Population Geriatrics

Professor Sir Muir Gray is the Founding Director of the Oxford Centre for Triple Value Healthcare, and a Director of the Optimal Ageing Programme. He is also an adviser to Public Health England and the Chair of the NHS Health and Social Care Digital service, which is responsible for maintaining the NHS Choices website. Muir’s work focuses on providing training to healthcare professionals on value based healthcare. He tweets @muirgray

Population ageing, both absolute and relative, is on every country’s agenda. The news is dominated by COVID, with the impact on older people at the forefront of the debate. The direct impact of COVID in older people has been well documented with the majority of cases and deaths being in the over 65 age group. For those working with older people, the indirect impact of the pandemic is almost as concerning. The prolonged period of lockdown has caused isolation and inactivity in many older people and will result in large numbers of older people experiencing deconditioning.

However, our understanding of what is happening to us as we live longer is now much clearer. Additionally, the scope for preventing, or delaying, the disability, dementia and dependence once thought to be the immutable effects of ageing is now recognised, for example in NICE guidance. It is also clear that although older people rightly have access to the best aspects of medical care, this brings with it adverse effects such as inappropriate polypharmacy and hospitalisation. Inappropriate admission or delayed discharge, or both, can result in serious deconditioning, which now needs to be tackled.

In what we might describe as the first cultural revolution, geriatric medicine has revolutionised older people’s healthcare, giving them the right to have the cause of their problems identified and the most appropriate treatment for their condition and their values to be determined and delivered irrespective of their chronological age. We now need a second cultural revolution that realises the potential for preventing major problems by tackling a new set of risk factors including deprivation, isolation and digital exclusion. The BGS is already advocating for change including in the report Healthier for Longer. We also need a new culture based on our understanding of how people can improve their physical and cognitive ability whatever their age and a focus on reconditioning instead of the culture of passive care. However, for consultants in geriatric medicine to realise the vision they need to be actively involved in changing culture, not just within the hospitals as in the first cultural revolution, but also in the whole population they serve.

The NHS structure is constantly evolving with a focus now on systems, partnerships and networks. What is emerging alongside this shift is a system for Living Longer Better, where networks of interested people come together within a population area, united by a common aim to:

• prevent and mitigate isolation
• increase physical ability and fitness and increase healthspan
• promote knowledge and understanding about living better longer among older people and the wider population to counteract the detrimental effects of ageism
• create an environment in which people can fulfil their potential
• support carers better
• minimise and mitigate the effects of deprivation
• reduce the risk of and delay or prevent dementia
• prevent and minimise the effects of disease and multimorbidity
• reduce the risk of a bad death

Locally the system is delivered by networks of healthcare professionals and voluntary agencies serving populations usually determined by the catchment areas of hospitals. How could this experience be scaled up? What is needed is for every department of geriatric medicine not only to be a key node in each network but to have at least one consultant with at least one and preferably two sessions a week to focus on the whole population of older people in their area. They would ideally be included in the set of people representing the key agencies that would provide the leadership for the network. They would have the autonomy to engage with colleagues not only in general practice, mental health and social services but also with Age UK, the Sport England Active Partnerships and a network of other players who have a tremendous contribution to make to helping people live healthier longer.

This activity could be called Population Geriatrics, reflecting the new focus of the NHS England, which even before Covid was expressed in Health Education England’s 2020 report on the Future Doctor. This emphasises that “Future Doctors will learn, while embedded in their local community, to better understand population needs and use resources optimally to improve the physical, mental and social wellbeing of the whole population. They will embrace a culture of stewardship and a sense of community responsibility”. Consultants in geriatric medicine, among others, are already doing this and the action will take many different forms reflecting local history, geography, need, and characteristics.

It is clear that physical, cognitive and emotional wellbeing can be improved and the need for social care can be reduced but a cultural revolution is needed and consultants in geriatric medicine, both nationally and locally, have a very important contribution to make.

Do you agree with this approach? Disagree? Would you like the opportunity to discuss this further with Sir Muir and other colleagues? Get in touch via communications [at] bgs [dot] org [dot] uk