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: general.information@bgs.org.uk Committees, Clinical Excellence Awards, Elections, EUGMS, General Office Management - Sarah Allport: committees@bgs.org.uk Membership, Age & Ageing subscriptions, Abstracts, Scientific Meetings Liaison, CPEC, NICE, Grants, CPD - Joanna Gough: scientificofficer@bgs.org.uk Finance - Susan Cox: accountant@bgs.org.uk Age & Ageing abstract supplements, Publications, Newsletter, Newsletter advertising, Websites - Recia Atkins: editor@bgsnet.org.uk 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 editor@bgsnet.org.uk 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 (editor@bgsnet.org.uk). 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: alex.mair@bgs.org.uk 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 sarah.allport@bgs.org.uk 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 (T.J.Aspray@newcastle.ac.uk) or Tim Cassidy (Tim.Cassidy@chs.northy.nhs.uk for more detail and send your nominations by 31 March to sarah.allport@bgs.org.uk 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 sarah.allport@bgs.org.uk 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 eirlys.harries@carmarthen.wales.nhs.uk 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: Debbie.Baker@thh.nhs.uk BGS Gastroenterology and Clinical Nutrition Special Interest Group 12 - 13 June 2008, Newport Contact: julia.newton@nuth.nhs.uk BGS Trent Branch 24 June 2008, The Dakota Contact: Janet.Joseph@derbyhospitals.nhs.u k BGS Trent Branch 16 Oct 2008, The Dakota Contact: Janet.Joseph@derbyhospitals.nhs. uk More details on: www.bgs.org.uk/Notices/regional_ sig_meetings.htm Regional Officers, please contact editor@bgsnet.org.uk 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: Stuart.nixon@gwent.wales.nhs.uk 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 julia.newton@nuth.nhs.uk 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 (sjturn@liv.ac.uk) . 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 sjturn@liv.ac.uk 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 copd.audit@rcplondon.ac.uk 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: editor@bgsnet.org.uk 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
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