Tuesday, 14 April 2015

Community Geriatrics: The Way In. Biography-Based Medicine

In the last blog I talked about the real nature of the challenge that faces community geriatrics: that of meeting the expressed and felt needs of the elderly, rather than their supposed or assumed needs. I talked about this in terms of biography, and I hope that I conveyed the sense that what is valuable to an elderly patient moves away from the objective to the phenomenological. The experience of being frail and elderly is something I can only appreciate vicariously. I have seen it hundreds or thousands of times, but I have never lived it; and while there are themes and commonalities, it is the differences between my patients that distinguishes them.

I recently told an elderly man that he had metastatic bowel cancer, involving his spine and liver. He painted me a context of that news, which took him back to reflections of his experiences of the 2nd World War in Burma. He recalled the men he’d left behind, who with him had endured very difficult conditions, but unlike him, hadn’t survived. Being told he had an incurable illness was of little moment to him, when every moment he had lived since 1945 felt like both a bonus and an undeserved privilege.

These are the narratives that frame the context in which we deliver care to the elderly. Where are they now, where have they been? The biography of the elderly sits at centre stage of our efforts to serve them well. It is our guide, and our obligation to them. Let’s call it biography-based medicine – medicine that fits poorly on protocols, medicine that urges you to understand deeply with whom you are dealing, and what it is that you can do to most faithfully serve them.

I still feel that I know my patients only superficially. There are moments when they let you in, and give you a real glimpse of what you can do for them. The challenge for creating conditions for their trust and confidence are the trickiest part of community geriatrics. It is the creation of these conditions that is one of the key challenges for a community team.

For a while I scratched my head about how to do this – but then a realisation crept in. The more I spoke to district nurses, community therapists and GPs, the more I realised that there already exist whole teams of people that know these patients well, and understand where they are in their lives. I heard vivid narratives of patients struggling on at home, and these teams struggling on to support them. These nurses and therapists are not just committed to their jobs, they are trusted by the patients they help, in relationships that have been forged and nurtured over time.

The more I listened, the more I realised that these teams were the way in. They have almost everything: skill, knowledge, commitment and the trust of patients. What they were lacking was the medical support to manage complexity, to deal with uncertainty, and to seek support rapidly and easily. My role started to become clear.

I have a running debate with a local practice manager. Her question to me is whether we know who all the frail and vulnerable patients are locally. I can’t yet give a definitive answer yet– we are still looking into that – but it is my sense that in a town like Bridport, it is rare for a frail, elderly patient in need of support and care not to be known to at least one of the health or social care services. I might be wrong, but I intend to find out. But if I am right, then it means that we have broad coverage of our local elderly patients, and the challenge is to ensure that if one of the teams notices a deterioration, or requires additional help in the management of a patient, then that help is easy to come by.

This is what we have been ramping up – the cross-support and co-ordination of community teams. We met every week to discuss our patients, and we coordinate our actions for the patients. It starts with the person who knows the patient best describing their situation, and continues with the team members clarifying, suggesting and offering actions to help the situation. Anyone can bring a patient up for discussion, and we keep the patient under review until we are happy that things are back on track. We discuss what to do in an emergency, we agree appropriate actions, and we follow it up.

It feels right, because it is based on a narrative of the patient from the team member who knows them best. It feels right because everyone who needs to be there is there, and we have a breadth of experience and expertise to call upon, from social services, safeguarding, GPs, nurses, therapists, and mental health services; there is an old-age psychiatrist, and of course, me.

Someone who came to the meeting told me that they thought it should be more structured. I could see their point, but I argued that too much structure can stifle. Not everyone in that room speaks the same form of descriptive narrative, and nor should they. What emerges from the description of the situation is an ever-more detailed picture, and it needs space to emerge.

What really matters is that these dedicated members of the team have the opportunity to enlist support with patients they know well, and that the team gives them the airtime to outline their concerns, in the context of the knowledge they have of the person. That’s the starting point from which everything else can follow.

Saturday, 28 March 2015

What is community geriatrics?

What is community geriatrics?

