Health CommitteeWritten evidence from the British Geriatrics Society (ETWP 26)

Executive Summary

The British Geriatrics Society is a multi-disciplinary professional membership association that seeks to promote better health and care for older people. We have over 2,500 members that specialise in the care of older people in a variety of hospital and community settings. Our members include doctors practicing geriatric medicine, old age psychiatrists, general practitioners, nurses, therapists and scientists. For more information please visit www.bgs.org.uk.

We have an ageing population and older people are the main users of health and social care services:

People over 65 are the core users of acute hospital care—60% of admissions, 65% of bed days, 70% of emergency readmissions, over 90% of delayed transfers.

Older people have more long-term conditions. An estimated 3.9 million (33% of people aged 65–74 and 46% of those aged 75 and over) have a limiting longstanding illness. This equates to 39% of all people aged 65 and over.

People with long-term conditions are the major users of care services. They account for 55% GP appointments, 70% of outpatient and emergency attendances, 77% inpatient days, 90% drug spend in over 75s.

People over 65 account for 2/3 of acute and elective surgical admissions and a significant proportion of these are over 80—often with complex medical needs or frailty and are at higher risk of post-operative complications.

The systemic failure to provide healthcare staff with appropriate skills and training and in sufficient numbers to meet the increasing complexity of frail older people in hospitals and in care homes is one of the key factors contributing to the failure of hospitals and care homes to meet the needs of older people.

All health and social care workers should receive training on caring for and understanding the special needs of older people and how to provide dignified person-centred care as the majority will have regular contact with older people.

Training curricula for doctors, nurses, therapists and other health and social service professionals should contain key elements on the giants of geriatric medicine -confusion/delirium, continence, dementia, immobility and falls—as well as information about comprehensive geriatric assessment and end of life care.

We have reservations about the re-organisation of post-graduate training in geriatric medicine in England and are worried about the loss of the expertise and structures contained within deaneries.

We are concerned that the transfer of more responsibility and power to local providers threatens coherent workforce planning. It also removes external standard setting and scrutiny of training in the NHS.

1. We welcome the Committee’s decision to hold an Inquiry into Education, Training and Workforce Planning.

2. We are concerned that health and social care professionals do not currently receive sufficient training and support to enable them to provide older people with quality care, despite the fact that older people are the main users of the NHS and social services.

3. There are 10 million people aged 65 and over in England. Of the population aged over 65, 40% aged 65–74 have illness or disability, 55% aged 75–84 have illness or disability and 67% over 85 have illness or disability. Nearly 70% of men and some 85% of women over the age of 65 will need care at some time. Older people account for 70% of bed days in NHS hospitals and 60% of admissions.

4. It is imperative that we have the right numbers of appropriately qualified and trained healthcare staff (as well as clinical academics and researchers) at national, regional and local levels and that training curricula reflect the needs of our ageing population.

5. The prevalence of older people in health and social care, and the complexity associated with key aspects of care of the most frail, means that there must be suitable attitudes and skill levels in the general workforce in community and hospital settings. In addition, there must be a specialist skilled workforce available in both settings to support primary care, community services and other specialists, as well as being the main provider of care for the most complex patients.

6. The UK is a world leader in having developed the medical specialisms of old age medicine (geriatrics), old age psychiatry and, more recently, stroke medicine, all recognised by the GMC and relevant Colleges. Geriatricians should be at the centre of clinical managemet in countries where most hospital inpatients are older people with complex needs.1 They should be part of adequately staffed multi-disciplinary teams enabling appropriate care for patients with complex needs such as dementia, frailty and communication difficulties. Geriatricians should also be involved in accident and emergency and urgent care facilities in order to avoid inappropriate hospital admissions.

7. The number of consultants needed (and therefore the number of training posts) will vary over time and according to the characteristics of local populations and their services. However, despite significant expansion in recent years, we are concerned that the specialty of geriatric medicine does not have sufficient whole-time equivalent (WTE) consultants to cope with growing demand.

8. According to the 2010 Royal College of Physicians workforce census there were 1,201 geriatricians in the UK. In 2008, it was agreed with the RCP that there would most likely be a need for 1,643 geriatricians by 2009—based on the workforce requirements for specific components of necessary services for older people.2 Not only has this figure not been reached, but the female workforce is continuing to increase and this has an impact on the number of WTE consultant geriatricians as many female geriatricians work part time. Furthermore, the latest census shows an increase in the number of geriatricians whose job includes being involved in acute general all-age adult medicine and stroke medicine, for which geriatric medicine is the “parent” specialty. Thus there are fewer clinical sessions remaining for core geriatric medicine. Furthermore, and as a very positive development for patients, geriatricians are increasingly providing clinical input and leadership for older trauma patients (orthogeriatrics—as required by Payment by Results Best Practice Tariff), community care and dementia services.

