Conversation with a consultant geriatrician
We had a great conversation with a politically active doctor about changes within the NHS since the 1980s, shifts in doctors’ training and about the relation between ward work and research. We looked at the position of a doctor, from a medical and a management point of view. For further reading about the contradictory elements within ‘being a doctor’ please check out this book review.
I worked most of my career as a consultant geriatrician, but I started off doing general practice, and then I went into cardiology, before deciding on the career I wanted. I qualified in 1983 and I moved around the country before I decided what I wanted to do. I ended up in geriatrics, which I love. I think it’s the only branch of hospital medicine bar psychiatry and paediatrics, which is still holistic where you can really spend time with people. I liked the fact that geriatrics was originally about the elderly but then became a frailty specialty. It’s much more about biological age than chronological age. So we looked after 18 year olds with lots of serious health conditions. We actually have time to look at all their health conditions and their psychological well-being and at their social structures. I think medicine has mostly forgotten that people live within families and social groups and how important that is for their well-being.
I went into geriatrics just as it was changing. Suddenly there were quite a lot of us who went into that field. We were doing a lot of research at the time. We were researching how to stop falls. We were looking at aging processes and dementia, there seemed to be things we could do. We started to remember just how important people’s social structures were. People often have carers and family and except when the patient is against this you have to involve them. I think that understanding does exist in general Practice, Paediatrics, and in Psychiatry, but not so much in any other areas. It might also be due to the social composition of geriatrics which has a lot of women in it, that might make the field more holistic, although plenty of our male colleagues understand the importance of holistic care too. Another thing I love about geriatrics is that no single individual in a team can generally understand this one particular patient and working in teams you get so much expertise from your colleagues. I’ve worked on wards where the cleaners will tell you when they’re worried about a patient. That is perfect because they’re often the people who talk to the patient or the patient will be most honest with them. It’ll be to them that the patient says, “oh, the pain isn’t controlled” or “I’m really depressed”. If you can get that kind of team working, then you’ve got eyes and ears everywhere.
Community care
Most people do better in their own homes once they’re stable because you tend to move more. You have to walk to the loo, you suddenly realize you would like to do something in the kitchen or whatever. It’s better psychologically for people to be in their own home, but you have to resource it and it’s not less costly if you resource it properly. It’s as costly as a hospital, sometimes more costly. The raison d’etre of the government and their push for community care is not necessarily better patient care. They want cost savings, which are easier to enforce in a decentralised system outside of the hospitals.
When I first started, there was quite a lot of community work, and I’ve done care home work, and community hospital work. The trouble with community medicine is that it’s great if you can properly assess somebody. But to do that, you often actually do need them to get to hospital to get their x-ray or to do some tests. But there was far too much of a push on geriatricians to move people right out into the community and never really get into hospital. That is a bad thing for people with multiple medical issues. Of course, you get them home as quickly as possible because it’s not good for them to be in hospital, but often they need to get to the front door for an evaluation. Examining somebody in their own home is really difficult and without longer evaluation hard to give them the right pain control or physiotherapy or palliative care. Sometimes you need a concentration of different therapies and specialities and we don’t have enough of that in the community. If you’re going to have community care, you’re going to have to ramp it up big time. And then you start to think, “well, how cost effective is that?” Is it better for people to be doing lots of travel time in between different cases?
We need more integration of hospital and community care. A friend of mine is doing a local care home project, which is really good. They are going into all the care homes in Bristol, looking at people’s medical needs, reviewing their medication and doing end of life care plans for people, so this reduces admissions and the number of drugs people take. Hopefully you make the quality of their lives better. I think we should be looking at care homes more and making sure that people are being properly looked after. That in combination with frailty physicians at the front door of hospitals who really look at the whole medical, psychological and social needs of people and come up with a proper medical plan. Then you need ‘care of the elderly’ teams or frailty teams throughout the hospital. Not just the surgical wards and the orthopedic wards but everywhere, that could make a big difference.
The other area I feel really strongly about is mental health. When Covid happened I went and worked for a mental health trust for 18 months. Basically a lot of psychiatric patients have frailty. A lot of them have multiple co-morbidities. And sadly country wide they are getting poor physical health care, so much so, that someone with serious mental health issues can die 30 years earlier than the rest of the population. Also there are lots of socio economic issues for people as a consequence of mental illness which also need to be addressed . The training for physical health care in psychiatric trusts is poor and just as we already have liaison psychiatry we need liaison physical health teams and more physical health training and support for psychiatric nurses. Until this happens psychiatric patients are not going to get all the care they need.
