1. health and fitness

Editor: David Oliver
n
e
BGS
BGS
w
s
l
e
t
t
e
Issue 15
March 2008
r
The Darzi Review
our NHS, our future; opportunities and threats for older people
I
n October 2007, Lord Darzi published
his interim report - Our NHS, our
future - which set out the purpose
and scope of a wide-ranging review of
the NHS in England.
The intention is to redesign how care is organised,
building on the success of the NHS to date but
redefining the relationship with patients by
providing more personalised services,
including choice. Building leadership
capacity, particularly among clinicians, is
seen as essential to ensuring effective high
quality services. Four major themes have
emerged.
Fair - equally available to all, taking
full account of personal
circumstances and
The BGS Members’
diversity.
Handbook and
Personalised
Directory will be
tailored to the needs and
prepared soon. To
be in it, members
wants of individuals,
MUST register their
especially the most vulnerable
permission.
and those in greatest need,
providing access to services at
the time and place of their
choice.
Effective - focused on
delivering the best outcomes
for patients
Safe - giving patients and the public
confidence in the care they receive.
An additional and important change is that whilst
the Department of Health sets out policy and
priorities centrally, the aspiration is that service
redesign and implementation is to be led through
strategic health authorities and more locally
through primary care led commissioning. The nine
SHAs have each convened eight groups, to
develop the following clinical pathways.
t Maternity and new born care
t Children’s health
t Planned care
t Mental health
t Staying healthy
t Long-term conditions
t Acute care
t End-of-life care
These groups comprise individual senior clinical
or social care staff, most of whom also hold
management roles in their workplaces. There are
not many geriatricians on these groups. Work is
well advanced. A variety of events such as a
clinical summit in November and consultative
workshops in January have been used to refine the
pathways. Each SHA’s vision for healthcare is due
to be published in the Spring. To provide additional support for the SHA work,
the Darzi team at the DH have set up eight
national groups to consider cross cutting themes:
quality, innovation, leadership, workforce,
President: Prof Peter Crome
President Elect: Prof Graham Mulley
Honorary Secretaries: Dr David Oliver and Dr Simon Conroy
Meetings Secretaries: Dr Michael Vassallo and Dr Adrian Wagg
Honorary Treasurers: Dr Tom Smith and Dr David Cohen
Chief Executive: Alex Mair
Sub Editor: Recia Atkins
for better health in old age
2
BGS n e w s
March 2008
In this issue
Editorial .................................................... 3
President’s column .................................
7
Falls Prevention Services - where’s
the evidence? .......................................... 8
Falls Prevention Services - a GP’s
perspectiive ............................................ 10
Appeal against NICE guidance on
osteoporosis upheld ............................... 11
Clinical Academic Medicine in
Newcastle ............................................... 12
CME Journal - good enough? ................. 14
Standards of Medical Care for older
people (compendium document) ............ 15
The NSF seven years on: a personal
view (Nurses’ Column) ............................ 19
Glasgow - host to BGS Spring
Meeting 2008 .................................... ..... 20
BGS Movement Disorders update ......... 21
NOTICES ................ .............................. 22
Education and Training .......................... 24
BGS Eduction/SAC Day at RCP(L)
E&T section on website
National CPOD audit ............................. 26
Trainees column
.................................. 27
In Memoriam - Ronald Cape ................. 28
National Stroke Strategy .. ....................... 29
From Nuclear power to table tennis
Dementia comes out of the shadows ... . 30
The Savages .......................................... 34
BGS Contact Details
Chief Executive - Alex Mair:
[email protected]
Committees, Clinical Excellence Awards,
Elections, EUGMS, General Office Management
- Sarah Allport: [email protected]
Membership, Age & Ageing subscriptions,
Abstracts, Scientific Meetings Liaison, CPEC,
NICE, Grants, CPD - Joanna Gough:
[email protected]
Finance - Susan Cox:
[email protected]
Age & Ageing abstract supplements,
Publications, Newsletter, Newsletter advertising,
Websites - Recia Atkins: [email protected]
information, systems and incentives,
primary and community care and a
constitution for the NHS. All these
will contribute to the final report to
be published in June 2008, setting
out the vision for the next decade.
Details of the national and local
groups and events, and Lord Darzi’s
blog can be found at
www.ournhs.nhs.uk/local/
What about older people?
Since older people are the main
users of health and social care,
criticism could be aimed at the
review for not identifying their
needs as a specific theme. On the
other hand, the issue of ageing and
health should be right there in all
work streams except maternity and
children’s health. In one of the
Prime Minister’s early speeches in
2008, celebrating 60 years of the
NHS, he stated - “One of the main
challenges that the NHS faces in the
coming decades is that of high
quality, cost effective care for
increasing numbers of older
people”. What is needed is to make
sure that this reality is competently
and adequately reflected in each of
the SHAs’ visions for healthcare,
and the details as they emerge from
this.
This is a challenge but also an
opportunity for geriatricians and
their multidisciplinary colleagues.
Many of us have been frustrated
before when trying to promote the
importance of the specialist old age
approach to the modern NHS, but
there is a real opportunity now to
bring our clinical and service,
expertise from the field into this
review. This is not about preserving
our services, as they now are, as
things around us change and
threaten what we have built. It has
to be about reshaping our services
but more important than this is to
export the lessons we have learnt
into the wider clinical world.
For example, centralising surgical
specialties coupled with a model of
decentralised post acute care simply
won’t work if assessment and
clinical management isn’t designed
to meet the clinical needs of older
people. This must include
revolutionising the traditional preoperative assessments to incorporate
identifying those at risk for frailty
syndromes such as delirium,
incontinence and immobility, and
changing clinical care accordingly.
Likewise the emergence of urgent
care centres, maybe in tandem with
services to avert acute admissions
needs comprehensive geriatric
assessment at the heart. We all know
how patchy this is in current
intermediate care.
This review is predicated on the
conviction that patients aspire to see
improvements in access, better
experience of care with dignity and
greater personal control, and
receiving the right care in a timely
fashion through better integration.
Embedding the necessary “old age”
skills in these clinical pathways is
vital if this is to be achieved. And if
not, then the service redesign
threatens to be an expensive failure.
Lord Darzi has promised an
improved vision for the NHS
through enhanced clinical
engagement. We should use this to
push at the doors and make sure
that neither we nor the needs of
older people become marginalised in
the new NHS.
Deborah Sturdy
Nurse Advisor Older People,
Department of Health
Finbarr C Martin
Medical Adviser Older People,
Department of Health
n e w s BGS 3
March 2008
Editorial
P
erhaps this issue’s editorial
should be re-titled “news roundup”. Only a few weeks into 2008
and already, issues affecting our
speciality have been in the news
repeatedly.
Many of the topics highlighted are linked directly to
BGS work or to health care of older people in general
and some will be linked to articles in this and future
newsletters. So where to begin?
Stroke
Well, for starters, we had the announcement from the
Department of Health of the National Stroke
Strategy (page 29) www.dh.gov.uk/en
/Policyandguidance/Healthandsocialcaretopics/Stroke/i
ndex.htm
This attracted a great deal of media interest and has
resulted in many hospital trusts rushing to set up
rapid referral pathways for thrombolysis, so as not to
be left behind in the commissioning race. The focus
on stroke is welcome. There are over 200,000 people
per annum in the UK suffering stroke and TIA.
Mortality rates have not dropped over the past decade
(unlike those for coronary artery disease). Our
outcomes fall below those of many European
countries. Though nearly all district hospitals now
have stroke units, many patients still never receive the
specialist care they provide. Stroke care remains
patchy and inconsistent. The Stroke Strategy does
emphasise rehabilitation, primary and secondary
prevention, stroke unit and post-discharge care. There
has been major input from BGS members. If I have a
reservation it is that the focus on acute
thrombolysis pathways and rapid access TIA clinics
which might divert attention away from equally
important but low-profile and “low-tech” areas of
care, which have traditionally been neglected (not least
by some neurologists). I find it instructive that the
moment stroke moved from the Older People’s to
Cardiac National Service Framework and a
pharmacological “high tech” and curative treatment
became available, interest seemed to increase
exponentially, (even though most patients with stroke
will never benefit
from thrombolysis
even with “Rolls
Royce” services);
another example
of covert
discrimination
against geriatric
medicine and frailty?
With moves to make
Stroke medicine a separate speciality, the evolving
relationship between geriatric medicine and stroke
care will be an interesting one and hopefully one the
BGS can continue to influence.
Darzi Report
Since our last edition, we have also seen the
publication of Lord Darzi’s Interim Report Our
NHS Our Future, (see Deborah and Finbarr’s
commentary on page 1). This report is ostensibly a
draft for comment (though I am bound to wonder
how much is already cast in stone and how much was
actually prepared by Lord Darzi himself – as an
academic surgeon from a London tertiary referral
centre). The report contains significant content on
preventative medicine; case-management for long
term conditions (despite the current poor evidencebase for community matrons and other forms of casemanagement and reservations expressed by the BGS);
and devolution of care from secondary care to “the
community” (i.e. PCTs) with a series of performance
metrics to assure that this is happening. Though as
Gerry Robinson pointed out in his recent TV
programme when visiting the excellent rapid
assessment service for older people in Rotherham,
what is a general hospital if not part of the
community? And why disband a popular hospitalbased assessment service for older people, merely on
ideological grounds? The report is supposedly at
consultation stage currently, and the Society will be
one of many stakeholders to comment. It will be
interesting to see how much the final report differs
from the draft or whether the consultation is more for
show. We hope to have an article in the next Newsletter
summarising the implications of the report for our
speciality. In the meantime, you can find the details
(along with Lord Darzi’s blog and comment from his
“listening roadshows” at www.ournhs.nhs.uk/. The
editor of the BMJ, Fiona Godlee also interviewed
Lord Darzi about the report and was able to include
4
BGS n e w s
March 2008
some specific questions we had suggested around
older people and the shift to primary care. There is
useful comment and debate on Darzi on the Kings
Fund Site www.kingsfund.org.uk/media/
news_in_context/lord_darzis_next_stage_nhs_review/
index.html
Gordon Brown and Heath Promotion
Since our last edition, the Prime Minister has made his
first major speech on the NHS and set out his vision.
For a summary of the speech there is a good piece by
Rebecca Evans in the Health Service Journal 10th Jan
www.hsj.co.uk/news/2008/01/brown_unveils_vision_for
_21st_century_health.html. For pithy expert
commentary, it is well worth reading Chris Ham’s
Piece in the BMJ 12 January www.bmj.com/content/
vol336 As he points out, “the government has willed
the ends, but will it provide the means and the
mechanisms for effective prevention and improved
outcomes” (a theme I will return to). Beyond the
emphasis on health promotion and preventative
medicine, the speech also echoed Darzi in highlighting
the need for better management of long term
conditions and an expert patient programme. Brown
also discussed personal direct payments or “health”
budgets - which in reality largely concern social care.
All these themes were short on operational detail
which might transform the visions into reality and
public-health benefits. A provocative opinion piece by
Julian Tudor Hart (BMJ Jan 2008 336) mischievously
suggested that there was too much emphasis on
extending the kind of “screening” currently
demanded by the middle class worried well to less
advantaged members of society, rather than majoring
on screening that would produce genuine public
health benefits.
Preventing Falls and Fractures
Moving from the rhetoric on prevention, screening
and case-finding and the major current focus on
Obesity (see BMJ debate “is the obesity epidemic
exaggerated” BMJ 2008;336:244); what could be a
better example of a pressing public health issue of
relevance to our speciality than the prevention of falls
and fractures? This issue also illustrates again the fact
that standards and aspirations for improving care
mean little without earmarked investment, a
willingness to invest in the short term for medium
term gains and binding performance targets. Fragility
fractures affect around one in two women and one in
twelve men over a lifetime and accidental falls, in
addition to causing such fractures, are one of the
leading causes of hospital attendance and admission
in older people. Despite the targets in the NSF and
NICE guidelines promoting secondary prevention of
falls and fractures, we know from our own national
audits in conjunction with the RCP
(www.rcplondon.ac.uk/college/ceeu/fbhop/index.asp)
that services for these conditions are patchy and
poorly integrated and that many patients still receive
no assessment. One of the reasons behind this is the
sheer scale of the problem means that whilst
secondary care has a fighting chance of “catching”
patients who attend hospital following falls or
fractures, there needs to be better input from primary
care to realise whole population gains rather than
pockets of good practice. Because of this, a
consortium of NOS, BGS and Help the Aged have
tried for a second time to incorporate falls and
fracture prevention into the Quality and Outcomes
Framework for the GP contract (page 10). I am afraid
that the falls standard has been rejected on the
grounds of being too difficult to record or measure,
but negotiations are still ongoing around fragility
fractures. An appeal has also be upheld against the
NICE guidelines on secondary prevention of fragility
fractures in view of the fact that so many of our own
patients are unable safely to take Bisphosphonates
(page 11) .
Whilst all this was going on, the BMJ issue 19th
January contained two reviews suggesting that the key
to secondary fracture prevention lay in preventing
falls, and a further systematic review (the first since
2005) suggests that the evidence for falls-clinic-style
multifaceted falls interventions might not be as strong
as suggested in earlier guidelines. The BGS Falls
Section response to this can be found on page 8.
Finally, in Feb 2 BMJ published a further systematic
review suggested that Calcium Supplementation
(widely accepted in the treatment of bone fragility)
increased cardiovascular risk with those risks
outweighing the effects in fracture prevention.
Interesting times for the Falls and Bone Health
section.
Better services for dementia care
An increasing feature of my day to day job (I am sure
echoed by colleagues around the country) is the sheer
number of patients arriving in the acute sector for
whom dementia is in reality their main problem (even
if they present with acute medical illness) See Martin
Curtice’s parliatmentary round up on page 30. It is
also clear when these patients default to or become
stuck in hospital, that our investment in community
services for dementia is grossly inadequate, however
hard our colleagues in old age psychiatry may work.
Previous reports in which the BGS has been a key
player such as “ Who cares Wins”
www.rcpsych.ac.uk/PDF/WhoCaresWins.pdf ;
“ Delirious about dementia” www.rcpsych.ac.uk/pdf
/Delirious-about-dementia.pdf as well as standards in
the original 2001NSF re-iterated in “ A New
A mbition for Old A ge” have highlighted that such
patients often get a raw deal from the system. It was
therefore pleasing to see an announcement from Ivan
n e w s BGS 5
March 2008
Lewis following the Junior Health Minister, endorsed
by the Alzheimer’s Society, that dementia services
should be central to service planning in the future.
And the public accounts committee called for the
appointment of a dementia “tzar”. (See Downs and
Bowers BMJ February 2nd and rapid responses for
comment). Again, whilst this emphasis is welcome, the
sceptic in me wonders where the money is to
accompany this initiative.