9. Prior to these developments, the BGS has recommended that to care for the population older than 75 years, there should be a minimum of one WTE geriatrician per 50,000 population (approximates to one WTE for 4,000 people older than 75 years). The ratio by which the population is served by a WTE geriatrician varies considerably across the country from the lowest ratio in Wales, Yorkshire and Humber and Scotland, with one geriatrician per 46,000 of the population, compared to the highest ratio of 76,000 to 86,000 in the East and West Midlands.3 There is clearly a need for additional consultant posts. This needs urgently an increase in the numbers of medical graduates training to be geriatricians, as the latest survey of trainees conducted by the BGS Education and Training Committee shows that there are currently 52 unfilled consultant posts.

10. Other professionals allied to medicine, such as therapists, and nursing have developed some specialist posts and career paths but these are not firmly established by specialist qualification or registration with the relevant regulatory agency. For example, although the nursing skills required for high quality care of residents in care homes are considerable, there is no requirement at all for any specialist training or qualifications, even for those with senior clinical responsibility. We support the development of specialist training and of consultant level appointments of these professions in community and hospital settings. Such appointments have demonstrated quality improvement in other healthcare settings such as Intensive care and surgical services.

11. We responded to last year’s consultation Liberating theNHS: Developing the Healthcare Workforce, and expressed concern at the proposals to reorganise the way in which the NHS workforce is planned and trained. We still believe that the scale of the re-organisation of the education and training of the healthcare workforce is unnecessary and potentially highly damaging. The implications for post-graduate medical training are worrying and while the network model may be effective for some healthcare staff, we do not feel it is applicable to postgraduate medical training. We believe that postgraduate medical training requires skilled organisation and governance at more than one level, including a sub-national or regional level. The current geographical structure of deaneries is broadly appropriate, and the skill base contained in deaneries should be valued and preserved.

12. The training of the medical workforce has already undergone massive reorganisation in the past five years, including the introduction of Modernising Medical Careers, the development of PMETB (Postgraduate Medical Education Training Board), multiple new curricula and assessment systems for specialty training, a complex new system of quality management, the results of the Tooke report, the merging of PMETB with the GMC. It must now be protected from further upheaval in order to deliver its core aim of training doctors without distraction. Skilled staff in the field of medical training will be diverted from their core activities by the need to learn how to develop and work in a completely new structure at a time of financial constraints.

13. We are particularly concerned that networks of healthcare providers should be given primary responsibility for both co-ordinating and providing training. Trusts already have competing priorities in service provision and often research, and many trusts still fail to support educational supervisors by recognising training activities in job planning, and developing relevant skills in their career grade workforce.

14. The loss of co-ordination at a regional level with the abolition of SHAs and deaneries will also be damaging. While foundation and early specialist training can often be provided in one hospital or a small group, in conjunction with Primary Care, higher specialist training requires rotations between a number of centres, and the current geographical size of deaneries and SHAs is designed to co-ordinate and oversee this for most larger specialties. Furthermore, the skills, experience and professional leadership necessary to co-ordinate training takes years to develop, both on an individual and organisational level. These reside within deaneries and their associated structures and must not be lost.

15. We support proposals to improve workforce planning but this will require a co-operative effort between the Centre for Workforce Intelligence and specialist societies such as our own, the Royal Colleges, the Department of Health and the training organisations (ie local provider networks). The Centre for Workforce Intelligence should obtain data from all healthcare providers and also needs to understand trends in disease patterns and treatments to predict changing needs for different specialist areas. However, workforce planning is inherently approximate, and any improved methods will take years to evaluate, particularly in the medical specialist workforce, which takes 15 years to train from school to consultant grade. The Centre for Workforce Intelligence must always recognise the inherent uncertainties in its predictions and make allowance for them.

16. In our own specialty in recent years many of those graduating from training have obtained consultant posts not in geriatric medicine, but predominantly in stroke medicine or acute medicine, neither of which could have been predicted at the start of those individuals’ five year registrar training programme. Conversely, we are aware of other specialties where highly trained doctors have found themselves without career prospects, which is clearly damaging to the individual and wasteful of training resources.

17. In postgraduate medical training, the organisation is very different between a specialty widely represented in every district or hospital (such as geriatric medicine), and a regional or more nationally-based specialty. The current system of training within deaneries is broadly successful in accommodating these needs, and also co-ordinating service and training between large and small centres and between urban and isolated rural centres. Broadly speaking, the more highly-trained and specialised the staff, the larger the overall framework for training needs to be. Education and training includes quality management of the training and also assessment of the trainees.

18. “Top down” co-ordination at a national level is vital for both economies of scale and overall coordination, and is particularly important for smaller and regionally or nationally-based specialties. There is a need for a responsible leading body but we are nervous about the ability of Health Education England to replicate the current role of deaneries and concerned that we will lose the existing expertise and structures that exist within them.

19. It is right that the Secretary of State should have an explicit duty to maintain a system for professional education and training of the healthcare workforce as part of the comprehensive health service.

