
for 35.000 population there is a current shortfall of over 600
whole time equivalent (WTE) consultants in geriatric medicine
in the UK.
1.4 The increasing use of private providers
of services.
2. How will the ability to meet demands be
affected by:
— financial constraints; and
— the European Working Time Directive.
2.2.1 Hospital doctors provide a 24 hour,
seven day a week service. As the largest contributors to emergency
medicine, geriatricians and their trainees have been profoundly
affected by the restrictions imposed by the implementation of
the European Working Time Directive (EWTD). The RCP and BGS have
examined this issue in great detail and have concluded that it
will be impossible with the projected workforce supply to approach
legal working hours for between six and eight years (if ever).
The calculations upon which this conclusion is based are presented
later.
2.2.2 The EWTD (with associated "hikes"
in pay for working outside the normal working week), "family-friendly"
Human Resource Policies and "flexible working" are pragmatic
steps to encourage recruitment and retention of staff and provide
the work-home balance which promotes quality of life for the workers
in health and social care services.
2.2.3 Indirect effect of the EWTD—The
indirect effect on consultants (of altered work patterns by junior
medical staff) is having an even more dramatic effect:
— less day to day continuity of care
and ward cover by junior staff who work full shifts and increasingly
are engaged in working in Medical Admissions Units; and
— Frequent absences due to being off
duty.
2.2.4 Many consultants in medical specialties
declare that they are the only doctors able to provide continuity
of medical care in a consistent manner. However if shift working
became necessary, even that continuity would be lost.
2.2.5 Direct effect of EWTD—In the
RCP surveys, consultants were asked to estimate the average excess
hours worked over 48 hours (the legal limit for the EWTD). In
the year 2000, geriatricians reported an excess of 6.4 hours.
From this it was calculated that an additional 160 WTE geriatricians
would be required comply with the EWTD. In the 2004 survey, despite
an increase of 4% per annum in consultant numbers, the situation
had deteriorated with geriatricians working 11.4 hours above 48h
EWTD legal maximum.
— For geriatricians' work to become
"legal" (48 hours per week), an increase of 357 (33%)
WTE consultant geriatricians would be required.
— To comply with the desired limit
by most Trusts of 40 hours a week (10 Programmed Activities) an
increase 54% in WTE would be necessary.
— In relation to all medical specialties,
projections indicate that unless current work pattern changes,
consultants will work.
— more than 48h (EWTD limit) till 2008.
— above contract till 2010.
— more than 40 hours till 2012.
2.2.6 The general conclusion is that most
acute specialties will be forced to operate a full shift system
at all levels.
— increasing international competition
for staff; and
3. To what extent can and should the demand
be met, for both clinical and managerial staff, by:
— changing the roles and improving
the skills of existing staff;
— the recruitment of new staff in England.
3.3.1 The disappearance of Senior Registrars
with Calman reforms some years ago meant that many new Specialist
Registrar (SpR) posts were created on the basis of "history
or equity" rather than their capacity as good training slots.
So some "dead-end" registrar posts, previously not considered
suitable for training have been incorporated into SpR rotations,
with several deficiencies possible:
— No research opportunities or the
need to rotate to a research oriented department.
— Services inadequate to offer exposure
to the specialty elements now required for accreditation, especially
in relation to rehabilitation, subspecialty work, long term care,
and the new service elements emphasised in the NSF such as falls,
stroke care and geriatric specialisation within acute services.
3.3.2 The demands of acute medicine compounded
by the dramatic effects of the European Working Time Directive
(EWTD) are widely believed to be detrimental to the quality of
specialty training and hence are likely to adversely affect recruitment
to the specialty. Most obviously, the majority of SpRs in Geriatrics
have been forced into partial or complete shift work in the service
of acute emergency medicine, with a detrimental effect on specialty
training (a situation also occurring in other specialties which
contribute to emergency medical care).
3.3.3 The requirement to choose a specialty
at an earlier career stage has reduced the market for geriatrics
which (as an acquired taste) previously relied heavily on "late
converts". The additional effects of "Modernising Medical
Careers" (MMC), a Government scheme to shorten post-graduate
medical training (to be implemented between 2006 and 2008) will
force doctors to choose their specialty even earlier in their
career than hitherto and might further disadvantage the specialty.
3.3.4 Competition for trainees with other
medical specialties which are expanding as fast or faster than
geriatric medicine
3.3.5 A recent survey of recruitment of
SpRs in geriatrics gives cause for concern. In 2005, certain
areas of England (Yorkshire, Mersey and NW Thames) noted a sharp
rise in the number of unfilled SpR posts while in Scotland, Northern
Ireland and Wales there appeared little difficulty in recruitment.
3.3.6 Additional problems for academic
geriatric medicine—In its recent submissions to the RCP
Workforce Unit (RCP 2000 census), the BGS Workforce Committee
has noted that only 91 out of 965 posts were academic appointments
(9.4%) compared with 16.3% average for medical specialties. Academic
Departments tend to be small but some are sub-departments or affiliated
with other groups. The 12 who gave detailed replies averaged four
members of permanent academic staff (but varied from one to nine).
18 of 50 identified posts were non-clinical in nature. Two of
12 departments were headed by Senior Lecturers.
3.3.7 There are several factors which cause difficulties
in recruitment to academic posts:
— Geriatrics is fairly recent specialty
without a long track record of academic work.