Investment in services for older
people
One of the reasons for the failure of so many of the
original NSF targets to be met in full was a lack of
earmarked funding or binding performance targets for
issues specific to older people. In a recent survey of
1,600 health service managers commissioned by the
Health Service Journal to commemorate the 60th
anniversary of the NHS, the groups identified to have
“benefited least from NHS reforms” and “received
the least investment” were overwhelmingly older
people and those with mental health problems. Going
back to the National Stroke Strategy, it has been
noticeable that when such an initiative is accompanied
by “must do’s” things happen quickly. Other recent
examples of radical change achieved in short order are
the welcome expansion in palliative care services for
older people and the focus on infection control or on
critical care outreach. But for the “geriatric giants” we
still have a long way to go. Beyond falls, fractures and
dementia, we know that delirium is still underrecognised and badly managed (Ref BGS
Compendium or Young and Inouye BMJ 2007). And
the recent joint continence audit with the RCP, led by
Adrian Wagg and reported in this month’s Age and
Ageing (Vol 37, No.1 p32) – tells a similar tale –
neglected even within our own speciality and again,
despite the existence of NICE guidelines.
Professor Ian Philp
After 8 years in post, the National Clinical Director
for Older People has recently moved on from the
Department of Health. I hope to twist his arm to
write something on his experiences for a future issue.
For now, I would like to thank him on behalf of the
Society for doing so much to put the care needs of
older people in the spotlight. Despite being “one of
us” he had to be careful not to be partisan in pushing
a doctor-led agenda and also had a tightrope to walk
between his corporate role within the DH and his
advocacy role for older people. There is no question
in my mind that the publication of the NSF led to an
increased focus on older peoples’ services (see page
19) and a stimulus to better joint working with
primary and social care organisations. His own 2006
document “A New A mbition” highlighted the
gains but also pointed out that we still had a long way
to go in delivering joined up, dignified or “age-proof ”
care. Again, within the unwritten hierarchy of NHS
performance targets and structural re-organisation, the
lack of dedicated funds and binding targets, and
almost certainly some covert discrimination against
the needs of older people by commissioners, may
have been partly to blame for some of the failures but
I believe we would have been a great deal worse off
without Ian’s contribution. Finbarr Martin remains as
the deputy clinical director, as does Deborah Sturdy (a
member of our nurse consultants group), as the
senior nursing advisor. But the future role of a clinical
director is uncertain.
Restrictions and Rationing in Social
Service Provision
Talking of politics and resources, the government’s
own recent report on provision of home care, the
third annual report of the Commission for Social Care
and Inspection http://image.guardian.co.uk/sysfiles/Society/documents/2008/01/29/csci.pdf shows that
despite an increase in the proportion of people over
75, fewer were receiving home care services. Services
are being increasingly rationed – with priority given to
those with “substantial care needs”. Denise Platt, the
chair, said in an interview with the Guardian that
“People who only five years ago qualified for councilarranged help are today excluded by the system and left
to fend for themselves. The poor experiences of people
and their carers trying and failing to get sufficient help
contrast starkly with those people who do qualify for
council-arranged care.” Also, that there was an “urgent
need to create a fair and equitable social care system,
which is sustainable and affordable.” The report
stated “it is striking that critical decisions over who
was eligible for care were not carried out by staff with a
professional social work background, in the six councils
it studied in depth”. A parliamentary enquiry has been
announced and Ivan Lewis was quoted as saying “the
rationing of services for vulnerable and frail older
people has become inconsistent and unfair” And that
applying a “vulnerability test” to restrict services only
to the most frail flew in the face of the government’s
own focus on promotion and prevention
www.guardian.co.uk/society/2008/
jan/29/socialcare.longtermcare
Resource to the fore again
Meanwhile, north of the border, the news emerged in
February from an Audit Scotland report
http://news.bbc.co.uk/1/hi/scotland/7220965.stm that
the Scottish decision to allow free personal care for
all, non-means-tested had resulted in a spend four
times that originally projected with an overspend of
£63m. Equity, universality and needs based provision
are seemingly irreconcileable goals in any resource
limited system.
6
BGS n e w s
March 2008
Useful
Articles
Not again
...there has been a longstanding
discussion of the Society’s name, with
dissatisfaction with the present name but
no consensus on an alternative...it was
decided that it would be important to
devote our time to discussing and deciding
other issues affecting the Society and our
specialty, and it was agreed to have a
moratorium on discussion of the name...
We had a recent
discussion at the
Policy
Committee on
the implications
for staff “at the
coalface” of
implementing
the Mental
Incapacity Act
and lessons from
the Scottish experience. We plan to have something in
the next newsletter on this. However, two recent
useful articles on practical application of the act can
What’s in a name? Everything and nothing.
If the purpose of a name is to identify our role as geriatricians,
then I think that the use of geriatrics is entirely appropriate. Most
people know what geriatrics means, more or less – something to
do with advanced age, frailty and proximity to death. Even the
TV shows that Martin Curtice reviewed for us have a fairly good
idea about geriatrics, even if some of the themes were negative.
So if the purpose of the name is to define, then geriatrics does it
well.
But if, on the other hand, it is about image and attitude, then
maybe there is still some work to do. Whilst big business can
change its name, re-brand and create a new image, we cannot
really do the same. Our core ‘product’ – the frail older person is
fixed. Whilst it is true that some geriatric subspecialties have
successfully rebranded to some extent – such as stroke
medicine, they have changed attitudes rather than the product.
Stroke is now ‘sexy’; the same can be said about cancer care,
and increasingly, end of life care.
Therein lies the bigger challenge – changing society’s attitude to
frailty. The key to this is in ensuring that opinion is well-informed.
This is slowly happening – whether it is the older people’s tsar
appearing on day time TV, or increased media coverage
generated by debate, we are hearing more and more about
issues relevant to the frail older person. Some of you may have
seen the secret millionaire series, in which millionaires go
undercover to find a worthy cause for their benevolence. I was
particularly struck by one programme (28th November 2007) in
which the millionaire worked in a care home. His initial
experience was predictably negative, with complaints about the
smell of urine and lack of appeal. But the programme ended
positively, with him giving a large donation to one of the young,
underpaid but very caring assistants. It was a good example of
how exposure to frail older people (and hence informed opinion)
influences attitudes. But we are also reminded that the exposure
needs to be deep and not superficial, if it is going to be
successful in changing negative attitudes.
I am increasingly convinced that attitudes is the battle that we
need to win if we are going to get our colleagues to look after the
growing number of frail older people properly. - Simon Conroy
be found in BMJ (Nicholson et al BMJ 2008;
336:322-5) and in Clinical Medicine (Muckherjee E et
al 2008; 8(1):65). Finally, as we all deal day to day with
malnourished inpatients, there was a recent very
useful review on this subject (Lean M, BMJ
2008;336:290) - which is in turn, a key part of the
dignity agenda.
Campaigning and Naming
All of this leads me finally, to the issues I raised in my
December Editorial. In response to the question of
whether or not we should campaign, I have received
no responses. As a busy DGH doctor myself, I realise
that this lack of response may simply reflect how busy
members are. What it doesn’t leave me with though, is
a sense of what BGS members think about this issue.
You may all be very opinionated one way or the other
or you may be supportive of the committees in
making decisions on your behalf. Again, views please.
On the allied issue of whether a change in our name
would help us in a campaigning role, we have received
three replies on this issue (summarised here in the
green boxes). How representative they are is hard to
say. However, it would seem that the issue of our
name has been raised and shelved repeatedly. Time
for a referendum of the members perhaps? If we do
change, I do believe that the new name should reflect
our specific focus on better health assessment and
health care for older people. But as things stand there
doesn’t seem to be a groundswell in favour of change
of any kind.
Until next time.
David Oliver
A vote for change
I wasn't at the Harrogate meeting but I am not
surprised to hear that the Society's name has
come up as an issue again.
I write as a long-term supporter of change, with
a suggestion for a new name.
Why not....... "Ageing UK" or "Ageing Britain".
It
a) ties in with the name of our journal.
b) describes a real demographic fact.
c) permits simple devolution to e.g. "Ageing
Mersey" or "Ageing Scotland".
d) gets us away from the G word.
e) lets people immediately know what we are
about.
Diabetes UK did it. Why can't we?
- Andrew Elder
n e w s BGS 7
March 2008
President’s
column
A
s David mentioned in his editorial,
members may be aware that
Professor Ian Philp has decided
to stand down as National Clinical
Director for Older People’s Services.
He has been a tireless advocate for older people in the
heart of Whitehall and many of you will have been
able to develop your service using the arguments
advocated by the National Service Framework and
subsequent policy documents. One less well known
aspect of his work was the creation of an Older
People’s Specialist Forum at which representatives
from all the relevant healthcare professions were able
to give views on current and proposed Department of
Health policies. The Society is now hosting the Forum
and is a clear manifestation of the multi-disciplinary
nature of our work. Ian, thank you. UKMC has
decided to mark his tenure in Whitehall by making a
special presentation at the Glasgow meeting.
Links with Help the Aged
At the last UKMC it was agreed to sign a
Memorandum of Understanding with Help the
Aged. We will be setting up a joint Health Advisory
panel to advise Help the Aged and they, in turn, will
have input into our policy developments. Expect to
see conferences jointly badged with Help the Aged
The BGS wishes to congratulate the following colleagues
who were recognised in the Queen’s Honours Roll in
November:
Dr Pradeep Balbir Khanna MBE, Consultant Physician, Care of
the Elderly and Chief of StaV for Community Services, Gwent
Healthcare NHS Trust. For services to Medicine
Professor Martin Peter Severs OBE, Associate Dean (Clinical
Practice), Faculty of Science, University of Portsmouth. For
services to Medicine.
Dr William Edward Wilkins OBE, Clinical Director of Integrated
Medicine and Consultant Physician, Bro Morgannwg NHS Trust.
For services to the NHS in Wales.
and joint
responses to
consultations.
Many of the
Medical
Specialist
Societies enjoy,
and benefit,
from close
links with
related patient
groups and this link-up advances our well established
relationship with Research into Ageing (now part of
Help the Aged) into a broader arena.
Have you ever been rejected?
Writing this the day after Valentine’s Day I should
explain that I am talking about rejected abstracts
submitted to our meetings. The Academic and
Research Committee has broadened the range of
types of abstracts that can be accepted. These now
include clinical effectiveness studies. We would be
interested in hearing from the membership whether
they feel that we are too restrictive. Any thoughts
would be welcome. Please email to
[email protected]
Knowledge Based Assessments
A formal test of knowledge (aka an exam) is an
obligatory assessment within the new curriculum for
registrars. Oliver Corrado has been leading a team of
experts who have been working hard producing
questions and I had hoped that we would be able to
announce that this process had been completed. The
examination will be administered by the MRCP (UK)
Office but will be a joint venture between the Royal
Colleges and the BGS. Unresolved issues include the
title of the award that will be granted, the cost to
applicants, and how and where the assessment will be
administered. I hope that we will be able to announce
that these issues are resolved by the time of the next
issue.
National Hip Fracture Database
I attended the launch of this project atf the House of
Lords. As a Senior Registrar I worked in a joint
geriatric medicine/orthopaedic unit at St Helen’s
Hospital, Hastings and it has taken a little while for
such joint working to become fully accepted. For the
8
BGS n e w s
March 2008
Society to work jointly with the BOA on such a major
project must be regarded as almost miraculous! (note:
the late Dr Tony Clarke told me that his unit in Stoke
was opened before the one in Hastings).
Annual Report 1960-1965
Tony started his consultant career before moving to
Brighton and I was recently presented with the
Annual Reports of the geriatric medicine service for
what was then called the Stoke-on-Trent Hospital
management committee. The two consultants had
responsibility for over 700 patients in 8 or 9 hospitals.
Between them they clocked up over 1,500 visits in the
year! How things have changed although detailed
reading reveals that many things have not altered – for
example, the reports contain details of elder abuse.
Honours
As you can see from the box on the previous page,
three of our members have been recognised in the
Queen’s Honours. It is good to know that the
governance of the Empire is in such capable hands.
The Society takes part in the nomination process and
provides letters of support. The President and
President-Elect are always happy to receive
suggestions from members. There is also liaison with
the President of the London College and other
organisations, as appropriate.
Glasgow
I am looking forward to this event and to seeing as
many of you as can make it. The Organising
Committee has produced a superb programme and
the dinner will take place at the recently restored
Kelvingrove Art Gallery and Museum*. See you there.
EUGMS Copenhagen
Could I draw members’ attention to the call for
abstracts now posted on the EUGMS website
(www.eugms.org). It looks a great programme and I
hope as many of you as possible will be able to make
the trip there. It is a marvellous opportunity for all of
us to meet colleagues from other countries and share
experiences and establish lasting professional and
social friendships.
*p.s. we have been promised that the event will be
bagpipe free.
Peter Crome
Falls Prevention Services
where’s the evidence?
T
he BGS Falls Section responded
to a systematic review published
in the BMJ suggesting that
evidence for falls-clinic-style
multifaceted falls interventions may not
be as cost-effective as suggested in
earlier guidelines.
The paper was the product of government funded
NIHR commissioned work under the Service
Development and Organisation (SDO) programme
(2006). The negative results of the analysis by Gates
confirms the findings of other reviews that there is
no evidence yet from clinical trials to show that
fractures or other serious injuries are reduced by falls
prevention services, or that falls prevention services
are cost effective. The main reason for this is that
large enough studies with at risk older people given
intensive targeted interventions have not been
conducted.
Where this report differs from previous reviews of
the evidence, is in finding no definite evidence of
reduction in the number of fallers and in being
unable to comment on falls rates reduction through
inadequate data. For an individual patient, a reduction
in the rate of falls would be important even if that
person remained an “occasional faller”. Why is there
inconsistency between this report and the conclusions
of the NICE guidance group? This is partly because
papers selected for the review were different, and
there were also minor differences in analysis methods.
Importantly it is not because there have been new
convincingly negative trials of multifactorial
interventions since NICE guidance was published in
n e w s BGS 9
March 2008
2004.
evidence of benefit in fracture reduction if
fallers
who sustain such an injury receive
There is clear
The studies selected for the
secondary
fracture prevention, yet recent
evidence of benefit
analysis in this report were quite
large scale audits in primary and secondary
in fracture
heterogenous, both in terms of
care in the NHS have shown that the
reduction if fallers
trial participants and of the
majority fail to receive such interventions.
interventions used, and
who sustain such
While we may have less clear cut evidence
although they employed
for overall falls rate reduction as the
an injury receive
subgroup analysis to explore the
assessments
and interventions are far more
secondary fracture
possibility that particular types
complex,
prevention
of interventions may have
there is a
benefit, the resultant numbers
public
are too small for safe
health imperative
conclusions to be drawn. Therefore, we think that no
to address this
definite conclusions can be drawn from this study as
issue as hospital
to whether what is actually happening in Falls clinics
admission rates for
is effective or not for falls, injuries or the quality of
fallers in the older
life of older people. There is no justification for
age range is
disinvestment or to abandon the aspirations of the
growing at an
NSF to develop falls and fracture prevention
alarming rate
strategies.
(more than 10%
per year in the last
In this apparent confusion there are some certainties
two years).
that should be kept firmly in mind. There is clear
The British Orthopaedic Association and the British Geriatrics Society have
developed an alliance to improve the prevention and treatment of fragility fractures in
older people. We believe that a combined falls and bone health approach is vital.
Fragility fractures make up the majority of the 310,000 UK patients who fracture each
year. Around a quarter are hip fractures, for which demography and a rising age-specific
incidence are leading to an overall 2% increased incidence per annum. Subsequent
mortality is high, about five-fold compared to their peers without fractures in the
following 12 months. These hip fractures account for direct healthcare costs of £1.8
billion per annum, estimated to reach £2.2 billion by 2020. As much again results from
the social care costs, associated with incomplete functional recovery.