In my last blog, I mentioned how I became frustrated at the experience of being practicing geriatrics in hospital; about how frustrating it was to deal with people only when they are sick, and have no role in keeping them well.

I embarked on a job in community geriatrics because I felt that it was an opportunity to at least explore whether the acute model we have is the best model available. In this blog, I will begin to outline what community geriatrics can do, and importantly, what it can’t do.

It is difficult to know what perspective to start this from – from the perspective of the acute sector, or the community sector. The temptation is to project the role of community services from the perspective of the acute hospitals, as these are the part of the healthcare system that garner the most attention for the pressure they are under, and these are the parts of the system that stand to gain the most from a community service that is achieving its full potential. However, neither is the right place to start: the perspective that counts is that of the patients.

In West Dorset, where I am currently working, the nearest acute hospital is 16 miles away. The bus takes over an hour, there is no direct train line, and a taxi costs about £30. This is where the consultants are.

In Bridport, there is a large GP practice, a community hospital, with just under 40 beds, and an x-ray machine. There is a great team of district nurses, and a superb rehab team who assess and support patients at home, as well as offer them rehab after discharge.

When I started in post, the community hospital focused mainly on taking patients from the acute hospital on discharge. On top of this main strand of work, they admitted some patients directly from home, as well as offering end of life care to local elderly patients. Day to day medical cover was provided by a middle grade ward doctor and a nurse practitioner, with 2 sessions a week from a consultant from the acute hospital.

With these facilities in mind, the first question I have been trying to answer, is how can these services provide the best overall utility to the patients that they serve.

To do this, one has to take a look at the needs of the patients involved. This is a key moment. The typical descriptions involve talking about elderly patients, often with cognitive impairment and multiple medical conditions, who are socially isolated. This covers the bulk of patients I deal with, but it doesn’t really describe any of them. Some of them have lived in the area their entire lives, some of them retired to Dorset; some of them have been in good health most their lives, some of them have struggled with illness for many years. Some aren’t even very old at all. I could list the different possible descriptors all day, and it would make for dry reading indeed. The point I want to make is that for all their similarities, they are all different, and with such differences come differences in needs, wants, expectations and goals.

The only way to serve my local patients well, is to be able to adapt easily to their differences, to tailor our approaches and interventions around what is important and necessary to them as individuals.
The worst time to meet someone for the first time is when they are sick. The two main presenting complaints of the elderly are falls and confusion. The worst time to ask someone what they would like you to do on their behalf is when they are scared, in pain, or not their normal selves. Planning for the future should, and could, take place, in good time, by teams of professionals engaged in knowing people when they are well, so that they already know what needs to be done when someone gets sick.
Some elderly people feel that they have lived fulfilled lives. They feel old, they feel tired, and they feel as if they are ready to die. Other elderly people feel that they are still living fulfilling lives, and would very much like to hang on longer should they get sick. With the former, if they became septic, would you admit them to ITU for intensive physiological monitoring, support and treatment, or offer them non-invasive ventilation for type 2 respiratory failure? Would you with the latter? Would you know what to do, if you had never met them before, or knew very little about their lives? Is it fair to base intervention only on what you have learned about them since they got sick? Knowing that someone is sick and old is hardly enough data to go on to determine appropriate treatment levels.

Over the last 18 months, I have therefore come to the realisation that one of the roles of community geriatrics is to fill in the gaps in patients’ biographies, to allow the right actions to be taken on their behalf when they inevitably deteriorate. It is our goal, that a call for an ambulance should not simply mean that that patient is whisked off to hospital, but that other alternatives are available to them: that they might be supported at home, that they could be admitted to the community hospital, and that if they need the kind of care that only an acute hospital can provide, then that is where they go.

My business, therefore, is about getting to know my local patients, and working with them and their GPs to plan in advance what are the possible avenues that could be used to best meet their needs. This means that they do not go to the acute hospital when their needs can be properly met locally, but when they do, that they go quickly and safely, and when they no longer need to be there, we get them home with support, review and monitoring, in their own home.
We have started to make great strides towards this, but there is still a way to go. In the next blogs, I will begin to outline the different parts of the system that help to make this happen, as well as outlining the steps we are making to ensure that as much as possible is done for the patient before they get sick.