NHS changes
In the 1980s, we still worked 120 hour weeks. Often you didn’t have proper cover, the consultants weren’t in the hospital at night and it could be dangerous. Paediatrics was the worst job I did. There were meant to be three of us, but there were only two of us. I was there 18 months after qualification. I was managing a paediatric ward at night, a special care baby unit and the maternity ward. The maternity wards were on a separate hospital site three miles away. They didn’t get us cover. The consultants would only come under duress. There were no registrars. We were managing premature babies and really complicated deliveries. It was absolutely awful. We were so tired. We did complain, but not enough. That kind of thing was quite common across the country. Then they started doing things like mandating that consultants have to see every patient within 12 hours. So suddenly that did improve things. The hours got better. I didn’t like Tony Blair, he was definitely Margaret Thatcher’s son, not a socialist, and Labour introduced negative changes to the NHS (PFI and more privatisation), but there was much more money, and it was the first time I felt that we could actually start developing new services and improving care. I had tried setting up services before but with no money and it would be really difficult. And then suddenly we had money to set up services and people were willing to listen.
Doctor training
Other developments are less good. I think the way training has changed for doctors is often not good. A positive thing about when we were training was that we really felt part of teams. They have taken that away. There was a real sense of camaraderie. I don’t think that exists now. People aren’t working with their own teams, because of the high turnover and the changing of location. You have junior doctors, they come to you for four months. They do on-calls at night with other teams, so you don’t really get to know them. The ones who you’re worried about, you aren’t seeing them enough to really manage their performance properly. I actually do feel very strongly about performance management. I did work with juniors with issues, but it became increasingly difficult to support or to evidence the fact that they were not doing well. Much of assessment has become a very tick box affair. They all have to do these assessments, where it is expected for their portfolios that they will do well. This doesn’t incentivise good learning. I’m saying to them: “Let’s talk about a case you really didn’t understand, so that you can learn something. “That might mean you don’t get above average feedback, but it will be more helpful for your training.” But they all just need to have their five stars for the portfolio.
In the past we were given too much responsibility, whereas now juniors don’t always get enough responsibility, especially in the early years when they may have an attachment with an esoteric sub-speciality. They streamlined the training and think it is more effective. So nowadays it’s all about getting a good portfolio. Have you done so many audits? Have you done this? Have you done that? And if you have, you go up the top of the tree, but you aren’t necessarily the best doctor. The system before led to biases around race and gender etc. but the new system doesn’t give you a sense of the person, or their potential. I don’t mind if they haven’t got all the tick boxes, if they’re the right person, but I appreciate the great importance of reducing discrimination.
Some things got better over the last 20 years, we really started to get the idea of a MDT team and the importance of listening to other professionals. When I started the consultant was a general rule all powerful and everybody had to bow and scrape them and they were terrifying. Certainly, the nurses wouldn’t question the consultants. That has generally got better, although the hierarchy still exists.
Setting up services
Setting up services is not an easy thing, you have to provide a business plan and involve the right people. They want you to present a business case, but no one teaches you how to do it. Hopefully you just pick it up or a colleague or a manager helps you, or in my case my husband. There’s nothing in the NHS that makes it easy for you to navigate the system and work out who it is you need to get on your side. There are criticisms of NHS management and the split between management and clinical staff. We need managers, but they also need the freedom to manage without constant directives and targets from the central government.
When I was working in stroke, they used to have stroke units with dedicated staff in other hospitals, but not in ours. I tried to set up such a unit, but trust management and the Clinical Commissioning Group wouldn’t give us any money. So we were giving poor service. I wasn’t happy about it but I went to a drug company and they paid for us to have a stroke coordinator for a year. I felt very uncomfortable, because I don’t think we should take freebies from drug companies, but I thought there’s no other way, as the trust wasn’t going to give me the money and we needed a stroke coordinator. It worked out as once we’d had her for a year, the trust started paying for the service. The drug company manufactured a drug we were already using, so I felt having them as a sponsor wasn’t going to affect our prescribing.
Of course by getting a stroke co-ordinator we were able to see more patients and so more of the drug was prescribed, but only appropriately. Eventually the trust saw the benefit and we got the money for a stroke service. It often feels that rather than evidence, services are more likely to get off the ground if you can tell individual patient success stories. But you also have to find out who’s got the power and who’s got the money, and you’ve got to get them on your side. You have to show them that spending money upfront will save them in the long run. This is really hard to do. They’ve got this worry: “But what if it doesn’t work and then you don’t save the money?” Well, you might, but you’ll never find out if you don’t want to try.