About half of patients experiencing a hip fracture have had a previous fragility fracture of
the wrist, upper arm or pelvis, usually after a fall. These fractures also contribute
significant pain, disability and health and social care costs.
The most effective strategy to prevent future hip fractures is likely to be based on
reducing the future risk of falling of those people who have a first fragility fractures or
other injury and present to hospital Accident and Emergency departments. BUT up to a
half of these have osteoporosis as well and therefore a combined falls and bone health
approach is needed.
Current evidence-based recommendations for preventing falls include regular strength
and balance training, taking Vitamin D and Calcium supplements, medication
modification and removal of hazards in the homes of at-risk people. These measures
can reduce falls but much more needs to be done to ensure that high risk people have
adequate assessments and treatments. The recent national audit from the Royal
College of Physicians shows that less than half of such patients subsequently receive
any treatment to prevent falls or fractures. There should be no further delay in ensuring
comprehensive application by the NHS of the current NICE guidance on falls (CG21,
2004) and secondary treatment of osteoporosis (Technology Appraisal guidance 87,
2005).
David Marsh, Professor of Clinical Orthopaedics
Finbarr Martin, Chair, Falls and Bones Section
Press Release - 18 Jan 2008
There is clear need for further
research on specific aspects of
falls prevention as well as how
best to organise services to
deliver these interventions. It
is important that the recently
announced increase in
government funding for the
MRC earmarked for research
on frailty in older people
addresses the real clinical
problems of older people.
This requires collaborations
between clinical service
providers and universities. In
the meantime we need to
direct strength and balance
training and multi-professional
multi-disciplinary falls services
at larger numbers of the
highest risk groups who have
a combination of a falls
history and a prior fracture or
osteoporosis.
Finbarr Martin
Chairman
BGS Falls and Bone Health
Section
10 BGS n e w s
March 2008
Falls Prevention Services - where’s the evidence?
a GP’s perspective
The rather mischievous edition of the BMJ on 18
January - which on the BBC at least completely
eclipsed the work of Sallie Lamb's team - once again
calls into question how well the peer-reviewers check
references at the BMJ!
I worry that the Department of Health (DH) will use this to
return to a position where falls interventions, particularly
expensive integrated falls services are seen as the principal
solution to fractures (rather than falls) with the more
evidence-based based osteoporosis indicators hanging on
to the coat tails! In secondary care, osteoporosis lags well
behind falls and the first RCP audit showed this.
If we were to be generous and say that the people seen in
a falls clinic were saved one out of the three of the falls
they might expect in the next 12 months, then at the
present rate of throughput and the estimated rate of
fractures following a fall, 0.84 hip fractures would be saved
per 100,000 of the population per year at a cost of £51,000,
according to the health economic data in the SDO report
underpinning the Gates paper. The same amount of money
could DXA and provide alendronate for a year to 485 new
patients presenting with a low trauma fracture which,
interestingly, is almost the exact number of postmenopausal
women presenting with a new fracture each year in a
population of the same size!
Jarvinen et al imply a 50% reduction in fractures and quote
My views about the QOF osteoporosis indicators are that
5 papers. One is Tash Masud's paper on cataracts which
having seemingly been recommended by the Expert
does show a fracture reduction but this may not be
Review Group and accepted by the GPC they may be
transferrable to visual interventions generally, where no
sacrificed at the time of writing to increased evening
benefit was seen (Cumming RG et al, Improving Vision to
opening hours for GP surgeries. Our view may be that this
Prevent Falls in Frail Older People: A Randomized Trial.
is a reasonable subject for negotiation but using QOF
Journal of the American Geriatrics Society. 2007;55(2):175resources is inappropriate as there is no link to improved
81). The PROFFET study
health outcomes or
did not show a statistically
care utilisation. My
significant fracture
take on it is that No. 10
Rather than shifting the emphasis from bone strengthening
reduction and 23% of the
is directing the agenda
pharmacotherapy towards interventions designed to
randomised patients were
at Richmond House
reduce falls, as suggested by Järvinen and colleagues, we
excluded from the
and despite 84% of the
believe that the better message should be to add falls
statistical analysis. Two of
population being
assessment and interventions to osteoporosis treatments,
the other studies did not
satisfied with GP
in the prevention of fractures.
even have fracture as an
opening hours, the
outcome and one was a
commuters win out. If
extract from J Baly and T Masud’s rapid response to the
comparison between two
extended opening had
BMJ article
wards i.e. a cluster
been part of the
randomised controlled trial
bargaining around
of two.
dropping 24/7 GP cover, I suspect it would have been
accepted, but not now as GPs have had pay restraint for
We need better falls prevention care in the older faller who
two years and feel they have earned the real-terms salary
has fractured. With the current doubts about efficacy for
increase in over-delivering QOF. Gordon Brown and the
falls interventions in hospitals, care homes and now the
DoH probably feel they have got less out of the new
community, we should not increase this activity at the
contract than the BMA as GPs are earning more money for
expense of osteoporosis treatment where this is directed at
less hours availability over the week, which makes the
the high risk patients. We need to perhaps concentrate
government look bad and so they have got to have a
more on the ‘evidence based’ strength and balance
victory here. I think this was decided months ago and all
programmes, as John Campbell is recommending.
the weeks we put into the QOF review process and all the
hard evidence we were asked to attest to was set up to fail.
Integrated falls clinics are good in getting older patients with The GPC are now attempting to out-flank the DoH to the
frailty related falls into a comprehensive geriatric
moral high ground on the basis of ‘we want old people to
assessment but are not a solution to fracture prevention as
have better osteoporosis care, heart failure and PVD
there are far too many who need to be seen.
treatment and you are just after the commuter vote’.
We discussed at the RCP symposium in November, the fact
that there would never be an RCT big enough to
demonstrate fracture efficacy from falls interventions. That
may be true, but if the incidence rate (hip fracture following
fall) is so low and the effect size (falls intervention to stop a
fracture) also so small that we cannot demonstrate this then
it is most unlikely that any falls service as currently
structured and with present throughput is likely to have any
noticeable effect on fracture incidence.
The argument is about 10 minutes difference per week per
1000 patients between the GPC and the NHS employers.
There must be a compromise if we could get both sides to
agree and if both sides want it.
Assuming about 50% of hip fractures have a prior fracture
and only 20% guideline care and that conservatively this
could reduce fracture risk by 35% then down the line every
year we delay implementation of NHS-wide FLS and QOF
n e w s BGS 11
March 2008
will cost 8000 potentially preventable hip fractures or
200,000 bed days, 1600 deaths and double that number
unable to live independently.
Jon Bayly
References
Jarvinen TLN, Sievanen H, Khan KM, Heinonen A, Kannus
P. Shifting the focus in fracture prevention from
osteoporosis to falls. BMJ. 2008 January 19,
2008;336(7636):124-6.
Gates S, Fisher JD, Cooke MW, Carter YH, Lamb SE.
Multifactorial assessment and targeted intervention for
preventing falls and injuries among older people in
community and emergency care settings: systematic review
and meta-analysis. BMJ. 2008 January 19,
2008;336(7636):130-3.
NICE guidance on osteoporosis
- NOS appeal upheld
T
he National Osteoporosis (NOS)
has announced that it is delighted
that the appeal against NICE
(National Institute for Health and Clinical
Excellence) on its draft guidance for
treatment of osteoporosis has been
upheld.
The draft Guidance issued in June recommended only
one mandatory treatment for osteoporosis –
alendronate – but up to one in four people cannot
tolerate the treatment or will not respond to it. The
NOS was deeply concerned that without alternatives,
thousands of people would be left without any
treatment option at all.
December’s appeal decision means that
recommendations will now be drafted on a range of
alternative treatments for these patients.
• In the UK, one in two women and one in five
men over the age of 50 will break a bone mainly
because of osteoporosis, although it also
affects younger people.
• Currently fewer than 500,000 of the 3 million
people with or at risk of osteoporosis are
currently being prescribed drugs to reduce their
chances of bone fracture.
• Three million people are at risk of
osteoporosis in the UK.
Mrs Claire Severgnini, NOS Chief Executive said:
“I am extremely pleased that the Appeal Committee
has listened. NICE should not have changed the
original scope of the guidance without full and proper
consultation and this outcome is a real success for the
charity.
We launched our appeal campaign in July with great
support from our members. Thousands of people
wrote to their parliamentary representatives to
highlight the shortfalls in NICE’s recommendations
and in October, a petition with 24,000 signatures was
delivered to 10 Downing Street. The NOS will
continue to work on behalf of people with or at risk
of osteoporosis to secure access to a range of
effective treatments.”
Professor Richard Eastell, Chair of the NOS Board of
Trustees welcomed the move towards greater clarity
and transparency within the Guidance. He added: “We
look forward to working with NICE to ensure that
clinically appropriate and scientifically robust
Guidance is made available for the NHS at the earliest
opportunity.”
The appeal was lodged by the National Osteoporosis
Society in partnership with The Society for
Endocrinology, The British Society for Rheumatology
and the Bone Research Society.
Dr Peter Selby, speaking on behalf of the Society for
Endocrinology said: “We welcome the decision and
now look forward to working with NICE to produce
straightforward, clinically workable Guidance that
provides patients with the care they deserve.”
National Osteoporosis Society Press Office
Tel: 01761 473 101
12 BGS n e w s
March 2008
Clinical Academic Medicine
a haven in Newcastle
I
n recent years, the number of clinical
academics in the UK has declined. In
fact, the number of academics in
2005 was approximately 84% of that of
the 2000 level. In 2005, the number of
clinical academics in the UK had
dropped below 3,000 for the first time,
to 2,982.
Between 2000 and 2005 there was a 50% reduction
in clinical lecturers, 30% reduction in senior lecturers
and 7% increase in professors, with geriatrics being
one of the hardest hit of the affected specialities.
There were also big differences identified between
medical schools, with recent surveys also suggesting
differences in the numbers of clinical academics at
all levels between the genders.
The reasons for this decline in clinical academia are
in part related to perceived and actual difficulties,
balancing the competing pressures between service,
research and teaching activities and the increased
length of time needed as a clinical academic to
complete specialist training. It is also important to
note that some of the issues around the appointment
and retention of clinical academics is related to a
lack of exposure to academia in postgraduate and
undergraduate training programmes, particularly in
specialities such as geriatric medicine.
In 2005, the UK CRN/MMC review of clinical
academia noted that there was a lack of a clear route
of entry and a transparent career structure in clinical
academia, with a lack of flexibility when it came to
balancing clinical and academic training and
geographical mobility, and a shortage of properly
structured and supported posts available on
completion of training. All of these were considered
in this report to be deterrents to a clinical academic
career. In recent years there have been three key sign
posts for the recovery of clinical academia which
have really put the issue on the map. The first has
been the appreciation by government that applied
biomedicine is critical in the UK’s economic growth.
The second, the Walport Report; ‘Medical and
Dentally Qualified Academic Staff;
Recommendations for Training of the Researchers
and Educators of the Future’, has led to recognition
of the need for an academic clinical career pathway
and outlined the strategies for achieving such a
pathway. Finally publication of the Department of
Health document “Best Research for Best Health”
has laid out the necessary steps to restructure NHS
research and development.
MMC and the UK CRC have therefore developed
properly structured and supported posts.
Development of these posts has included bids to
central government for approval and funding. The
Walport posts include:
t academic foundation posts,
t academic clinical fellowships,
t academic clinical lecturer programme.
Academic Foundation Programme
Newcastle had the first academic foundation
programme in the UK and currently has six posts.
This programme has been so successful that there is
a desire to expand the number of available posts in
this programme in the very near future. Academic
Foundation posts are designed to provide generic
research training, and the Newcastle model has three
four month blocks for both F1 and F2 years with
one four month block in each year as the academic
period. The other blocks in F1 are medicine and
surgery and in F2 these generally mirror the
individual’s academic interests. Individuals applying
for an academic foundation post have a specific
interview where foundation and academic issues are
considered equally, they are supported by an
Academic Foundation Mentor and both academic
and clinical progress are assessed.
Academic Clinical Fellowships
Applications for round 1 of the Academic Clinical
Fellowship (ACF) programmes were invited by the
UK CRC in 2005. Since then there have been 2
further rounds, with round 2 focussing upon specific
clinical areas and round 3 mapping to the Biomedical
Research Centres. ACF’s combine 25% academic
n e w s BGS 13
March 2008
training with 75% clinical training, these posts are
now centrally funded and are speciality specific.
Appointment to these posts is now out with the
MTAS system and the sole end point of the posts is
that individuals will put together an externally funded
fellowship leading to a higher degree (PhD/MD).
The posts are currently competency based.
In Newcastle we now have sixteen programmes in a
variety of different disciplines which were awarded
after successful bids to the UK CRC. Specialities
where posts are funded relevant to ageing in its
broadest sense include: geriatric medicine, old age
psychiatry, pathology of ageing, pulmonary
immunosenesence, ophthalmology of ageing and
clinical pharmacology in ageing. Newcastle over a
five year period has a total of seven ACF posts in
geriatric medicine.
The national picture however is less rosy. Over a 5
year period there are 8 ACF’s in geriatric medicine,
with 2 in Oxford, a total of 4 at St Georges (which
is combined with clinical pharmacology) and
Southampton with a total of two.
Academic Clinical Lecturer
Deaneries have also had the opportunity to bid for
Academic Clinical Lecturer programmes. The
programmes are aimed at speciality specific trainees
who have completed a higher degree to enable them
to complete specialist clinical training whilst also
facilitating development of a post doctoral research
career. The posts combine 50% research and 50%
clinical training and will allow individuals to develop
their own research group. The hope is that they will
also lead to an application for a senior fellowship. In
Newcastle we have three academic clinical lecturer
programmes, the first is in
ageing specialities where we now
Newcastle is the
have two posts per year for the
only centre in the
next five years, dental specialities
UK to have run
and psychiatry. Oxford also has
one academic clinical lecturer
through training in
post in geriatric medicine over
academic geriatric
the next five years.
medicine (ageing)
Taken together, these
programmes underline the fact that Newcastle is the
only centre in the UK to have run through training
in academic geriatric medicine (ageing).
Assessment of Academic Trainees
The Academy of Medical Sciences has provided
guidance regarding how academic trainees should be
assessed. The training needs for these individuals
must be flexible and trainee centred with mentoring
to ensure the attainment of both academic and
clinical goals. The focus of the training and
mentoring is aimed at the development of
competitive peer reviewed research training
fellowships. Individual academic trainees should be
assigned an academic educational supervisor in
addition to their clinical educational supervisor and
this individual should ideally be an established
clinical academic. He/she should have a formal
mentoring role and meet with the trainee within a
month of their commencing their post to develop
realistic, achievable, and timely goals for the delivery
of their training. Academic trainees will have both
clinical and academic competencies assessed.
Academic competencies will be assessed generically
in three domains of (i) research experience, (ii)
research governance and (iii) communication and
education. In addition, significant outputs should be
recorded such as presentations at national or
international meetings, submitting application for a
grant, publishing a peer reviewed article or delivering
an educational lecture or seminar.