Tuesday, 24 March 2015

Community Geriatrics - an opening salvo

As I was contemplating my return to blogging, I remembered a story I once heard: following his release after a 4 year detention by the Spanish Inquisition, Luis de Leon opened his comeback lecture with the words, ‘As we were saying yesterday….’

18 months ago, when I all but stopped blogging, I wasn’t interrupted in quite the same manner as Leon, but things did change: I went from being a geriatrician in a North London DGH, to a community geriatrician in West Dorset. I suspect that some people thought I was crazy, but I had a sneaking suspicion that it would turn out to be a fabulous move. It has been, and I’d quite like to tell you a bit about it.
I’m not going to hark on about life in Dorset. I don’t want to irritate you. But allow me to set the scene: we live in Bridport, where Broadchurch was filmed. It is a lovely place, where people ask you ‘Where’s that to?’, when they mean ‘Where is that?’ It is rural community, fuelled by farming, agricultural industries, and tourism. It is a place people retire to. We swapped a two-up, two down terraced house in Maida Vale for a 17th Century farmhouse, with all the accoutrements to horrify the parents of a toddler: it has a well, a pond, and an Aga. Sometimes when I get home, I stand outside my house and just stare at the night sky – it is like God has shaken his dandruff.

But my aim is not to convince you of the merits of rural life. Instead, I would like to share with you what I have learned about the scope and potential for community geriatrics. My radio silence on these pages has been borne of a number factors (ibid move, house purchase, new job), but only one really counts as a legitimate excuse: I have been learning a new trade. Community geriatrics is different to hospital geriatrics. My out-patients clinics take place in patients’ homes, one of my community hospitals has an x-ray machine, the other does not; my patients are different, my working patterns are alien, the nature of decision-making outside of hospital is dramatically different. The nearest geriatrician to me is 16 miles away.
I came into this job with the skill-set of any other geriatrician, forged and honed in acute hospitals, and have had to learn how to adapt to a totally different environment of practice, where the nature of risk-management is harder, where the access to diagnostics and expert opinion is harder, and where the goal for the patient is different.

I am an introverted thinker (remember your Myers-Briggs) – this means I take my thoughts and experiences, and put them inside my head, where I let them swirl around, until there is some order, and then I share them with the world. So if you are wondering where I have been for 18 months, you have your answer – I have been right here, trying to make sense of this new world I find myself in.

And I have finally reached a point where I not only have questions, but I have some answers as well, and I would like to begin sharing them with you. Of course, the question of how you care for an ageing population more effectively within existing funding streams is a question that can never be ticked off as complete, but my experiences may help to start finding answers to questions like this.

Over this series of blogs, I would like to outline to you what I have learned about caring for the elderly in the modern health service, and what community geriatrics can contribute to the solution. There is a lot to cover, and I would test your patience to attempt it all in one go. And even now, I suspect that I am reaching the limits of your tolerance, so let me end with a final consideration.

Does the structure of geriatric services we have now correspond with what we think the goal of geriatric services should be?

Let me fuel the discussion a little. Towards the end of my registrar training, out of the swirl on my introspective thinking came the realisation that as a hospital physician, I met patients when they were sick, learned about them, about how their illnesses responded to treatment, and tried to get them better. When patients were discharged, I would have nothing to do with them until they got sick again. All that I had learned about them and their collection of illnesses went untapped until their health deteriorated.
I don’t know what geriatric training was like 30 years ago, but I do know that current training has become enmeshed within the acute pathway. Very little time is spent with GPs, or with community services. Virtually no time is spent in the patients’ homes.

The most striking aspect of being a community geriatrician is how much more you can find out about a patient from assessing them in their own home. You are flying blind as a geriatrician until you find out about how a person manages day to day in their own environment. The problems I assess are the same ones I used to assess in my hospital clinics, but my response is often very different. My tests are more considered, my understanding of what the person needs is sharper, and more of it is organised around the needs of the person in front of me, than the demands of the particular disease process we are dealing with.