20. We also believe that Clinical Commissioning Groups and the NHS Commissioning Board should have a duty to promote the education and training. This should also be a mandatory part of commissioning contracts.

21. The implementation of Modernising Medical Careers, introduction of PMETB, national coordination of appointments at specific times of year and restriction in employment of overseas trained doctors, all introduced in 2007, resulted in an over-rigid system that was not flexible to training or service needs, and required a stifling level of “tick box” style quality management. The new approach must allow for greater flexibility and autonomy, and reduce the bureaucracy in quality management.

22. Accountability needs to occur at different levels. For training doctors, the current system whereby local education providers (such as hospitals) are accountable to their regional body (deanery) and thence to a national body (GMC) is a good one for generic aspects of quality management, but has become too detailed and cumbersome. There are also specialty-related quality matters that need to be overseen by specialist societies and medical royal colleges.

23. Local authorities and the private and voluntary sector employ both healthcare professionals and less highly trained carers that require skills that overlap with those in the NHS. Therefore, it is logical to work with them in the provision and planning of training. However, in practice it is likely that healthcare professionals working outside the NHS will have moved there after a period of training and employment within the health service, so the NHS should be the main focus of training and staff development. However, workforce planning must take into account these staff who move into the social, voluntary and private sectors.

24. Whatever the structure of the training system, an important principle is that each Trust should commit to training the full breadth of medical specialties commensurate with their patient population.

25. We welcome the principle of multi-professional training, but feel that this is, in practice, only rarely applicable to trainee doctors. For example, considering the assessment of mental capacity in the confused “older patient, the skills needed by a doctor, a nurse and a physiotherapist do overlap but also differ considerably and a ‘one size fits all’ approach is not appropriate. Nonetheless, there are areas in which generic training may be shared between professions, and these include some of the basic skills needed to understand and care for frail older people which are relevant to a very wide range of health professionals as well as those involved in social care. For example, all health and social care professionals should have training about what compassion, empathy, dignity and humanity in routine care means to the patient, resident of a care home and their next of kin.

26. Two thirds of people in care homes have a form of dementia and up to one quarter of hospital beds are occupied by people with dementia. People with dementia stay in hospital up to twice as long as other people who go in for the same procedures. The failure to recognize their needs has contributed to the poor care that they often receive. It is important that individuals suffering from dementia receive timely and appropriate care. The acute care workforce must receive adequate training to understand the specific needs of people with dementia.

27. Geriatricians are ideally placed to provide a lead in promoting good care for people living with dementia. People with dementia may present with increased physical complaints long before their dementia diagnosis is made via current systems of care. Geriatricians may have opportunities to detect the signs of dementia at an earlier stage, when they see people presenting with other symptoms of frailty such as falls, declining mobility, weight loss and incontinence. Conversely, people with dementia may have more difficulty in accessing physical health care than other older people. Geriatricians with an interest in dementia are able to assess both mental and physical health problems and provide integrated and holistic care. Within the acute hospital they can act as role models in the provision of good inpatient care sensitive to the needs of those with dementia. It is therefore imperative that geriatricians should receive advanced training in the care of people with dementia so that they can act as leaders within their own hospitals. The BGS is supporting this training through its plans to provide training for dementia champions within acute hospitals.

28. There should not be an assumption that healthcare professionals are automatically empathetic and compassionate. This does not come naturally to all and role models are needed. There must be regular communication skills courses to keep all up to date and these should be put on the same footing as learning appraisal skills—something currently built into consultants’ job plans.

29. We recommend that the General Medical Council should look at undergraduate curricula across the UK in the context of geriatric training to ensure this is adequately covered. The BGS would be able to supply expert advice on curricula content but in addition to covering the giants of geriatric medicine—dementia/delirium, continence, dementia, immobility, falls -there should be content on human rights, comprehensive geriatric assessment and end of life care.

30. All medical undergraduates should receive training on comprehensive geriatric assessment—a multidimensional and usually interdisciplinary diagnostic process designed to determine a frail older person’s medical conditions, mental health, functional capacity and social circumstances. The purpose is to plan and carry out a holistic plan for treatment, rehabilitation, support and long term follow up.4 There should be multi-disciplinary training programmes covering CGA as the evidence demonstrates that those patients who receive comprehensive geriatric assessment have better outcomes.5 In the longer term CGA may save costs by reducing hospital readmissions and lowering the need for long term nursing home care.

December 2011

1 BMJ 2011; 343:d6799doi:10.1136/bmj.d6799

2 See Consultant Physicians working with Patients, 4th Edition, 2008 p 167.

3 See Consultant Physicians Working with Patients: Duties, Responsibilities and Practice of Physicians in Medicine, 5th edition, 200, p 11.

4 See Comprehensive Assessment of the Frail Older Patient, BGS Good Practice.

5 BMJ 2011; 343:d6799doi:10.1136/bmj.d6799ref.

Prepared 22nd May 2012