In Newcastle the success of our bids for the
academic programmes has been achieved within the
context of an academic clinical career pathway
committee which is chaired by our Dean of Clinical
Medicine, Professor Alistair Burt. This committee
brings together all the potential stakeholders
including University, Trust, Royal Colleges and PostGraduate Deanery as well as the leads of each
academic programme and representatives drawn
from the trainees themselves. The system in
Newcastle has been such that academic interviews
are performed in addition to the same clinical
interviews at those level of staff, academic ARCPs
and progress assessments are in addition to the same
clinical assessments and the academic lead for each
programme are present on the ARCP panels.
Perhaps the most important has been the
development of an active and effective mentorship
programme.
National Institute of Health Research
(NIHR)
In light of ‘Best Health for Best Research’, the
Department of Health has developed a NIHR
virtual National Research Facility that allows the
position, management and maintenance of academic
and research staff within the infrastructure of the
NHS. This is intended to enable the NHS to
become an organisation which supports outstanding
individuals working in world class facilities and
conducting leading edge research focused on the
needs of patients and the public. In order to achieve
this, the NIHR has built infrastructure in the form
of Biomedical Research Centres (BRC). The centres
14 BGS n e w s
March 2008
are within leading NHS and University partnerships
aimed at driving the progress of innovation and
translational research in biomedicine within the
context of NHS service, quality and safety. In 2007,
eleven biomedical research centres were announced
after NHS organisations and their academic partners
bid to central government for this status. Newcastle
Hospitals NHS Trust in combination with its
academic partner Newcastle University was
designated a Specialist Medical Research Centre in
Ageing. This investment has led to a major focus
upon age related chronic diseases and brought
established clinical and basic science researchers to
the study of ageing across a wide range of diseases.
Other Recent Research
Developments in Newcastle
Newcastle has been awarded funding to develop a
Clinical Ageing Research Unit (CARU) with the
specific intention of investigating the biological basis
of dementia and cognitive decline and the basic
mechanisms of cell and tissue damage during ageing.
All these initiatives have led to the development of
significant infrastructure in Newcastle based on the
Newcastle General Hospital site where a Campus for
Ageing and Vitality is being developed. This exciting
new initiative includes the Newcastle Magnetic
Resonance Centre, Institute for Ageing and Health
Research Laboratories, CARU and a Translational
Research Building including new laboratories, clinical
and social science facilities, incubator space and
opportunities for new commercial links.
The future of Academic Geriatric
Medicine
There have been many recent positive developments
regarding training the future academic geriatricians.
There is still much to do. It is vital that we continue
to invigorate the speciality and encourage young
clinicians to consider geriatric medicine as their
speciality of choice and to recognise the limitless
research opportunities that present themselves in
ageing medicine. It is critical that we do this from
the very earliest stages of medical education and
ensure that geriatric medicine is fully considered in
the undergraduate curriculum. We need to ensure
that funders appreciate the value of research in this
area and that true translation of research findings
into changes in clinical practise is essential if we are
to see real improvements in the care for older
people.
Julia Newton
CME Journal Geriatric Medicine
Good enough for your needs?
With this edition of the Newsletter you will have
received your third volume of the CME Journal
Geriatric Medicine and so by now you should
hopefully be getting a feel for the added value of
the journal to your CME needs.
Several colleagues were kind enough to afford me
their opinions on the journal in Harrogate; I am
delighted to say that the majority were favourable
with only one person suggesting that some of
the reviews were not sufficiently detailed for
their liking. The most enthusiastic comment
was sent by e-mail to me stating that having
read the first review the reader felt
"compelled to read the rest of the journal."
Moreover, they did not regret doing so!
So, is the journal meeting your
expectations / needs? Please let Allan
Sinclair (BGS CPD Director) or I know via the
editor ([email protected]). As always, I would
welcome feedback from readers as to how you would
like to see the journal develop, its
educational content and any
recommendations for future
topics to be reviewed.
If you consider
yourself an
expert in any
particular aspect
of caring for older
people then why
not offer to review
that area, the worst I
can say is "we would
welcome your
submission for
consideration"!
Duncan Forsyth
Editor
CME Journal Geriatric Medicine
n e w s BGS 15
March 2008
Standards of medical care for older people
expectations and recommendations
T
he compendium document,
“Standards of medical care for
older people”, is one of the most
downloaded files from the BGS website,
having a popularity well beyond the
borders of the UK. In November, it was
overhauled and is published in summary
here.
The document describes the British Geriatrics
Society's recommendations for standards of care for
specialist services for older people and those with
whom they work, while providing a useful synthesis of
the BGS’s more specialist policy guidelines (there are
convenient direct links to the specialist policy
guidelines on the online version of the document). It
is envisaged that it will be of value to health
professionals, primary care groups, NHS managers,
general practitioners and voluntary agencies, in
addition to geriatricians, old age psychiatrists and
specialist registrars.
Introduction
The document has as its premise that older people are
important and valuable members of society who are
entitled to effective and efficient health services to
promote health and minimise disability in late life.
Comprehensive geriatric assessment of
older frail people
The essence of geriatric medicine is to assess and treat
the medical and rehabilitative needs of older people.
The key expertise of the speciality in assessing the
clinical needs of the patients is the comprehensive
geriatric assessment. This is recognised as a
multidimensional interdisciplinary diagnostic process
focused on determining a frail older person’s medical,
psychological and functional capability in order to
develop a co-ordinated and integrated plan for
treatment and long term follow up. The standards
document links to many aspects thrown up by a
comprehensive geriatric assessment including
rehabilitation, acute care, the treatment of older
people in A&E, discharge and transfer, as well as
collaboration with other specialist colleagues.
Statutory Service Frameworks for Older
People
The NSF in England and similar initiatives in Wales
and Scotland set out appropriate standards of care to
be provided by the NHS and partner agencies
including local councils with social services
responsibility. In Northern Ireland, Health and Social
Services are integrated to promote collaborative
working. Older people throughout the UK can
therefore expect:
t Access to programmes that predict and prevent ill
health and disability, where possible and desirable;
t Full access to the NHS and all its facilities when
clinically appropriate, regardless of age;
t A correct diagnosis at the time of acute illness or
loss of independence;
t Assessment and treatment by a team of appropriate
disciplines when recovering from an acute illness or
change in health, even when recovery has been or is
expected to be limited.;
t Prompt access to the equipment and aids needed to
facilitate recovery and promote independence;
t A supportive multi-agency plan of continuing care
where full recovery to independent function is not
achieved;
t A comfortable and dignified death.
Delivering High Standards of Care for Older
People
Achieving the high standards of care will require:
t Understanding of the needs of older people and a
strategic plan to deliver services which address them;
t Involvement of older people, including carers, in
service planning;
t Partnership working between primary care, local
authorities and NHS trusts, voluntary sector groups;
t Recognition of the role and structure of the
interdisciplinary team (defined as a group of nurses,
doctors, specialist nurses, therapists, social workers,
dieticians and other health professionals organised
around the needs of older people or other patient
group where leadership and composition of the team
may change according to individual patient
circumstances); and
t Realignment of hospital based services to develop
integrated specialist services for stroke, falls/fractures
and osteoporosis, intermediate care support and
mental health services for depression and dementia.
Eliminating Age Discrimination
The BGS opposes discrimination against older people
16 BGS n e w s
March 2008
(either direct or indirect) and in particular decisions
about health and social care made on the basis of
chronological age alone. There is evidence that certain
interventions have a greater benefit in older people
e.g. thrombolysis after myocardial infarction and
hypertension management.
The principle is that health and social care delivery
will be based on need rather than age. Age should not
be used as a factor in eligibility for health or social
care.
Older people must be represented, consulted and
involved in local planning and decision making. Local
champions for older people should be identified at
each level in NHS trusts including non-executive
director lead and clinical leads. The clinical leads
should come from the specialist department and all
clinical policies and resuscitation policies should be
regularly reviewed to ensure no age bias and that the
latter is in accordance with national guidelines.
Moreover, staff from every level, involved in the care
of older people, need to be empowered to challenge
disrespect shown to older patients, and to change
attitides in their own and other departments.
Person Centred Care
Older people should at all times be treated as
individuals and offered choice in treatment, discussion
and planning of future care. Services need to be
modelled so as to be easy to access regardless of the
end provider e.g. Health, Social Services or private
provider. This can be achieved through involvement
of older people (including users and carers) in service
planning, for example:
t Integrated commissioning arrangements between
NHS trusts, local authorities and primary care groups
or trusts as currently exists in Northern Ireland;
t Utilisation of the single assessment process;
t Integrated community services to ensure rapid and
flexible access to equipment; and
t Ensuring a single point of access to services.
t To be involved in decisions made about their health
and future care;
t Adequate numbers of appropriately trained staff;
t Clear and sensitively expressed explanations of
their medical condition/illness unless their ill health
prevents this, and of the treatment options available,
in writing if required;
t If the older person wishes, this information will be
shared with relatives, friends and carers;
t That relatives, friends or other advocate may give
and receive information on their behalf, if the older
person has difficulty in understanding or
communicating and gives consent;
t Practical advice on appropriate support services
and information to enable them to adapt to illness and
disability;
t Written detailed information on local health and
social services, voluntary organisations and on
benefits;
t That support will also be available to their family
and significant friends;
t Access to their health records and the security of
knowing that everyone in the NHS is under a legal
obligation to keep records confidential;
t Health premises accessible to people with disability;
and
t Appropriate and punctual transport arrangements.
Discharge Planning and Equipment
provision
The discharge of older people with high levels of
dependency and complex health and social care needs
requires careful planning, should be timely and to an
appropriate location. A more detailed guideline is
available as part of the BGS Compendium
(Document 3.3)
Abuse of Older People
Abuse of older people is common, frequently hidden,
and insidious in its capacity to deny respect and basic
human rights for one of the most vulnerable sectors
of society. It is the responsibility of those working in
health care of older people to understand risk factors
and signs of possible elder abuse, and know the
correct way of managing this when suspected. For
more information please read the compendium
document on Abuse of Older People
Intermediate care
Intermediate Care is conceived as a range of service
models aimed at “care closer to home”. The two
underpinning aims are, firstly, to provide a genuine
alternative to hospital admission for some carefully
selected patients and, secondly, to provide
rehabilitation and supported discharge.
An intermediate care service should have a clear
function (admission prevention and/or post-acute
care), incorporate comprehensive (multi-disciplinary)
assessment, have an enablement process, offer timelimited contact (to differentiate I.C. from maintenance
services) and involve multi-agency working. More
detailed guidelines are available as part of the
compendium.
Community based care
Departments catering for older people in hospital
should provide comprehensive services in the
community to support general practitioners and
primary care teams caring for older people.
Continuing Care
All older people are entitled to receive a
n e w s BGS 17
March 2008
comprehensive geriatric assessment prior to
placement in a care home or NHS Continuing Care.
Acute Assessment and General Hospital
Care
Older people benefit as much from appropriate
investigation and treatment as younger people and
they are entitled to receive equivalent, efficient, timely
and effective services as them. They are entitled to be
treated with dignity, compassion and humanity and
their human rights should be respected.
Specialist Services
Stroke
Accurate diagnosis and prompt treatment is essential
in stroke. Older people are more likely to suffer from
strokes and transient ischaemic attacks simply due to
ageing. Prompt investigation (with urgent CT
scanning) will allow appropriate acute therapy (i.e.
thrombolysis for acute ischaemic stroke) and
supportive therapy (e.g. oxygen, intravenous fluids,
nutritional therapy (where appropriate) and further
therapy as required) to allow maximum recovery to
take place. Guidelines are in place to improve the
standards of care and should be followed where
appropriate.
Falls
Thirty percent of people aged over 65 and forty
percent of those aged over 75 fall each year. Falls are
associated with significant mortality and morbidity.
Multi-component programmes and comprehensive
geriatric assessment have been shown to be effective
at reducing the negative consequences of falls.
Pressure Sores
Immobile or frail older people in hospital or in care
homes are more likely to suffer from pressure sores.
Prevention will always be better than cure. For more
information read – NICE Guidance on Pressure
ulcers: The management of pressure ulcers in primary
and secondary care (September 2005) http://guidance.nice.org.uk/CG29
Pain
Any health assessment of older people must include
the identification of pain when present, remembering
that many of them will not acknowledge or report
pain. Careful history taking and examination of the
older person are essential to identify the location of
pain. It must be remembered that behavioural
problems in older people with Dementia may often be
caused by pain. For further information read The
British pain Society and The British Geriatrics Society
Guidance on the Assessment of Pain in Older People
(2007).
Orthogeriatrics
Fractures are the most significant consequence of falls
in osteoporosis currently 70-75,000 hip fractures a
year in the UK cost the NHS £1.4 billion with
numbers set to double by 2050. The outcomes of
fractures in older people have been shown to be much
better when there is close collaboration between
departments of orthopaedics and geriatric medicine.
Continence Problems (Bowel and Bladder
Control)
Incontinence is a common and distressing condition
of later life. Rates of urinary incontinence vary from
about 3% to 60%, depending on how incontinence is
defined and the type of population studies. Studies
have found approximately 2% of the general
population and about 60% of the nursing home
population to be incontinent of faeces. When ill,
continence problems are more likely to develop. This
may be exacerbated by inadequate history taking and
examination as well as lack of attention to their
privacy and dignity. Appropriate management will do
much to reduce and alleviate distress.
Mental Health Services
Good mental health underpins the well being of older
people. Older people with mental health problems are
entitled to have a diagnosis made and appropriate
treatment initiated as recommended in the guidelines
referenced in the full document.
Medicines and Older People
Medication offers older people the opportunity of
enhanced life expectancy, enhanced functional
independence and quality of life. Older people are
more likely to suffer from multiple diseases and hence
be prescribed multiple medications increasing the
likelihood of poor compliance and adverse drug
reactions. When prescribing for this group
consideration must be given to risks and benefits.
Palliative Care
All older people at the end of life, wherever they are
living, are entitled to holistic person centred palliative
care equivalent to that provided to people suffering
from cancer.
Further Information
The BGS compendium has been largely overhauled in
the past couple of years, and each document is wellreferenced, pointing to useful guidelines produced by
NICE and other specialist societies. A full list of the
compendium documents is published overleaf.