Over this series of blogs, one of my overarching themes will be the idea that geriatrics is the specialty of managing a constant state of poor health in the elderly, derived from multiple medical problems and acquired frailty. I will make suggestions about how community services, and changes in the way that geriatricians manage their local patients can contribute a better experience of care from the people we serve.

Tuesday, 15 July 2014

Community Spirit

After months of not having anything new to say, I was struck by something I read this week in the local parish paper.

Ever since I moved down here, I have seen walking around the village, through the lanes, and, on occasions, along the busy highways, a tall, elderly gentleman, who wore the unmistakable look of the dementia sufferer. But I have not seen him for a few weeks.

The update in the parish news told us that he had recently been admitted to hospital, and subsequently discharged to a care home. However, the message from his wife, was one of gratitude to the locals. She was thankful for the care, consideration and kindness they had shown to him when he went on his walks. He would spend many hours every day strolling outside. It seemed to be the one thing that kept him connected to the past, that was, for him, slipping out of memory. Locals would acknowledge him, talk to him, and when he wandered somewhere dangerous, they would bring him home, or alert her to where he had gone.

His wife was grateful for the support that her neighbours had shown him and her,  and for their indulgence. She could trust that wherever he went, he would be safe, and that people were looking out for him. She was thankful that with community support, they were able to stay together for as long as they did. Importantly, he was treated as a member of the community, and not just an elderly man with dementia.

I was touched by her ability to see the positives in his life as the fog of dementia descended. And I was touched by the realisation that she was talking about my community, about the people I see every day. I am relieved to discover that a common decency is alive and well in the place we live. It makes it feel like a good place to be.

There is something in this story for all of us, and to me, it talked openly about something I have been feeling for some time.

As I grapple with the challenges of caring for an ageing, and ever frailer community of patients, I increasingly feel that health and social care services can ever only be part of the solution. On their own, healthcare professionals can make a huge difference, but they cannot change the game. That is up to all of us.

Do we value the elderly? Do we empathise with them? Do we ever imagine what it might be like to when we age, and wane? I seem to recall my Dad once telling me, with the fervour of the first generation immigrant, that our health service, is the pinnacle of civilisation. I may have made this up, but it seems like the kind of thing he might say. I imagine the system was a little more limited where he grew up in Nairobi. For years, I agreed with him (a rare enough occurrence), but now I am beginning to wonder.

The NHS is a marker of a strong society when compared to what came before; but now it has been in place for over 60 years, perhaps we have started to rest on our laurels. What is the next marker of progress? If the NHS was a sign of a country keen to take care of its most vulnerable, then perhaps the time has come to take the next step.

Sometimes I wonder if we are up to it, but then I read stories in the parish paper that give me some hope. Can there be anything more rewarding than for a society to make the choice to protect better its most needy members?

Of course, the challenge is to decide what the response looks like. Perhaps, the key is not define the answer, but to define the challenge. Perhaps we could set the goal that no elderly person should go an entire day without social contact.

Of course, there is no imperative in all of this. That is perhaps what makes it such a compelling choice. We could, of course, allow our elders to continue to live lonely, marginalised lives. Or we could make the choice to make them part of the routine of our community living.

I'll let you know when I've had some ideas about how to make this a reality, but in the meantime, I would welcome any help I can get.

Sunday, 15 December 2013

It's more than 7 day working we need to change

7 day working is back on the agenda. It's been cropping up now at regular intervals - it keeps cropping up because it is something we haven't yet solved.

It sounds like a good idea to have consultant presence on the wards 7 days a week, and it reflects a reality of modern day health care: consultants are the means through which investigation and treatment plans are currently achieved. Another solution might be to have teams that function effectively even in the absence of the consultant, but this does not seem to be a solution on the wider agenda. Consultants are the de facto clinical leaders, and they should be the experts. More junior doctors may be expert as well, and in many cases they offer leadership - but there is too much variation. The difference in expertise between a first year registrar and a final year registrar can be huge. The best way for the system to guarantee the best expertise is to focus on the provision of those people who have successfully navigated the training, and demonstrated the ability deliver the level of care required to be a consultant.