— As an expanding specialty, there
are plenty of NHS posts to choose from.
— The generality of the specialty makes
research themes hard to identify, though sub-specialties emphasised
by the NSFOP have helped.
— Departments tend to be small with
varied research interests which make for a lesser impact.
— Small departments amalgamated with
nearby departments of medicine lose their identity.
— Geriatric Medicine has never been
an attractive target for mainstream research funding and in general
does not attract strong support from the local medical schools.
The specialty has depended very much on the valiant efforts of
the Charity Sector: Groups such as Research Into Ageing, the
Stroke Association and the Alzheimer's Disease Society to
fund research.
— The relatively low level of research
activity and patchy research training at registrar level, recently
highlighted in submissions to the BGS Training Committee.
— A low proportion of consultant posts
in Teaching hospitals: in the 2000 census only 273 out of 965
(28%), compared with medical specialties such as cardiology (38%)
and gastroenterology (37%).
3.4 International recruitment.
4. How should planning be undertaken:
— To what extent should it centralised
or decentralised?
— How is flexibility to be ensured?
— What examples of good practice can
be found in England and elsewhere?
5. How should planning be undertaken:
— To what extent should it centralised
or decentralised?
— How is flexibility to be ensured?
— What examples of good practice can
be found in England and elsewhere?
5.3.1 The above three issues will be answered
together as follows:
5.3.2 The Government has recognised the
need to increase rapidly the number of consultants not only to
improve compliance with the EWTD but to address important health
targets such as reducing deaths and morbidity from heart disease
and stroke, and to improve detection, speed assessment and improve
outcomes from treatment of an array of cancers.
5.3.3 A number of general measures are in
various stages of development:
— The current expansion of UK Medical
Schools and opening of new ones is welcome but will take 10 or
more years to have an impact on consultant numbers.
— "Modernising Medical Careers"
is an important initiative to shorten the time from basic qualification
to attainment of specialist training, Initial implementation has
just begun. One positive effect in terms of specialty recruitment
may be the release of funds from a number of discontinued Senior
House Officer posts which could be used to fund new Specialty
training posts, an idea which the Joint Committee on Higher Medical
training (JCHMT) has recently (January 2006) indicated a willingness
to explore, provided the specialist training capacity can be found.
— Recruiting consultants from abroad—never
a strong card, since few countries in the developing world have
well-developed geriatric services (apart from the moral and ethical
objections to such a strategy).
— The Workforce Numbers Advisory Board
controls workforce numbers in the NHS. Doctors are the remit of
a subsidiary Committee, the Medical Workforce Review Team. In
previous years, strict controls or "ceilings" were imposed
on specialties to curb the unbridled expansion of popular specialties
at the expense of less popular ones. Encouragement by provision
of some central funding was given to unpopular specialties which
were either politically sensitive (eg psychiatry) or necessary
for key health targets such as cancer (requiring an infrastructure
in specialties such as histopathology and radiology). As the impact
of the EWTD on doctors numbers became apparent the restrictions
on SpR numbers has been eased especially in acute medical specialties.
— In Geriatric medicine, 80 new SpR
posts were allowed in 2003 and a further 30 in 2004. Because of
the subsequent emergence of difficulties in filling SpR posts,
no further SpR numbers were allocated in 2005.
5.3.4 New workforce planning arrangements—The
Strategic Training Authority (which issues certification of Specialist
training) has recently been replaced by the Medical Education
Standards Board. This is likely to diminish the power of the professional
Colleges to decide where training posts should be placed. At the
Department of Health, there has been a radical review of NHS workforce
planning. The new NHS workforce arrangements are in their early
days, but it is now clear that the traditional way of replacing
"like with like" is considered a concept of the past.
We now have to consider the total workforce needs for health and
social care needs of a particular patient group. It is also clear
that the traditional professional roles, boundaries and overlaps
of roles are being challenged.
5.3.5 The Older Peoples Care Group Workforce
Team was established in December 2001 to take a broad view of
the workforce required to care for frail older people. Amongst
its early priorities was to help with filling the "medical
gap" in the care of older people, especially in relation
to supporting new initiatives in Intermediate Care. It was proposed
in 2002 (with mixed support from the Royal College of General
Practitioners) to create a large number of General Practitioners
with a Special Interest (GpwSI) in care of older people (and a
number of other specialty areas).
5.3.6 Unfortunately this initiative has
been largely unsuccessful because:
— There are few GPs not already involved
in Elderly Care Services who are interested in this work.
— There was deep concern that this
sort of work would distract GPs from providing basic services
(in the context of a severe shortage of GPs especially in inner
cities).
— Pre-occupation with establishing
a new GP contract and a new range of General Medical Services
(GMS 2).
Dr Jeremy R Playfer
President, British Geriatrics Society
15 March 2006
REFERENCES:
1 Department of Health 2001, National Service
Framework for Older People.
2 Bendall J, Evans J G, Bowman C, Main A (1998),
Manpower Planning in Geriatric Medicine (Internal BGS publication).
3 British Geriatric Society 1998, General internal
medicine/Geriatric medicine. Statements of principles and recommended
practice, consultant manpower projections to provide an effective
service.
4 Federation of the Royal Colleges of Physicians
of the United Kingdom (2004), Census of Consultant Physicians
in the UK, 2004.
5 British Geriatrics Survey (2005), Internal
survey of national training numbers (Registrars in Geriatric Medicine).
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