Jacky Morris
Past Chairman
BGS Policy Committee
18 BGS n e w s
March 2008
Specialty of Geriatric Medicine
the Community)
1.1 British Geriatrics Society - Aims and Functions
(Revised 2000)
4.4 Geriatric (Medical) Day Care Hospitals for older
people (revised Jan 2006)
1.2 BGS Strategic Review (Published 2004)
4.5 Falls (published July 2007)
1.3 Standards of Specialist Care (Revised 2003 and
2007)
4.6 Assessment of Older People for Continuing Care
(published May 2005)
1.4
4.8 Palliative Care (published 2004, revised Sep 2006)
Rehabilitation of Older People (Revised 2004)
4.9 Geriatricians and the management of long term
conditions (published Feb 2005)
Ethics and Legal Issues
4.10 Abuse of Older People (published April 2005)
2.1 Advance Directives (published 2005)
2.2 Capacity and Testamentary Capacity (updated March
2006)
2.4 Procedures for Compulsory Admission of Patients
with Psychiatric Illness (published 2005)
2.5 Nutritional Advice in Common Clinical Situations
(Revised 2006)
2.6 Copying Letters to Patients (revised January 2008)
Acute Hospital Based Issues in Health Care of Older
People
4.11 Orthogeriatric Models of Care (published November
2007)
4.12 Interface between primary and secondary medical
care in the new NHS in England : the care of frail older
people by GPs and consultant geriatricians [replaces
Guidelines for appointing General Practitioners with a
Special Interest in older people] - see 4.14 for Scotland's
guidelines
4.13 Hospital discharge of older people with cognitive
impairment to care homes (published December 2006)
4.14 Interface between Primary and Secondary Medical
Care in the new NHS in Scotland: The care of frail elderly
people by GPs and Consultant Geriatricians. See 4.12 for
the English guidelines
3.1 Acute Medical Care for Elderly People (revised 2004)
3.2 The Older Person in the Accident and Emergency
Department (Revised 2001)
3.3 The Discharge or transfer of care of frail older people
for community health and social support (Revised May
2006)
3.4 Collaboration between Geriatricians and Psychiatrists
of Old Age (revised November 2007)
Training Section
5.1 The Medical Undergraduate Curriculum in Geriatric
Medicine (revised July 2007)
5.2 Curriculum in Old Age Psychiatry for Specialist
Registrars in Geriatric Medicine (revised June 2005)
5.3 Geriatric Medicine - Reading List (revised July 2005)
3.5 Comprehensive assessment for the older frail patient
in hospital (published Jun 2005)
5.4 Diploma in Geriatric Medicine (DGM) - Reading List
(published Dec 2005)
5.5 Training in Geriatric Medicine (published July 2007)
Community Interface Issues in Health Care of Older
People
4.1 Health Promotion and Preventive Care (published
2005)
Individual Service Specifications
6.1 Parkinson's Disease (revised 2007)
4.2 Intermediate Care: Guidance for Commissioners and
Providers of Health and Social Care (revised Feb 2008)
4.3 The specialist health needs of older people outside
an acute hospital setting (published 2005 replacing
"Community Geriatrics" and "The Role of the Geriatrician in
6.2 Continence (published November 2007)
6.3 Stroke (published November 2007)
n e w s BGS 19
March 2008
The NSF Seven Years on:
a personal view
O
lder people are particularly
vulnerable to the effects of poor
quality nursing and medical care.
Increased longevity means that older
people are now living with a greater
number of co-morbidities than in
previous decades.
When the National Service Framework for Older
People was introduced I’d been working with older
people for twenty years. It was clear that many of
them did not benefit from evidence based care
delivered by carers with a real understanding of
ageing and age related problems. It is unthinkable for
children to be cared for by nurses who are not
specially trained to meet the needs of children.
Intensive care units would not be run without nurses
who have specialist knowledge in intensive care. But
the same privilege was not afforded older people and
too often they were at the mercy of care and medical
staff who did not have specialist knowledge of
gerontology. Time and again I saw reversible
conditions ascribed to ageing. I saw people prescribed
inappropriate medication that made things worse not
better. Demographic changes led to increasing
numbers of older people requiring
assessment and treatment. I saw
The NSF - at last,
pressures building in acute and
an evidence based community settings. These
document that
pressures meant that there was less
opportunity for staff to properly
identified most of
diagnose,
treat and provide holistic
the geriatric giants.
care.
The NSF was a potential turning point. At last, an
evidence based document that identified most of the
geriatric giants. The NSF not only identified the giants
it set out a programme of action that if implemented
could make an enormous difference to the quality of
care older people receive.
Seven years on things are a little better for older
people. Intermediate care has been one of the great
successes. It has, in my view given many older people
the time and the space to fully recover following
illness and injury. But there is so much to be done.
Still falling short
Older people who fall and fracture are still leaving
hospital without having falls assessments to determine
what can be done to reduce the risk of falls and
fracture. Some are discharged on medication such as
benzodiazepines, and Z drugs that are not indicated
for long term use and which increase falls risk. Some
are being discharged without bone protection. Older
people continue to lose functional ability in hospital.
The number of older people leaving hospital
malnourished has doubled in a decade. Despite all our
advances, Marjory Warren would recognise many of
the problems older people face today.
We still have a mountain or two to climb in our
efforts to ensure that older people receive high quality
care. It can be done but radical action is required. We
need to educate pre-registration students so that they
understand the needs of frail older people and put
gerontology at the heart of nursing, therapy and
medicine. We need to change the culture in the health
service so that caring for older people is viewed as a
core skill and a highly skilled specialism. Moreover, we
need to attract the brightest and best to our specialty.
The role of the nurse consultant is crucial in driving
through these changes. Functioning as clinician,
educator and strategist we can help to move elder care
forward. The problem is that there are so few of us.
In London, a city with nine million people, there are a
handful of nurse consultants. Many acute and primary
care trusts consider expert nurse clinicians and
educators to be either unnecessary or an unaffordable
luxury.
If we are to move forward, support from the
Department of Health would be helpful. It could
encourage NHS Trusts to improve services for older
people and to ensure that staff working with older
people have at least a basis grounding in gerontology.
Until then those of us who are privileged to work as
nurse consultants will continue to advocate the
principles begun by the NSF. As Churchill said, the
NSF may not be the end; or the beginning of the end;
but it may well be the end of the beginning. With
support we could see it come to fruition.
Linda Nazarko
Nurse Consultant
20 BGS n e w s
March 2008
Spring Meeting - April 2008
I
do hope you will be able to come to
Glasgow to join us for the Spring
Meeting. As well as a fantastic
scientific programme, Glasgow and the
surrounding area has must to offer in
terms of leisure and recreation
Hopefully there will be time for you to enjoy some of
this during the meeting itself and you may even wish
to extend your stay! The centre of Glasgow, where the
meeting is held, has a great buzz. It is now recognised
as one of Europe’s premier
shopping destinations. The
restaurant and café scene is
thriving with numerous
informal eateries of all styles
and types. Modern Scottish
cuisine, Indian, Italian and Chinese – all tastes are
catered for.
Glasgow also has many music and theatre venues and
every week there is something worth seeing from rock
or modern pop music at venues like The Arches or
the EBC to classical and jazz at the City Halls and ‘old
fruit market’. Again, there is something to suit all
tastes. There are also regular opera, ballet and theatre
performances in venues like the Theatre Royal. The
Art Galleries and Museums in the City are fantastic
and nearly all boast free entry. The Burrell Collection
on the South Side of the City is worth a visit, set in
woodland with an extraordinary collection of ancient
tapestries, Rodin sculptures and impressionist art to
name but a few examples. Alternatively, within the
City centre itself there is the Gallery of Modern Art
to tickle your visual imagination and other exhibition
spaces such as architecture and design at the
refurbished Lighthouse Gallery.
Within the surrounding area, some
beautiful countryside can be
reached in a very short
time. The Trossachs
and Loch Lomond are
only 30 minutes away
with opportunities for
walking through the glens,
climbing hills, cycling and
mountain biking. The region
has hundreds of golf courses.
You could even have a trip ‘doon
the watter’ on a boat on the River
Clyde. Therefore, in Glasgow there
is ‘something for everyone’. The
locals are also incredibly helpful – you
just need to look a bit lost on a street
corner and half a dozen people will stop
to help you with directions.
We hope you will take the chance to come to
Glasgow and experience the City, to meet the
locals as well as benefiting from the
educational opportunities at the Scientific
Meeting.
David J Stott
Professor of Geriatric Medicine
n e w s BGS 21
March 2008
BGS Movement Disorders
T
he fifth BGS Movement Disorders
Section’s Specialists’ annual
update meeting 2008 saw over
seventy delegates convene on
Birmingham at the beginning of
February.
On the gathering evening, participants heard a lively
pre-dinner talk on the PD GEN study with an
overview of future developments in genetic testing in
PD from Prof Karen Morrison. Karen graciously
stayed behind after dinner to network and discuss
genetics with the delegates. One of the more senior
committee members took her at her word and
interrogated her on her Celtic lineage!
The next morning opened with an old friend of the
Section, Prof David Brooks who gave a state of the
art talk on imaging in PD past, present and future
which was a model of clarity. This encompassed
aspects of non motor function such as depression as
well as the role of imaging such as SPECT and
transcranial sonography in early diagnosis. He also
highlighted less familiar roles in detecting and
quantifying inflammatory aspects to neurodegeneration. Jane Liddle then expertly led us in a
session on audit with the
participation of Steve Ford,
This house believes that
Chief Executive of the PD
treatment should be initiated in
Society. This session helped to
all patients from the time of
diagnosis’
develop and build on the
16.7% for; 83.3% against
Section’s ongoing work with
PDS on NICE guideline audit If diagnosed with Parkinson’s
keep
checking the Section
disease tomorrow (as active
website for more details of this
working individuals) would
and other ongoing audit
you, personally wish to start
treatment?
activity.
28.7% for; 71.4% against
If diagnosed with PD
tomorrow, would you wish to
initiate therapy with rasagiline,
(being studied with regard to
neuroprotection or neuromodulation)?
31.4% for; 68.6% against
Our own neurocognitive expert
Dr John Hindle then gave us
a valuable overview of current
concepts of depression in PD
and the exciting research going
on in the PD PROMS study,
supported by the Section. The
Northumbrian hard hitter Richard Walker then
appeared in a double header with a thought provoking
presentation on ‘information prescriptions’ and then
an update on the work of DENDRON. Richard was
honest enough to ascribe the initial cynicism of some
of his team to the introduction of further paperwork
on ‘information’ provision.
Our next guest speaker, Dr Huw Morris gave us a
masterclass in dementia and parkinsonism with
extensive video footage and reference to his own
genetic work in Cardiff. This was Huw’s first visit to
the Section but we will try and ensure a speedy return!
Roger Barker from Cambridge presented on the
future of cell therapies in PD in a fascinating talk
which dispelled many of the myths and clarified
concepts and misconceptions in this area which clearly
still has significant potential therapeutic efficacy.
The meeting finished with a debate on the ‘hot topic’
of early drug treatment. The proposition was that ‘this
house believes that treatment should be initiated in all
patients from the time of diagnosis’. Before the
debate began 19.4 % of the audience supported the
proposition while 80.6 % refuted it. Dr Graeme
Macphee entered into a passionate defence of the
proposition once the debate proper was underway. He
highlighted quality of life issues and also the putative
effects of treatment on disease modification and
mortality. He was countered by Dr David Stewart
who pointed out the complications of early
medication and illustrated the small print from some
of the studies that have been previously put forward
in support of the hypothesis. Following the debate
and the summing up, the percentage in support of the
hypothesis had fallen to 16.7% while those refuting
the proposition had risen to 83.3%. However, these
figures do not tell the whole story. Asked whether
members of the audience if diagnosed with
Parkinson’s disease tomorrow (in other words as active
working individuals) would wish to start treatment,
those in favour of the hypothesis rose to 28.7% while
those against fell to 71.4%. Specifically asked if they
would wish to initiate therapy with rasagiline, (being
studied with regard to neuroprotection or neuromodulation) the figures rose further to 31.4% in
favour while the figure against fell further to 68.6%.
Draw your own conclusions!
Graeme MacPhee
22 BGS n o t i c e s
March 2008
BGS OFFICERS
NOMINATIONS INvITED
Meetings Secretary
President Elect of the BGS
Nominations are now invited for the post of
Spring/Autumn Meetings Secretary – to
preside from Spring 2009 and Spring 2010
meetings as Deputy Meetings Secretary, and
then, as Meetings Secretary over the Autumn
2010 and 2011 meetings. (4 meetings).
At the Society’s AGM in November, our President will be handing the reins
of office over to our President Elect, Prof Graham Mulley. Nominations
are now invited for the post of President Elect of the Society,
effective from the 2008 Annual General Meeting.
Job description and Procedure for nominating candidates
The job description of the President Elect takes account of the job description
of the President as the President Elect will serve for two years followed,
subject to endorsement by the membership at the Annual General Meeting,
by another two years as President.
Prospective candidates (who must be full members of the Society) are
welcome to self-nominate; there is no requirement to apply via your Region
or Council. The only requirement is that a nomination must be supported, in
writing, by at least five other members who are eligible to vote at an AGM of
the Society.
For a more detailed job description and instructions for nominating
candidates please go to www.bgs.org.uk (Select Notices and Vacant Posts)
The statement of consent and supporting signatures must be received by the
Company Secretary, at the registered office of the Society, no later than
Monday 31 March 2008. Late or incomplete nominations will not be
accepted. Submissions via email are perfectly acceptable.
All email submissions should be sent to: [email protected] and any
queries should be directed to the Chief Executive at this address.
Each year, the BGS holds two scientific
conferences, one in April (the Spring meeting)
and one in October or November. The
Secretary is responsible for the scientific
content, social, planning and financial aspects
of each meeting.
Job description
For a more detailed job description please go to
www.bgs.org.uk (Select Notices and Vacant
Posts).
Nomination process
Nominations should consist of a brief CV and a
supporting citation from the relevant region or
national council, sent to
[email protected] to arrive by 1 July
2008. The UKMC will vote on nominations
received at its meeting on 10 July 2008.
Other posts vacant on BGS committees
Members of the BGS Northern Region are invited to apply for the position of Treasurer of the Northern Region. Contact Terry
Aspray ([email protected]) or Tim Cassidy ([email protected] for more detail and send your
nominations by 31 March to [email protected]
Members based in England are invited to put themselves forward to represent England on the Clinical Practice Evaluation
Committee. For more detail on what the Committee does, visit www.bgs.org.uk (Select Officers/Committees/CPEC). Send your
nominations by 31 March to [email protected]
RG AWARD 2008
Applications are invited from all junior doctors including FP1/SHO/FP2/SPR
/Staff Grade doctors in Geriatric Medicine in Wales for an yearly RG Award
2008 to be awarded at the Annual Autumn Welsh BGS meeting for
submission based on Best Research-project done/presented/published
during the last year.
The award will be adjudicated by a scientific panel from Welsh BGS
Last date: 30th June 2008
Send your application with a summary of your research project on one A4 page
along with any evidence of presentation/publication/poster to Eirlys Harries, Secretary to Dr Abhaya Gupta, West Wales Hospital, Carmarthen
SA31 2AF
[email protected]
The BGS regrets that owing
to restrictions on space, we
are not always able to
publish all events we have
been asked to publicise.
Please visit the Notices
section of www.bgs.org.uk
for details of more events,
courses related to geriatric
medicine and for
downloadable programmes
and registration material
n o t i c e s BGS 23
March 2008
BGS REGIONAL AND SIG
MEETINGS
BGS North West Thames Branch
5 March 2008, West Middlesex
Contact: [email protected]
BGS Gastroenterology and
Clinical Nutrition Special
Interest Group
12 - 13 June 2008, Newport
Contact: [email protected]
BGS Trent Branch
24 June 2008, The Dakota
Contact:
[email protected]
k
BGS Trent Branch
16 Oct 2008, The Dakota
Contact:
[email protected].
uk
More details on:
www.bgs.org.uk/Notices/regional_
sig_meetings.htm
Regional Officers, please contact
[email protected] to publicise
your region’s meetings.