How well our training system does this is the topic of another conversation. But I can see why the currency of expertise in the current health service is measured in terms of consultant numbers.

Consultants are useful tools around which a health service can be shaped. But they are also the most expensive tools. We have to ensure that consultant time is used to the greatest possible utility.

If we look at how we might offer greater presence of consultants on the wards at weekends, there are a number of solutions that we might choose.

  1. Employ more consultants - costs more money, and requires more consultants to be trained. 
  2. Pay current consultants more money to work more hours - costs more money, risks burn out, risks deterring young doctors from entering specialties that require 7 day working
  3. Focus 7 day provision on acute services, and cut elective services to create the capacity for more acute work - this will lengthen waiting times, and perhaps create a perverse incentive for more people to use acute services for chronic problems: we might arrive at a situation where the best way for patients to receive timely, expert care is through the acute services. 
Something has to give, and it is not simply an issue of giving the problem money: even with unlimited resources, we would not currently be able to staff 7 days services across the country, for the want of appropriately trained consultants to take up the work. Within geriatrics at the moment, within current service provision models, many trusts across the country are struggling to recruit suitably trained doctors. 

Therefore, we need to decide how important this is, compared to the work that consultants already do. 

And this, I suspect is where the possibility for change lies. Implicit in the attention being focused on 7 day working is the knowledge that the acute pathways are struggling with demand, and the evidence that emergency outcomes, and surgical outcomes are worse at the weekends. 

Now this really is a complicated issue, but I've had a simple thought about it: the acute services experience high levels of demand, not just because we have high levels of sick people, but because they are the only services that mirror the preferred usage patterns, and expectations of the patients. They are the only services that respond to patient's needs when they have them; they are the only services which provide patients with answers in the time-scales that they feel they need, or they expect.

And let's remember, many of the people who use A&E are not really patients: 40% of them are sent home with only advice. This is telling us something. 

I know there has been a whole heap of work done around how people use health services, and how we can provide better out of hours care for non-urgent problems. But perhaps it tells us something else as well, and perhaps one of the areas that needs real scrutiny is how we provide routine, elective and non-urgent care.

If we accept that acute services respond to individual's needs in the time-frame that patients expect them to be, then what does that say about the way we deliver out-patient and elective care. 

If you take the kinds of out-patient services I have worked in, then it is evident that the nature of care provided to patients is significantly organised around the capacity and structure of the service. The ability of a clinic to review new patients is often a function of clinic capacity, not of patient need; and the frequency and time between follow-up appointments is not always dependent on clinical need, but on the nature of the service. 

Too much out-patient care is based on an old-fashioned and historical structure which bears little resemblance to the health care habits of the modern day. The time of need is not weeks or months after the referral was made, but on the day that they went to their GP with the problem in the first place, or the day that the ailment started. 

Too much out-patient care is delivered too late, too infrequently, and is influenced too much by the limitations of the service. 

This is the area of care that we need to deliver differently. This is the area of our system that we could revolutionise to provide more rapid diagnostics, assessments and treatment plans, and the area of our system that could share more of the burden currently borne by the acute services.

So let's figure out how we can use consultant time more effectively for the benefit of our patients, but while we have the chance, let's also figure out, at the same time, how we can adapt the way we work, to help consultants help patients better. 

Monday, 25 November 2013

0800 4 70 80 90

When I first started at prep school, the only way I could communicate with my parents was by letter - something we were made to do every Sunday after Church. These letters were screened by the teachers, to make sure we were gave them appropriate care. Aged 8, I barely wondered whether it was acceptable to have my missives home checked by someone who worked at the school that I might well have cause to complain about.

I never felt like I needed a more immediate, less monitored means of reaching my parents - I was too busy having fun, larking around in the woods with my mates, planning raids on enemy bases, to be too concerned by such matters. I was too busy being happy.

But boarding school is a relentless place to be sad, or lonely or scared. And someone realised this.