The last service I set up was the Complex Assessment and Liaison Service (CALS) at NBT. I was asked to move from Cheltenham to set up the front door service, but for some time we had no staff. So I had to first gather evidence and talk to all the relevant people and even then the service might never have got off the ground if a colleague hadn’t been so effective at persuading the CCG and trust. We started in the acute admissions unit as a multidisciplinary team. Basically we were seeing anyone who was frail, anyone who had fallen or anyone who had multiple illnesses or disability. Now the service is in the emergency department as well.
We trained advanced nurse practitioners and Allied Health professionals so they would do a lot of the clinical assessment. I’ve worked with advanced nurse practitioners who are better than many doctors, but because the way the teaching is set up, they don’t always get very comprehensive training. Medical training is very different from nurse training. Nurse training is not really about diagnosis. Without proper training and support then it’s difficult to do things well, so this must be built in and there needs to be good monitoring of performance until people are well established. If you introduce these new professional groups like advanced practitioners, then you need the structure to support them. The trouble is, all doctors are meant to be teachers, but some people are poor at teaching. If they’re not interested or they don’t know how to train people then that can reduce the effectiveness and skills of trainees.
Physician Assistants
I would say that in some areas physician assistants are not being properly supervised or supported and if that’s the case it’s dangerous. I think it is important that if people are going to take different roles, they gain the correct experience and training. I have worked with really good PAs they’ve wanted to learn, but they’ve also been in good teams. I think there’s a lot of anger among doctors that PAs are going to take their roles or reduce the training they get. There’s already anger among doctors because their relative pay has gone down, but I think the anger is also due to difficulty getting more senior roles and the loss of team cohesion. The most important thing is to make sure there’s good care but this is compromised when staff are unhappy.
With some new job roles you might have one position consistently with clear job roles, such as an advanced nurse practitioner who’s only doing diabetes. Or you can have advanced nurse practitioners/PAs who are doing many different things (critical care or frailty ANPs) and then it’s not so clear anymore what those roles are. If I work with an F1 or a F2, I’ve got a rough idea of what I can ask them. Whereas if I’ve got a physician’s assistant, I’ve got to really get to know them a bit better before I can gauge how much they can do. I think when you’re working in a good, cohesive team, then it becomes easy because then you know exactly who can do what and you know who you can trust and you know who will tell you if they can’t do something, then it’s fine.
But also what happens if you start using AI or physician assistants to fill the majority of the early junior roles? How do you train up the people who are going to become consultants? There must be enough people who have the seniority and the expertise to train people below them. Medical training, the full medical training, there’s so much to it. I’ve met nurses and advanced nurse practitioners, people who have acquired that knowledge through years of working on the wards by just being really interested and who could easily do those jobs, but then there needs to be a recognition of their skills and status. Senior and junior staff can be reluctant to believe other professional groups who challenge their opinions.
I worked on a ward where the ward sister trained up the health care assistants. They would not only take bloods and do observations, but she also trained them up with specific skill sets. They would have a really good grasp of diabetes. The whole point was that they would come and say to us: “I’m really worried about that patient’s diabetes. Could you come and check them?” You need the training and a team that communicates and works together well.
Research
When it comes to drug research you have to be careful, as it can be flawed. Trials exclude so many people (the elderly, people who are pregnant or have other significant illnesses), which has the result that the drugs may not be appropriate for the people you give them to. They’ve got to get this drug to market, which can mean that there may not be time to see long term side effects. In theory there might be less bias if a lot of drug trials were taken away from the drug companies, but the trials are expensive and so this isn’t practical. Independence can be a real issue. The problem with research is that you’ve got a capitalist model, drug companies want to make money, so it’s not really about social good. It’s difficult because we need drugs and many drugs are very effective and useful. Statins, for example, are incredibly helpful for certain people but people are taking them who may gain no or little benefit. Geriatrics is often about stopping drugs for patients because they don’t need them, or, they’re doing more harm than good.