7TH WELSH STROKE
CONFERENCE
20th June 2008
at the Riverfront Centre, Newport
Multidisciplinary Conference
Speakers from Wales, UK and
Abroad
Themes to include:
• Acute Stroke Treatments
• Secondary Prevention
• Stroke Rehabilitation Stroke
Services – a Welsh perspective
• Transient Ischaemic Attacks
The Bhowmick Lecture to be
delivered by
Professor Werner Hacke Heidelberg
Booking enquiries &
Poster Presentations invited:
[email protected]
01633 238944
GERIATRICS 2008
5 - 8 April
Antalya, Turkey
Geriatrics Society, Turkey is
organising “Geriatrics 2008”
congress in April, 5-8, 2008 in
Antalya, which is one of the most
fascinating cities of the
Mediterranean shore and this
congress is supported by
International Association of
Gerontology and Geriatrics-IAGG,
and International Institute on AgeingINIA.
Website: www.geriatrics2008.org
CANADIAN GERIATRICS
GERIATRIC MEDICINE
SyMPOSIUM
28 May
Edinburgh
An RCP (Edinburgh) conference, this
year’s Geriatric Medicine symposium
is very clinical with a focus on
providing a practical approach to the
common and challenging problems
presenting in older people in both
primary and secondary care. This
should appeal to Geriatricians and
General Practitioners as well as
Physicians working in Acute Medical
Assessment Units and the
Emergency Department. All levels of
training grades should also find this
symposium a useful update.
www.rcpe.ac.uk/education/events/
geriatric-med-may-08.php
2008 CGS Annual Scientific
Meeting
AGEING CONFERENCE
10 - 12 April
Montreal, Quebec, Canada
Health in Ageing - Achievements
and Potential of Longitudinal
Research
As the baby boomer cohort gets
older, the "aging imperative" will
likely be felt more strongly over the
next several years. This cohort is
expected to be in better health and
to enjoy a longer life expectancy
than previous generations, creating
ample opportunity for primary
prevention.
www.geriatricsjournals.ca/ocs/
index.php/cgs/CGS2008/about
BGS GASTRO AND
NUTRITION SIG
Annual Meeting
Hilton Hotel, Newport
Dinner and debate June 12th
followed by meeting June 13th.
Please contact
[email protected] if you
would like further details.
ALL WELCOME
29 - 30 May
Dublin
Organised by Prof Rose-Anne Kenny
on behalf of the Irish Longitudinal
Study of Ageing, this conference will
have world-leaders talking on
cognitive and cardiovascular health,
as well as frailty, biomarkers and
future directions in research in
ageing.
Download programme from BGS
website (Notices/Non BGS meetings)
BONES AND
ORTHOPAEDICS
Second Joint Meeting of the Bone
Research Society and the British
Orthopaedic Research Society
23 - 25 June
Manchester
Download programme from BGS
website (Notices/Non BGS meetings)
24 BGS n e w s
March 2008
Teaching and training in geriatric medicine
A
meeting of the BGS Education
and Training Committee and RCP
(London) Specialist Advisory
Committee was held in December.
The meeting, chaired by Professors Steve Allen and
Tash Masud, had the objective of updating
organisers of training programmes in Geriatric
Medicine about some of the recent changes and to
discuss how we can continue to develop and improve
our training in the future.
Winnie Wade, Director of Education at the Royal
College of Physicians London, gave the opening talk
on “How assessments contribute to successful
training in Geriatric Medicine”. She gave a
background explanation about how we are trying to
meet the standards set by PMETB (Postgraduate
Education and Training Board) for our assessment
strategy. Further assessments need to be validated
and confirmed reliable for use with registrars. In
particular Case based discussion, Acute care and
assessment tool, Patient survey, Teaching observation
and Audit assessment need to be piloted. Volunteers
to take this forward around the UK are actively being
sought. As these are likely to become standard for all
our specialty trainees it will be good to be involved in
the development stage, so if you think you could help
please let me know ([email protected]) .
Professor Tash Masud gave a pragmatic talk on how
to implement the new assessment methods.
There was much discussion about the time involved
and the number and type of assessments. Ian Hastie,
London Postgraduate Dean gave assurance that some
deaneries are tackling protected time for this work, at
least for training programme directors. More work will
need to be done in negotiations between deaneries
and trust providers on ensuring sufficient time for
educational supervisors, which currently are estimated
at 1 hour per week per supervised trainee
Professor James Barrett has been working very hard
as director of the eportfolio project for the Royal
Colleges of Physicians. He updated us on how the
project is developing, showing us a draft of an
educational supervisors report which we requested.
Work is ongoing to make the whole system user
friendly without it degenerating into a “tick box” affair
and with active learning on the part of the trainee and
useful formative contributions from the educational
supervisor.
In the afternoon Julia Newton, Senior Lecturer in
Geriatric Medicine in Newcastle gave us a most
uplifting talk on how academic training is shaping
up based on the Walport recommendations (see
page 10). It had never been clear to me how this
might work but she made it all seem simple, though
obviously there will be significant challenges for
trainees following this pathway. There was discussion
about how the system might develop in those parts of
the country which are not blessed with the excellent
background of ageing research, both clinical and in
the basic sciences, in the Northern Deanery. It was
concerning that even in the Northern Deanery there
are not sufficient numbers of interested and talented
trainees with a background in Geriatric Medicine to
fill the posts. This is a challenge to us all to attract the
high achievers into academic training in our specialty.
Adam Gordon who is a specialist registrar in
Nottingham and is undertaking a Masters degree in
Medical Education gave an excellent presentation on
the role of the registrar in teaching
undergraduates. He is currently conducting a survey
of how well universities deliver the components of
the BGS undergraduate curriculum in Geriatric
Medicine. This is encouraging because we need to
attract medical students into the specialty and the
more we highlight what there is to learn and achieve
in our specialty at an undergraduate level, the better
chance we have of recruiting high level doctors into
the specialty. Adam told us about the teaching log
book which seems a valuable idea to help document
experience in teaching and also to allow registrars to
reflect on what they have achieved and how effective
their teaching is. I am sure this is something the SAC
will be considering in its review of the curriculum and
assessment methods.
Finally Ian Hastie, Postgraduate Dean for the
London Deanery and geriatrician gave us a cheerful
evaluation of what has happened with MMC
(Modernising Medical Careers) and MTAS
(Medical Training Application System) pointing
n e w s BGS 25
March 2008
out what we have learnt from mistakes and what will
be happening in 2008. By the time you read this
trainees will be applying for next year’s entry to
specialist training which will “uncouple” Core Medical
from Higher Specialist Training. There will be local
appointment of approximately 90% of ST3 posts but
10% plus some newly funded ST3 posts will be
advertised and appointed nationally in the specialty
(maybe 40 posts). It is expected that applications for
these posts will exceed considerably, the posts
available for various reasons (doctors in fixed term
specialty training appointments, locum posts,
international medical graduates with HSMG (highly
skilled migrant programme) status will all be able to
apply.
Overall it was an excellent day exposing lots of work
to be done (develop assessment methods, update
curriculum, develop the eportfolio, develop academic
training programmes, promote good undergraduate
teaching etc). All the powerpoint presentations of the
day may be found on the Education Section of the
BGS website, talking of which we hope to develop
the BGS education website so this and other useful
information such as the assessment tools are readily
available to everyone.
Chris Turnbull
Secretary SAC in Geriatric Medicine
Education and Training
Resources now on the BGS website
As Secretary of the SAC I get quite a lot of inquiries
from people looking for advice about educational
issues concerning Geriatric Medicine; for example:
homepage. You will find answers to many of the above
questions and can also access the slides from talks at our
most recent training day.
t What does a registrar training in Geriatric Medicine need
to know about ageing physiology or biological gerontology?
t Where can I find workplace based assessment tools for
trainees in Geriatric Medicine?
t How to I go about setting up or applying for an academic
fellowship in Geriatric Medicine my deanery?
t How do I find out if my teaching of medical students is
achieving the necessary objectives?
t How does the ARCP process work?
t How do I apply to train partly abroad?
t Can I obtain a CCT in Acute Medicine (level 3)?
t Can I take a career break while training in Geriatric
Medicine?
t What should I use my academic
sessions each week for?
t Where can I find the higher level
training grids in Movement
Disorders, Community and
Intermediate Care, Psychiatric
disorders in Old Age, Continence,
Orthogeriatrics or Falls?
t How do I improve my chance of a
successful application for entry into
the Specialist Register in Geriatric
Medicine under Article 14?
t Where can I find a reading list for
undergraduates or postgraduates
interested in Geriatric Medicine?
Much more work is needed to make these pages really
useful so we need your help. Please let us know how we
can improve the site or send us information or links that we
can put on the site. Write us an article about an educational
issue or tell us about your latest educational research or
audit. Perhaps you would even like to take responsibility for
managing the content of these webpages. For any of these
things please contact me at [email protected]
The BGS website now has a
section administered under the
auspices of the Education and
Training Committee. You will find
this on the website by hovering your
pointer over Education/Training on
the menu to the left of the BGS
Chris Turnbull
Secretary SAC Geriatric Medicine
and member BGS Education and Training Committee
26 BGS n e w s
March 2008
The National COPD Audit
2008
I
n case you haven’t heard, the next
national COPD Audit is due to begin
this month. This project is being
carried out under the auspices of the
National COPD Reources and
Outcomes Project (NCROP).
It is a very ambitious
project and we’d really
appreciate the BGS
members’ support!
The purposes of this
National Audit are
t to assess the process of
care, outcomes, and
resources available for the treatment of patients with
acute COPD exacerbations requiring hospital
admission in the UK in 2008
t to compare results with the 2003 audit with
nationally agreed standards, thereby highlighting areas
of improvement and areas requiring further attention
t to assess the effect of the NCROP peer review
process on achieving change within COPD care
You can read more about the NCROP at:
www.rcplondon.ac.uk/college/ceeu/ceeu_copd_home.
htm)
What’s happening? (Method)
The audit will mirror the methods used for the
National COPD Audit 2003, but has
increased in breadth this time to
reflect changing patterns of
COPD care.
Acute hospital units will
be asked to complete a
one-off resources and
process of care survey,
and there will also be a
clinical case note audit of up
to 60 consecutive
admissions of patients
with an exacerbation of
COPD. These data will
be submitted to the
Royal College of
Physicians London
(RCP) via a web-based
data collection tool.
For the first time, there are
two additional paper-based surveys
that peripherally affect acute units. Firstly there’s a
survey to be sent to General Practices to identify
factors in pre-admission community care that may
influence admission and secondly, a sample of
patients included in the study will be asked to
complete a short questionnaire to help us better
understand the patient perspective of an exacerbation.
We are also asking Primary Care Organisations in
England, Northern Ireland, Scotland and Wales to
complete a survey about the organisation of COPD
care in their area.
Sharing results
As in 2003, a National COPD Audit report will be
published and widely circulated. In addition, each
participating unit will receive an individualised report,
presented alongside the aggregated national results in
order that teams can examine their performance.
Please help!
Remember the National COPD Audit starts in March
2008. Contact your respiratory or clinical audit
colleagues, or indeed the project team at the RCP if
you want to know if your unit has registered to
participate. Contact us for more information
[email protected]
Please offer your support / assistance
to colleagues – perhaps you could
help identify patients that need to be
entered to the audit, or offer to enter
data on a specific area of practice
e.g. palliative care, or manage the
primary care element of the
audit.
We will be working with Primary
n e w s BGS 27
March 2008
Care Organisations (PCO) for the first time. If you
have a relationship with someone in your local PCO
who is involved with COPD services, perhaps a
commissioner, service development lead, public health
specialist, please ask if they are participating and if
not, encourage them to do so.
Thank you very much for your support
Rhona Buckingham, NCROP Project Manager
Phyo Myint, Steering Group Member, NCROP
Trainees
column
A
new trainees committee was
elected at the Autumn meeting in
Harrogate in November.
Our role is to represent Trainees on the various
committees of the British Geriatrics Society, which
gives the opportunity for our ideas and opinions to
be put forward and considered at the highest level.
The Trainees Committee also co-ordinates the
dissemination of important information amongst the
trainees nationally, a role of increasing importance in
the current times of changes to training curricula and
assessments.
The current members of the committee are:
Jo Lindsay, representing us on the Finance
committee. She trained at Glasgow University and
worked in and around that city until moving to
Woodend Hospital in Aberdeen to take up her ST3
post.
Jonathan Birns is continuing to represent trainees on
the Policy committee. This group is involved in the
writing of policies and statements for the BGS on a
variety of pertinent topics relating to health care of
older people, and also responds to Parliamentary
inquiries.
There are now two representatives on the Education
and Training committee. The committee helps to
determine BGS policy with regard to under-graduate
and postgraduate education and has a role in
formulating responses on behalf of the Society with
regard to generic training issues, such as Modernising
Medical Careers and the Tooke Report. We are
represented here by Claire Steves, an SpR on the
South East
Thames
rotation,
currently
working at St
Thomas’s
Hospital in
Lambeth and
Adam
Gordon, a
year 3 SpR on
the mid-Trent
rotation. He has an academic interest in medical
education and is also helping to co-ordinate the
National Survey of Under-graduate Teaching in
Ageing and Geriatric Medicine. Adam is interested in
hearing from colleagues who have suggestions or
proposals as to how training in geriatrics might be
better co-ordinated or delivered, and if anyone has a
specific training issue where they feel the Society may
be able to help, he is happy to liaise on their behalf.
Emma Vardy, currently a 4th year SpR in the
Yorkshire region, is Vice-chairman of the committee.
Her primary role is to serve on the Academic and
Research Committee of the Society. She has a strong
background in research, having taken time out of her
SpR rotation to complete a PhD, and is concerned
with the issue of how to promote and develop the
academic geriatricians of the future. She will soon be
emailing all BGS trainees for views on this topic and
experiences of research to date.
We also have representatives on the national Councils.
English trainees are represented by Andy Clegg, a 2nd
year SpR on the Yorkshire rotation, currently based in
Halifax; and Mark Baxter.
28 BGS n e w s
March 2008
As chair of the committee, I am a member of the
Education and Training committee, the SAC for
geriatric medicine, and the UK Management
Committee(UKMC) of the BGS, which oversees all
the Society’s committees. I am in the 4th year of my
SpR rotation in the West Midlands, and although I am
undertaking a part time MSc in Geriatric Medicine, my
interests are predominantly clinical rather than
academic. I would like to increase the role the trainee
body as a whole has within the Society – we want to
hear from you, so it is not only our own opinions
being discussed at meetings, but the feelings and
concerns of the SpRs and ST grades as a whole. We
plan to keep you updated via this column in the
newsletter, and also through email. All the committee
members are contactable through the BGS website.
Knowledge Based Assessment Update
This issue was discussed at length at the recent
UKMC meeting. There will definitely be a KBA exam,
taking the form of 2, best of 5, 100 question MCQ
papers, based on the Geriatric curriculum. This has
been agreed by PMETB as part of the suite of new
assessments. The provisional start date for the exam
was May 2008, and in terms of the question bank, the
assessment is ready to run.
There are two concerns, currently under negotiation,
which could cause the KBA to be delayed. The fee for
In Memoriam:
the assessment has been set at £800 per candidate per
sitting. I have raised the point that this is much more
than initially expected, and may be hard for trainees to
afford, especially with the recent cuts in study leave
budgets. This issue is of concern to all the speciality
organisations, and is currently the subject of
negotiation. The BGS has asked for a breakdown of
the anticipated costs to run the exam, to try to assess
how much is cost, and how much profit.