When Child Line was introduced in the late 80s, the school was fitted out with a pay phone that took those old school phone cards, that you could renew with the judicious use of some Tippex. It was all just a game to me - one term, when I was off games with a broken arm, I once phoned up Child Line and asked them for help with my Latin homework. To their credit, they gave it a go. I guess it all seemed like a bit of fun to me.

But under other circumstances, it might not have been fun - it might have been my only window to the outside world. Not all kids had the fun I had at school, and not all kids at my boarding school had the fun I had. For some, the chance to phone home, to phone Child Line might have been a Big Deal indeed.

The launch of the Silver Line reminded me of all of this. I have written before about loneliness being a big illness in the elderly. I have watched it, seen it, touched it, but I have never found a way to do anything about it.

That embarrasses me. But my embarrassment means nothing - it is not important. It is, important, however, that someone has found the energy to do something about it.

I don't really know what it feels like to experience the kind of aching loneliness that many of our elderly must feel. I do know that I don't want the people in my life to experience it, and I do know that I don't want our elderly folk to experience it.

Silver Line may just be a phone line, but to some people, it may just be a very Big Deal too. And perhaps, more than that, it might serve as a reminder to all of us, that while we are out there exploring the world, for some people, that is no longer possible.

For them, the challenge is to bring the world to them. Perhaps Silver Line is the start of something, just as Child Line was the start of something.

I hope so. I hope that Silver Line has the kind of impact that Child Line had, and I hope that its reach is broader, and that from this simple, important intervention, something bigger in our society can spring up.


Thursday, 21 November 2013

The right intention, but the wrong idea?

Here at the British Geriatric Society Conference, much of the conversation so far has been based around the challenge of meeting the needs of residents in care homes.

At face value, it seems like a good idea: care homes are where the frail elderly often go to live. It makes sense, therefore, to organise care around these units, as they are good ways of selecting out the people most in need of comprehensive geriatric care.

But I have a number of concerns about this shift in organisation. Let me explain:

1) A great many frail and elderly patients live in care homes, but a great many do not. By organising care around care homes, the risk is that we create differential levels of care for those inside care homes compared to those outside them. Perversely, this may create a driver to admit patients to care homes, so that they receive the kind of long term care that they need. Our challenge, however, is to create a system that meets all need, not just those of an artificially selected care home population.

2) By organising services around care homes, we are doing very little to influence the use of care homes in the first place. As a strategy, it does not change the game enough: it is a response to a situation we find ourselves in, and not an attempt to modify that situation to something more acceptable, and more effective. By organising services around care homes, are we acknowledging that there is nothing we can do to support the frail elderly in their own homes? Could we not, with differently organised, and better managed services, respond to the needs of the frail elderly at home, and forestall or delay the need for them to enter care homes altogether.

3) A care home is simply where someone lives. It is perhaps a marker of their needs, but it also represents more: it could be a function of the choices that individual has made, the nature of their family and social support networks, and a whole range of other factors. A good system responds to the needs of individuals wherever they live, and adapts around that person. A system that organises around care homes is using the admission to the care home as its surrogate marker for frailty. This may well be fairly accurate, but it is not comprehensive, and it encapsulates a fatalistic view of our ability to influence the need for individuals to enter long term care.

The current use of care homes is currently unsustainable, and it is impersonal. Stories abound about patients admitted to hospital in a crisis, and then without ever having the chance to visit their own homes again, are admitted to long term care. Life sometimes falls off a cliff, but perhaps, with better and more intelligent organisation, we could slow down that falling trajectory.

My fear is that, as we enter a period of great change in how we look after our frail, elderly patients, we resort to type, and continue to organise care around physical units (acute hospitals, community hospitals, and care homes) and not around the individuals. The care we give, and how we give it should be influenced by the needs of the patients. The organisation of services should adapt to those needs. Historically, and currently, the care we offer our patients is significantly influenced not by their actual needs, but by the resources and set-ups available. We approximate the needs of the patients to the needs we can meet.

This is classic cart before the horse stuff, and I think we ought to put it right. Perhaps more importantly, I think we can put it right.