Some research is flawed. In my opinion a good example of flawed research was using probiotics to prevent antibiotic related C.difficile infections. That research was poor. The group who got the probiotics were different from the group who didn’t get probiotics, in terms of age, sex etc.. The probiotic group was also given antibiotics that are less associated with Clostridium difficile and the control group had more of the increased risk antibiotics. So we spent years giving probiotics to all patients taking antibiotics in hospital before it was decided that they made no difference. That cost a lot of money. Now we’ve got weight loss drugs with people buying them on the web when they don’t need them. These drugs can have very serious side effects. But they also do not address the underlying problem that has led to obesity. The problem is that many people who are very overweight don’t have access to decent food, often for socio-economic reasons. If we want a fitter, healthier society, we need more exercise in schools, access to affordable healthy food and a curb on the food industry pushing heavily processed foods.
Setting up business cases, you can look at research, but it’s often qualitative research often rather than quantitative. They are quite often small studies so people don’t necessarily trust them. Then there is the problem of the dissemination of that research. When I was setting up the front door team, I wasn’t the first person to do this. It was already going on in other parts of the country. People at Guys and St.Thomas’ in London had done some really good research on it. I tried to use their model, but initially it was difficult to get trust buy-in based on other people’s work. When I set up the team Guy’s and St.Thomas had called theirs OPALS (Older People’s Assessment and Liaison Service). I wanted to call ours OPALS so that people would know we were doing the same thing”, but I was told “we’ve got to have our own name for the service.” If all hospitals used the same name around the country for this service model, then exchanging experiences and knowledge is easier. What can we learn from you? And vice versa? Now there is a frailty forum that has done exactly that.
There are ways to exchange ideas. I go to geriatric conferences and chat to people and they tell you about their service and you can swap experiences. These conferences are organised by the British Geriatric Society, who are a good organisation. The best part of the conference is the networking and you get a lot of information and support. Things have changed over the years and it is not just doctors who can join the Society, anyone doing anything that’s frailty related can join the BGS. It’s a much more open society.
Class medicine
I think the medical student teaching has got better in lots of ways, but maybe there’s too much formalised teaching. When I was training we had to see every patient, on the ward we were attached to. We had to take a history from every patient, examine every patient. So we had a lot more practical experience. Now they see far fewer patients. Not all medical students come from backgrounds where they understand socioeconomic problems and have an understanding of where patients are coming from. What has led to this patient’s illness? What does it mean to go home again?
I came from a political family, my grandfather was a trade unionist, in the shipyards. Maybe class was more obvious back then, but you still have poverty and austerity, poor housing. I don’t understand why so few doctors are politicized. I don’t understand how you can see the effects of what our society does to people, racism, austerity etc. and not want to do something about it.
Look at the age people die, it’s very related to their socio economic situation. How long they live with ill health is also related. In geriatrics, we ask people what kind of life they live. What kind of housing do you live in? Is it rented? What’s your landlord like? You should be getting a bit of social history, because you could discharge a young person with pneumonia back into a mouldy flat. They’re just going to get worse again. The class markers might be different today. If somebody is working in a call center, would you even think that it could be a difficult job? Maybe they don’t have much money and maybe the job is actually not good for them. A lot of people have to do jobs that are poorly paid, have no protection and they don’t feel are really worthwhile. With more lone and home working they may not have companionship. When I did factory work, as a student there was a real sense of camaraderie.
Political activities
My first really political activity was when Margaret Thatcher came into power. I was a registrar at that stage. A group of us ran a campaign called Save the NHS. I went to talk to public meetings and to unions and to MPs and read lots of things. We went on telly and tried to get people to understand that the Conservatives were about to start privatizing the NHS. It’s amazing how many people just said, “but I don’t use the NHS”, but everyone does at least some time. I have been a member of Medact on and off for years. It is an organisation which evolved during the peace movement against the nuclear arms race and has now taken on everything to do with health justice.
I think there’s a big role for doctors in political movements and volunteer organisations. There’s a role for doctors in emergency situations, like Doctors Without Borders, but I would find it really difficult if I was going to places like Gaza, because I’d want to be publicly political about the situation, which can then impact on the organisation’s ability to work there. As healthcare workers I feel we should all be political.
I find the most recent doctor strike difficult. Of course there are issues about how doctors are trained and how they’re paid. But it is difficult when you’re the best paid of all healthcare workers and you have people in other roles on really low pay who are struggling. I think we need to band together as healthcare workers and start saying, let’s stop privatising the NHS, let’s make it free for all. Let’s look at how we can manage this service more equitably. Let’s try and disseminate practice and share things. Let’s try and find ways to work as communities to support people and look after people. Let’s look at the wider aspects of society and what makes us ill, from food to bad jobs. What can we change in order to become a happier and healthier society?