Concerns have also been expressed by the speciality
regarding the qualification that will be awarded once
the exam is passed. The RCP are planning on running
the exam overseas so that it can be taken by those
who have not been through an accredited Geriatric
Medicine training programme. It is important that
those who have completed specialist training are easily
differentiated and given due recognition, from those
who have not. The also needs to be a clear distinction
between those who have passed the Diploma in
Geriatric Medicine fromh those who have passed the
KBA.
Unless these issues are resolved, the KBA is unlikely
to run in May this year.
Zoe Wyrko
Chair
Trainees Committee
Emeritus Professor Ronald Cape, Melbourne
University (1921 - 2007)
Professor Ronald Cape passed away last November, as a result of pneumonia following a shoulder infection.
Professor Cape had been serving as a World Health Organisation consultant at the University of the West Indies
in Jamaica.
Educated at Daniel Stewart’s College and Edinburgh University, Professor Cape served as house surgeon at Stirling
Hospital, followed by a stint in the RAF before going to Canada as a research fellow. On return from Canada in 1952, he
worked as a senior medical registrar at Selly Oak Hospital, and as a consultant at Queen Elizabeth Hospital in
Birmingham. In 1972, he helped establish the West Midlands Institute of Geriatric Medicine and Gerontology, and was
appointed its first director, where he and a small cadre of committed physicians began to educate the medical profession
about the scope of the emerging field of geriatric medicine.
In 1975, he was appointed professor and chief of geriatric medicine at the school of medicine at the University of
Western Ontario, London, Canada. His centre of excellence attracted trainee specialists from North America, New
Zealand, Australia and the UK. During his 11 year term in Canada, Professor Cape was seen as a pioneer in this field.
In 1997, he was presented with the BGS’s 50th Anniversary Medal for outstanding services to geriatric medicine. He is
remembered by generations of students, nurses and colleagues as a skilled clinician, administrator, teacher, researcher,
author and advocate for older people.
Extracted from an obituary written by Dr Philip Henschke, Director of Aged Care, Repatriation General Hospital, Daw
Park, South Australia, and published in the Australian Newspaper “The Age”
n e w s BGS 29
March 2008
The National Stroke Strategy
commentary
T
he recent launch of the National
Stroke Strategy by the Department
of Health (DH 2007) is a welcome
development for stroke patients.
The strategy addresses for the first time, the process
across the whole stroke care pathway and aims to
improve all aspects of care (prevention and awareness,
emergency access and acute treatment, rehabilitation
support and long term care available post discharge
and involvement of the voluntary sector) using a
number of quality markers.
Implementing the
recommendations in an
effective and efficient
manner will be a major
challenge for the NHS.
For this development to
be a success, it is crucial
that adequate funding is
made available to ensure
that the recommendations
are met. Surprisingly the
strategy makes no
reference to actual funding
commitments. Spending
proposals with initial
pump priming for the
strategy has been agreed
centrally. Funding will be
directed towards much
needed stroke training
posts, public awareness,
stroke research and
development of acute and community demonstration
sites to pioneer best practice. The proposals at first
glance appear to be very ambitious and even
unrealistic, however aiming for high standards should
be viewed as an opportunity and a challenge for both
health providers and commissioners to improve the
quality of stroke care.
Time is brain
A major theme emerging from the strategy is the need
for urgent specialist assessment and intervention
within an environment of organised stroke care. The
strategy applies equally to patients suffering a TIA at
high risk who will require assessment and appropriate
imaging (MRI) within 24 hours of onset. There is a
real need to improve access to thrombolysis services
in the UK. The strategy’s proposal for this service is
through a ‘hub’ and ‘spoke’ model based upon
experience of cardiac networks. The suggestion that
thrombolysis should only be delivered exclusively in
hospitals with a 24 hour hyper-acute service is
tempered by the fact that many hospitals are able to
provide a ‘daytime’ (9-5) service, which has the
advantage of treating patients locally, therefore
potentially more quickly, while reducing the need for
repatriating patients, thus enhancing their continuity
of care. This approach is currently being piloted
across the South West
London Sector, led by
Wandsworth PCT.
Whichever structure is
deployed, the clear message
is that commissioners
should work collaboratively
with clinicians and other
health care organisations to
ensure that there is 24/7
coverage for all stroke
patients.
Life after stroke
Throughout the strategy
there is a commitment to
life long specialist support in
the community. Enhancing
the smooth transition of
patients from hospital to
home through early
supported discharge
schemes, involvement of
carers, social and voluntary
services and providing opportunities to participate in
work are highlighted as key action points. Although
key targets and milestones have been set for acute care
previously, which undoubtedly has been a strong
driver for change, specific targets and standards for
community rehabilitative services have not been made
explicit enough here. There is no reason why we
should not be adopting a seven day week
rehabilitation service. Unbundling the national tariff
for acute stroke care to direct funding for high quality
specialist rehabilitation in the community also remains
30 BGS n e w s
March 2008
a challenge to commissioners.
Joint Working
The establishment of a stroke network approach
appears to be logical one. The concept is to ensure
that the relevant agencies are working together to
support patients across the whole stroke pathway.
Stroke networks may vary considerably according to
geography with some centres specialising in hyperacute care and other in specialist rehabilitation.
Collaboration with the cardiac network may also be
beneficial in delivering shared preventative strategies.
Ultimately, high quality care will only be delivered if
the appropriate workforce is in place and the strategy
has outlined its intentions to address this through the
NHS National Workforce Project.
This strategy is a 10 year framework to deliver the
highest quality services to stroke patients. Some of the
service proposals represent a big culture change to
both primary care trusts and providers. The hope is
that with adequate central support, we can begin to
implement these changes with immediate effect.
References
Department of Health (2007) National Stroke
Strategy. www.dh.gov.uk/stroke
Ajay Bhalla
Consultant Stroke Physician
St Helier Hospital, Epsom and St Helier University
Hospitals NHS Trust
From nuclear power to table tennis
Dementia emerging from the parliamentary shadows
I
n the last few months, the important
issues of elderly mentally ill people
and dementia have finally been the
subject of significant and hopefully,
ground-breaking debates in
Westminster.
In a debate about dementia sufferers, Jeremy Wright
MP (Con) put this in startling context when he noted
in parliament there are “531 all-party groups, which
range in significance, on subjects from nuclear power
to table tennis but, as of June this year (2007), there
was no all-party group on dementia”.
In October 2007 there was a debate on ‘Dementia
Sufferers’ and more recently in January 2008, ‘Elderly
Mentally Ill People’ was debated at length.
Dementia Sufferers – 24th October 2007
An erudite opening speech by chairman Jeremy
Wright MP explored a variety of issues related to
dementia sufferers. He noted that dementia affects
700,000 people, is contracted daily by approximately
500 new people and will grow in incidence by 40 per
cent in the next 15 years (to more than 1 million
sufferers by 2025 and to 1.7 million by 2051). He
observed, as many clinicians already know, that despite
these facts there has been no sustained pressure on
the Government to take action on dementia in the
way there is for other medical conditions. He ponders
why this is the case, particularly in light of the
Dementia UK report published in February 2007
(Alzheimer’s Society, 2007). This report, partcommissioned by the Alzheimer’s Society was
intended to provide coherent evidence of the
prevalence and economic cost of dementia in the UK,
and in particular to combat the inadequate attention
by policy makers. Another important report from the
National Audit Office (NAO) entitled, “Improving
services and support for people with dementia” was
published in July 2007 (National Audit Office, 2007).
He also noted the Government was due to pull all this
together in completing a National Dementia Strategy
due for release at the end of summer 2008.
Economic burden
The huge economic cost and burden was illustrated by
these reports – the NAO estimated the annual
economic burden of dementia to be a colossal £14.3
billion. The scale of this is again put into startling
context as this is more than the costs incurred by
strokes, heart disease and cancer combined.
Mr Wright considered the emotional aspects of the
disease and suggested because of the current lack of
effective treatments and cure, there is potentially a
nihilistic view in the sense of ‘what’s the point?’ in
referring for a disorder with no effective treatment.
However, whilst acknowledging lack of resources in
n e w s BGS 31
March 2008
some areas, he pointed out the benefits of an early
referral, not only for diagnosis but also for the
sufferers and families to begin to make plans and cope
better with what is going to happen, with appropriate
advice, education and support.
The NAO report was discussed by officials from the
Department of Health when they appeared before the
Public Accounts Committee in October 2007. The
officials reacted positively to the idea of providing a
single point of contact to enable people to get the
necessary information and advice on help and
services. It was noted that “less encouragingly (the
officials) spoke only of how such provisions might be
made within the NHS”. Mr Wright hoped there could
be more joint working with the voluntary sector as
demonstrated by the Newbury Memory Clinic where
everyone who attends is referred to an Alzheimer’s
Society advisor. He envisaged this model of good
practice to be rolled out nationally.
Royal College of Psychiatrists
Mr Wright further noted and quoted Dr David
Anderson, the chair of the Royal College of
Psychiatrists faculty of old age psychiatry, who
levelled “fairly robust criticism” at the situation of
mental health services for older adults. Dr Anderson
opined that “some PCTs and Trusts are proposing the
dissolution of specialist older people’s services with
patients transferred to the care of general psychiatry
services with no training in older people’s mental
health…claiming this creates an ageless service. This
is a dishonest way of cutting costs to the detriment of
older people…and it will provide older people with an
inferior, second-rate service…PCTs have no interest
in anything other than target-driven working-age
mental health services”.
Dementia research
There was an interesting passage in Mr Wright’s
speech about the state of dementia research. He noted
only 1.4% of research papers since 2002 have been on
this subject and between 2000-01 and 2004-05, in
respect of national research programmes, funding for
research dropped in cash terms from £12.9 million to
£6.8 million and, as a percentage of the health budget,
from 0.03 to 0.01%. He further observed the UK
spends 24p per citizen on dementia research
compared with 66p per citizen spent in the USA. He
summed up this odd state of affairs succinctly, “it is
illogical that we should spend so much less on
research into dementia than we do on research into
other conditions that cost us, as a state,
proportionately much less”. Graham Stuart MP (Con)
noted that the “missing link” as Help The Aged called
it, was the area of research.
Care homes
The NAO report noted one third of dementia
sufferers live in residential care homes, and that half
of people in residential care homes and two thirds of
people in nursing homes have some form of
dementia. Mr Wright felt that whilst staff training in
care homes was essential – “there are no two ways
about it: care home staff need to be properly
equipped to deal with dementia” – the quality of such
training was not widespread and he had concerns
about the inappropriate administration of sedatives.
Dr Pugh commented that 40% of dementia sufferers
in care homes are treated with neuroleptic drugs, and
that whilst in some cases this was wholly appropriate,
some chemically managed situations could be treated
in other ways. The NAO report also noted too few
specialist places available, it estimated there are
124,000 registered places for 201,000 dementia
sufferers.
Carers
The issue of dementia sufferers living in their own
home was considered. This group is looked after in
the main by the lifeline of 476,000 unpaid carers who
stand between the dementia sufferer and much more
expensive, and ultimately undesirable, admission into
residential and nursing care. Mr Wright also drew
attention to emerging technologies that may assist
independent living such as telecare and extra care
housing. Mr Stuart posed the question: “who will care
32 BGS n e w s
March 2008
for carers, if we do not?” He suggested there will be
no one to save the Government £6 billion a year as
those carers now do. He also noted that it has been
estimated that £1 of Government money spent in the
voluntary sector provides between £11 and £15 in
services. The Parliamentary Under-Secretary of State
for Health, Mr Ivan Lewis MP was present and
outlined the development of an expert carers
programme to be launched in the summer 2008. This
national programme would involve local training
courses for carers to help them with practical issues
such as lifting and handling and with some emotional
issues “so that they feel confident in taking on and
working with the professionals and the public services,
not confrontationally but to represent the best
interests of the person whom they love”.
Mr Wright finally commented on the vital concerns
about respite care; being essential that respite care is
both readily available and that the quality of care
should be extremely high. He was hopeful that all the
issues he raised needed to feature in the Government’s
National Dementia Strategy, but more importantly
clearly outline how they will be delivered. Dr John
Pugh MP (LibDem) whole-heartedly endorsed these
highly specific requests by Mr Wright because “they
are entirely deliverable”.
Single reference point
Dr Pugh strongly advocated there needed to be better
community management of dementia and the need
for a single reference point for carers. He suspected
such a reference point would not be the GP, but a
specialist attached to a practice who was trained in
geriatric medicine. Towards the end of the debate Mr
Lewis agreed this was a difficult point. He believed
however that in every community there should be a
single point of contact, “which I would describe not
as a one-stop shop, because that is unrealistic, but as a
first-stop shop”.
Mr Lewis suggested the national strategy would firstly
raise awareness about dementia and secondly enhance
early diagnosis and intervention (ensuring that primary
care professionals have the maximum possible
knowledge about dementia and a professional
commitment to ensure referral to specialist secondary
care services – such secondary services hopefully
having resources suitably and proportionately
bolstered and funded?). The third focus of the
national strategy was on improving the quality of care,
whether that be in people’s homes, hospitals or care
homes. He suggested that we must continue to
campaign to put dignity at the heart of all care
services but that he did not accept the idea that we
should always blame the lack of resources. He
interestingly proposed that wards where more than
50% of the patients have dementia require different
staffing arrangements from those where that is not the
case and that “we pay NHS managers to make those
decisions and to get that right”. He compared this to
the well-established debate about pupil-teacher ratios
in the education system and that there should be a
debate “not about Ministers prescribing a certain
number of nurses per patient on every ward in the
country - that is not our job - but about managers,
whose job it is to ensure appropriate staffing
arrangements” on wards where dementia sufferers
predominate to ensure “high quality, personalised
care”.
The Minister, in announcing the transformation plan
of the national dementia strategy, was determined
“that this disease is brought out of the shadows…By
concentrating on improving awareness, diagnosis and
managing the disease, we will help transform the lives
of those with dementia by improving their quality of
life.”
Elderly Mentally Ill People – 15th January
2008
Dr Vincent Cable (LibDem) opened this
Adjournment debate in Westminster Hall. In his initial
statement he produced further statistics pertaining to
the elderly. He noted that ‘crude’ figures suggest that
about 3.5 million people are loosely defined under the
general heading of having mental illness in old age;
one in five people over 80 have senile dementia, and
two in five have depressive illness – these numbers
being ‘enormous’ and likely to reach ‘pandemic’
proportions. Depression amongst the elderly is
expected to double by the middle of the century to
approximately 5 million sufferers and the total
mentally ill elderly population would be about 7
million. This debate sensibly expanded to also include
anxiety, delirium and problems related to drugs and
alcohol.
Mr David Taylor (Lab/Coop) felt the care of older
mentally ill people must transfer to general hospitals
in many circumstances “as they were often left to
vegetate in entirely inappropriate circumstances” with
unsatisfactory informal caring arrangements. In reply
Dr Cable commented that it is often not general but
specialist hospitals where the best treatment is found.
He further expanded on the problem of underdiagnosis of mental disorders in the elderly (Age
Concern, 2007), even though 40% of people who visit
GPs are elderly people with some form of mental
illness.
