The evolution of Geriatric Medicine in the UK: Are there any lessons for Taiwan?. 12 th January 2008 Dr David Oliver Reading University and Royal Berkshire Hospital Secretary, British Geriatrics Society. Outline. I: How Geriatrics and BGS started in the UK II: Evolution 1947 to 1977
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12th January 2008
Dr David Oliver
Reading University and Royal Berkshire Hospital
Secretary, British Geriatrics Society
And the role of the BGS (founded 1947)
‘Dr Warren’s routine was carefully studied, the method of admission, examination, diagnosis and treatment, the return home or transfer to Home or hostel, the careful follow-up, the close contact maintained with the relatives, the help obtained from almoner, physiotherapists, OTs and chiropodist. The metamorphosis of an utterly hopeless helpless patient into an active, energetic and everlastingly grateful one was observed again and again.’
Adapted from Isaacs B* The Challenge of Ageing 1982. * Pioneer of stroke units
Recommendations of Royal College Physicians (1977) working party on medical care of the elderly(Note how little things have changed 30 years on!)
MDT case conference. party on medical care of the elderly
Geriatric day hospital.
Domiciliary visits requested by GP
Outreach clinics in general practitioner surgeries.
Old age psychiatry.
Stroke rehabilitation units and services.
Specialty clinics—for example, falls, parkinsonism, stroke.
Rapid assessment clinics.
Geriatrics more and more hospital based
Only 14% consultants with dedicated community or long stay care involvement
And increasingly involved in acute general internal medicine
Stroke becoming a separate speciality with more acute focusKey Services pioneered before 1977 and expanded 1977-2007
Current NHS structure party on medical care of the elderly58.5 M Pop£ 70 billion expenditure (£8 b drugs, £6 b IT)1 M employees. 35,000 GPs. 34,000 hospital consultants, 350,000 nurses
Performance targets and “star ratings” for Primary and Secondary Care. Quality and Outcomes Framework (QOF) in GP contract
Regulation of Quality By HealthCare Commission, complaints procedure, National Patient Safety Agency
Local Social Services. Provide assessment, home care and long term residential/nursing care (means tested). Funding through local tax (20%) and national government. Elected local political leaders. Regulation by National Commission for Social Care and Inspection (CSCI)
Where are we now?
Threats, challenges or opportunities?
especially where the typical patient is young or middle-aged."
In the study, the authors, from the University of Oslo and the University of Science and Technology, Oslo, sent questionnaires to 305 senior doctors, 500 general practitioners, and 490 final
Derek Chan Taipei 2006 www.bgs.org.uk)
“How do we convince all our colleagues in Taiwan of the need for geriatrics and help them understand what we do?”
My mother (again and again!)
“David. I don’t understand why there needs to be a separate speciality for older people. Why couldn’t you be a proper doctor?”Negative perceptions
Source: D Wanless Report 2006 that we
“Frailty is a failure to integrate responses in the face of stress. This is why diseases manifest themselves as the “geriatric giants”….functions …such as staying upright, maintaining balance and walking are more likely to fail, resulting in falls, immobility or delirium”
Rockwood Age Ageing 2004
i.e. Poor Functional Reserve
Fried 1999 that we
Fried L, et al J Gerontol Med Sci 2001: 560: M146-M156
UK National Care Home Census Bowman et al Age Ageing 2004 vulnerabilities
Comprehensive geriatric assessment for older hospital patients systematic review and meta-analysis G Ellis, P Langhorne British Medical Bulletin 2005 71(1)
1586 stroke patients were included; 766 were allocated to a stroke unit and 820 to general wards.
The odds ratio (stroke unit vs general wards) for mortality within the first 4 months (median follow-up 3 months) after the stroke was 0.72 (95% CI 0.56-0.92), consistent with a reduction in mortality of 28% (2p < 0.01). This reduction persisted (odds ratio 0.79, 95% CI 0.63-0.99, 2p < 0.05) when calculated for mortality during the first 12 months.
Tinetti ME et al. N Engl J Med 1994;331:821-7
Close J et al. Lancet 1999;353:93-7
Harari D et al Systematic ReviewThe older persons' assessment and liaison team ‘OPAL’: evaluation of comprehensive geriatric assessment in acute medical inpatientsAge Ageing July 2007
Harari D et al Proactive care of older people undergoing surgery (‘POPS’): Designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients Age Ageing 2007
We still have a long way to go. Some examples…