Old age services being dismantled
Dr Cable, in discussing the issue of mental health
services for the elderly, quoted the Royal College of
Psychiatrists who stated, “Older people’s mental
health services, which have been among the most
n e w s BGS 33
March 2008
innovative, are being cynically dismantled” and “there
is clear discrimination within Government health
policy”. Mr Norman Lamb MP (LibDem) concurred
and further noted the Royal College of Psychiatrists
has observed that PCTs throughout the country
seemed to be transferring the care of older people
with mental health problems to general psychiatric
services. He felt that part of the justification for
transferring specialist services for the elderly mentally
ill people to general psychiatric services is to end age
discrimination by providing the same service for all
ages, but he noted the obvious paradox in that
dismantling specialist services for elderly people
actually increases age discrimination, as the services
provided would not be appropriate, suitable or
suitably specialist for the particular needs of elderly
people with mental health problems. The College
feared the emergence of a second-rate inferior old age
service that will lose specialisms, and drew attention to
the fact that the NSF for mental health has introduced
the targeted commission of new services e.g. early
psychosis, assertive outreach and crisis resolution
home treatment teams, and the £300 million
investment in these new services broadly excludes
older people and hence is again discriminatory (as is
the £1.65 billion cash increase for adult mental health
services over four years - yet again excluding older
people!).
References
Age Concern (2007) Improving Services and
Support for older People with Mental Health
Problems. London: Age Concern England.
Age Concern (2007) The Age Agenda 2007.
Public policy and older people. London: Age
Concern England.
Alzheimer’s Society (2007) Dementia UK – a
report into the prevalence and cost of dementia
prepared by the Personal Social Services
Research Unit (PSSRU) at the London School
Of Economics and the Institute of Psychiatry at
King’s College London, for the Alzheimer’s
Society. London: Alzheimer’s Society.
Department of Health (2007) Putting people first:
a shared vision and commitment to the
transformation of adult social care. London: The
Stationary Office.
House of Lords House of Commons (2007).
Joint Committee on Human Rights: The Human
Rights of Older People in Healthcare. Eighteenth
Report of Session 2006-07. Volume 1 – Report
and Formal Minutes. London: The Stationary
Office.
National Audit Office (2007) Improving services
and support for people with dementia. London:
The Stationary Office.
Payment by
results
Mr Lamb also
noted the
potentially
important issue
of payment by
results (PBR)
where he
surmised there
may be a
tendency to
channel money
disproportionately
into acute
treatment to
meet stringent
waiting-time
targets. He
pointed out the
vital fact that
currently, because
PBR does not yet
operate within
mental health,
there is less
“money in the
pot” for PCTs to
enter contractual arrangements with mental health
trusts for funding their services and hence they suffer.
He also noted the report ‘Improving Services and
Support for older People with Mental Health
Problems’ (Age Concern, 2007) which put into
context the ridiculous paradox whereby the majority
of patients in acute hospitals are over 65, of which a
significant proportion have mental health issues, but
there are poor old age liaison services (compared to
‘embedded’ psychiatric liaison services in acute
hospitals for under 65s) in many hospitals and overall
insufficient co-ordination between psychiatric services
and acute hospitals. There are acute hospitals with a
captive audience as it were, of elderly people with
mental health problems not being accessed en masse
in such a venue. Every acute hospital should have an
embedded old age liaison service in it – this would
lead to more patients being seen with a better
response time and earlier interventions, better joint
working between the geriatric and psychiatric services,
and the potential to access other services such as OT,
social services and physiotherapy in a seamless way, to
promote the holistic and person-centred care that
elderly people inevitably need. I wholeheartedly
concur with Mr Lamb’s observation that there is
“insufficient input” for older people with mental
health problems in the acute hospital setting. The
report very worryingly, given the huge numbers
involved that will only increase further, came to the
conclusion that nobody, including commissioners, had
this matter on their agenda.
Depression
Mr Mike Penning (Cons) observed the “shocking”
figures and statistics quoted in the debate. He added
some more pertaining to elderly people with
depression. He felt “passionately” that depression
among older people is one of the “undiscussed, quiet
areas that does not quite receive the publicity it
deserves.it is a major problem”. He quoted Age
Concern figures that one in four older people have
symptoms of depression, but sadly, only one third of
those with depression ever seek medical advice or ever
discuss it with their GP. He noted witness statements
from the Age Concern report implied a poor response
from GPs even if older people do discuss these issues
with their GP. Mr Penning felt this contributed to the
disproportionately higher suicide rate for older people
and went on to say “it cannot be right that the older
generation, who have done so much for us, have a
disproportionately higher suicide rate because they are
not receiving the help that they often need”.
The Parliamentary Under-Secretary of State for
Health, Mr Lewis concluded the debate. He made
several salient and encouraging comments about
future governmental initiatives in the area of older
34 BGS n e w s
March 2008
people’s mental health. He again reiterated that he
intended “to bring dementia out of the shadows” and
further admitted with regard to dementia that “public
policy has almost been in denial about it”.
Mr Lewis also explained he was putting the dignity of
older people at the heart of the care services at all
times and promised personal leadership on this
matter. This may loosely correspond to the human
rights-based approach being strongly advocated
nationally currently by various organisations (e.g.
Mental Health Act Commission & Ministry of Justice)
and in particular a response to that scathing report
from the Joint Committee on Human Rights (House
of Lords House of Commons, 2007) which strongly
criticised the government for the overwhelming lack
of leadership and promotion of the Human Rights
Act 1998 (Mr Lewis also presented oral evidence to
this committee on behalf of the Government).
He advocated a joined-up, integrated approach to
health and well-being in every local community that
shifts towards early intervention and prevention. He
announced the government had signed the ‘Putting
People First’ concordat (Department of Health, 2007)
in December 2007 with local government and the
NHS. He believed in the next three years (beginning
from April 2008) this “radical transformation of the
social care system in partnership with the NHS”
would focus on early intervention and prevention, and
empower people through personal budgets and access
to more information and advice.
The future
Finally Parliament has acknowledged the vital, yet
seemingly forgotten issues in the upper echelons of
power, surrounding older people’s mental health. It
does seem ludicrous that there have not already been
such all-party debates but hopefully now it is receiving
such airtime in parliament, this will act as a significant
catalyst to future developments. Encouragingly the
proposed National Dementia Strategy may be an
important part of this new beginning and
governmental strategy. As I write the All-Party
Parliamentary Group on Dementia inquiry into
antipsychotic drug use in care homes has recently
happened and is due to report its findings in March
2008.
The time is certainly ripe for long-awaited and
overdue investment at all levels for dementia and
mental health elderly care. It will be interesting to see
if the forthcoming National Dementia Strategy will
seriously address these previously ignored and underresourced areas and come with more than adequate
(pump primed) funding unlike the relatively toothless
NSFOP which had no additional funding. Hopefully it
will herald a long overdue epoch for the care of the
elderly with dementia or mental disorders.
Martin Curtice
Consultant Old Age Psychiatrist
The Savages
‘is it like Alzheimer’s?’
I
’ve never been to Buffalo, New York
but I’m guessing it’s not as dreary
and as bland as it is depicted in the
movie, “The Savages”.
The movie revolves around Mr Lenny Savage (Philip
Bosco) who has dementia and is moved back to
Buffalo to be near his estranged children, Wendy
(Laura Linney) and Jon (Philip Seymour Hoffman),
when his elderly girlfriend suddenly dies whilst having
her nails done in a beauty parlour.
The movie begins with the sound of harps and a
troop of older ladies in sparkling blue leotards
performing a dance routine (I assume as part of a
regular exercise group or similar) under a beautiful
blue sky in Sun City, Arizona. This is a plush
retirement complex where Lenny is living. He resides
with his elderly ‘girlfriend’ who herself is significantly
more demented than Lenny and needs the assistance
of a ‘home healthcare professional’. The home carer,
whose uniform is theatre scrubs, makes it clear he’s
there only for the girlfriend and this grates on Lenny.
An incident ensues whereby Lenny has failed to flush
the toilet and is lambasted by the carer for his
forgetfulness. In a fit of pique Lenny is involved in a
‘handling faecal matter’ incident which he uses to
write an obscenity on the wall about the carer. This
acute episode of BPSD then triggers off calls to
n e w s BGS 35
March 2008
Lenny’s children. Soon after, his girlfriend dies and it
becomes a social problem as Lenny is taken into
hospital.
The son and daughter arrive, carrying the “baggage”
of their own respective relationship problems,
including the myriad unresolved issues from their
relatively loveless and repressed upbringing,. added to
which is now the dilemma of having to deal with, and
make decisions for, their estranged father. On their
arrival at the hospital, their father is lying pitifully on a
bed, immobilised by wrist restraints attached to the
bedsides (thankfully having an IVI and been
catheterised). The nurse explains the restraints are
necessary to manage Lenny’s difficult and probably
delirious behaviour.
The family meet a physician who fumbles through the
possible diagnoses whilst flashing head scans at them.
He mentions a possible diagnosis of ‘vascular
dementia or multi infarct dementia’ upon which the
daughter asks (as often happens in my experience) ‘is
it like Alzheimer’s?’ and is relieved when it isn’t (again
often the case in my experience. Alzheimer’s is
unfortunately misperceived as being a much worse
disease). The physician also proposes a diagnosis
of Parkinson’s disease. Soon after the son
and daughter are seen in a bar
reading educative books
about dementia and
Parkinson’s disease.
Prior to seeing their
father in hospital they meet
the family of Lenny’s
deceased girlfriend where it is
made clear that the flat where
Lenny and his girlfriend lived,
was owned by his girlfriend and is
now to be sold. The upshot is that
their father is homeless and in
hospital.
Predictably there is tension between the
son and daughter as to what the
best course of action is for their
father; the usual tension between
trying to keep an older person at
home, or considering assisted
living (sheltered accommodation)
or the inevitable placement in a
care home. The son is pragmatic
and clearly thinks a care home is
the only viable option but the
daughter, more guilt-ridden,
wants to consider him living
independently or in an assisted
living environment. Again this
reflects a process seen in many families who find
themselves in this predicament whereby the needs and
wishes of the individual have to be balanced against
those of family and friends.
Discussion between the son and daughter leads to the
inevitable conclusion that their father needs a ‘facility
for older people’ which the son translates bluntly for
his sister as ‘it’s a nursing home’. He finds a quaintly
named care home in Buffalo called the Valley View
Rehabilitation Centre. The father is discharged from
hospital with the mandatory poly-pharmacy of several
bottles containing tablets (and a pile of incontinence
pads), but needs a plane ride to Buffalo with his
daughter escorting him. He is unceremoniously put on
the plane in the busy middle section. During the flight
he suddenly wants to use the toilet and becomes
agitated. His daughter struggles to assist him walk to
the toilet whereupon his trousers sink to his ankles
(the daughter had removed them because they “aged”
him). There is poignant shot of him from behind standing helpless in the aisle with his trousers around
his ankles sporting a drooping, presumably sodden
incontinence pad.
They arrive late at night and there is a
rather funereal drive to the care home
which resembles an industrial building
and is probably without a valley view!
To keep up the small quota of elderly
stereotypes in the movie
(interestingly seemingly the same
the world over) the nurse on his
arrival at the care home greets
him with ‘…you like bingo,
Mr Savage?’ He is shown
into his drab soulless
shared room with little or
no potential for
individuality and his
privacy guarded only
by a wafer-thin
curtain around his
bed.
The following
day the family
meet the care
home manager
where the
reality and
inevitability of
the situation is
further
highlighted
when she asks
them to
discuss their
36 BGS n e w s
March 2008
father’s advance directive for future healthcare and to
ask their father about his wishes for his funeral. The
son and daughter take their father to a café/diner
where these issues are uncomfortably discussed with
him and he becomes somewhat distraught.
The daughter still feeling ‘horrible and guilty’ at the
Valley View placement, decides to view some
promotional videos of plusher care homes and they
end up having an ‘interview’ for admission into the
Greenhill Manor nursing home (Valley View and
Greenhill – contrasting with the tree-themed names of
care homes in the UK!). During the interview Lenny
undergoes an MMSE and struggles despite the
daughter trying to silently mouth him the answers for
which she gets berated by the interviewing nurse! This
visit heightens the discord between the son and
daughter as the son feels he can see beyond the
‘wellness propaganda and landscaping’ which he feels
is more to entice the carers and family and covers up
the bleak fact that it’s a place for old people to die in.
The son and daughter also have a discussion as to
who has the more ‘portable life’ to be the main carer
for their father.
The son and daughter also attend a dementia support
group where the lady leading the session expounds
her views of the carer’s bible – ‘eldercare for
dummies’ (which actually exists - author Rachelle
Zukerman, 2003; and there’s also the book
‘Alzheimer’s for dummies’ which can easily be found
on Google).
PUBLICATIONS INFORMATION
The BGS Newsletter is published every second
month by:
British Geriatrics Society
Marjory Warren House, 31 St John’s Square, London EC1M 4DN
Tel: 020 7608 1369 Fax: 020 7608 1041 Url: www.bgsnet.org.uk
Email: [email protected]
The opinions expressed in articles and letters in the BGS
Newsletter are the views of the authors and contributors, and
unless explicitly stated to the contrary, are not those of the British
Geriatrics Society, its management committee or the
organisations to which the authors are affiliated.
The mention of trade, corporate or institutional names and the
inclusion of advertisements in the Newsletter does not imply
endorsement of the product, post or event advertised.
©British Geriatrics Society 2008
Production: Recia Atkins
Towards the end of the movie Lenny begins to fail to
recognise his daughter and becomes nicely spatially
disorientated, thinking he is in a hotel. The inevitable
terminal decline occurs, preceded by the ‘curling toes
sign’ (noted by the carer to occur shortly before
death), and Lenny dies peacefully (in hospital)
attended by his son and daughter. The end of the
movie did unfortunately descend into the obligatory
uplifting and schmaltzy finale, characteristic of
American movies. The daughter rescues her lover’s
dog (the lover is one of her father’s carers) that was
due to be put down because of arthritic hips and in
the last scene we see her jogging along (in the sun for
once!) followed by the dog padding along behind her
with the use of a wheeled contraption (maybe a doggy
zimmerframe!) attached to its hind legs.
The movie has received much critical acclaim, and
whilst it is a little one-paced, it has some humorous
moments; but creates a sombre and gloomy
atmosphere throughout. I’m not sure the Lenny
character really conveyed the essence of a dementia
patient when compared to the compelling and
probably benchmark portrayal of dementia by Dame
Judie Dench in ‘Iris’. If anything, the short portrayal
in the movie of Lenny’s girlfriend was much more
convincing. Equally however, the behavioural
problems were not so horrendous as to further
propagate the negative stereotype in dementia
sufferers.
The strength of the movie was really in following the
emotions and dynamics between the son and
daughter, rather than the depiction of dementia.
Oftentimes the death of an older person can
crystallise longstanding rifts and dynamics between
family members as they each try to deal with issues in
their own individual way. This movie touches upon
the issue of the ‘emotional duty’ of estranged families
faced with caring for someone they’ve long since
ceased to love or respect. I think carers of dementia
patients may well identify with the various aspects of
the care of a dementia sufferer, and in particular the
agonising and emotive issues surrounding that
wrenching decision to place someone in care.
A mainstream movie with dementia as a core element
has got to be good in raising the overall profile of the
disease and all the issues of care it engenders.
Encouragingly another current movie, ‘Away From Her’
starring Julie Christie is based on the main character
developing Alzheimer’s disease, and is in the running
to win various awards.
Martin Curtice
Consultant in old age psychiatry
QEPH
Birmingham