First

In my life there have not been many occasions where I have come first.

Sure, I have done well sometimes, but rarely first.

First suggests sometimes the best. It can also allude to novelty – the first step on the moon comes to mind; it is hard to say whether that was the best step on to the moon, but, certainly, no one had ever done it before.

Here I am talking first in the Armstrong sense, rather than any kind of aspirational, ‘could do better’ as has so often been my experience.

I am writing this in the shadow of my recent blog about tigers and their traps. I thought I would try to be a little less abstruse for those who prefer a more concrete approach.

As you can see, I have not gotten-off to the best start.

I am also keen that this blog gets published by the British Geriatrics Society – as with the Q-Community I haven’t had any success so far, although for the Q, moaning seems to have proven a winning strategy. Thank you.

Anyway.

An abridged version of where I am for those of you who haven’t yet given-up with the introduction;

I am, to the best of my knowledge, the first physician in the UK who has taken his frustrations with secondary care not into management or leadership, but into the community.

Many will be familiar with the sub-specialism Community Geriatrics – this refers to a specialist (Geriatrician – doctor, nurse or therapist) working in the care of older people who is principally employed by a primary or secondary care trust (aka big NHS bureaucracy) who spends some or occasionally all their time supporting patients in the community – that is, not in acute hospital beds or clinics.

This has been a fantastic development over the past decade or so and helps maintain many frail, older people in the community, out of hospital.

This is part of my job, but, you see, I wanted more.

I have long realised that most older people are not in hospital or intermediate care facilities; they are out-there – in their own homes, living with children or getting-by in residential and nursing homes.

They are in the community, but not in the community in the sense of hospital specialists, rather, they are sitting at their kitchen table struggling with beans on toast, or negotiating the short distance between front and back room; sometimes making it up to the GP surgery for a check-up, often not.

To see me in hospital or even in the community when I am wearing the badge of ‘community geriatrician’ mostly, something has to go wrong.

The person has to fall, develop pneumonia, struggle to eat, break a bone; some trigger must happen that results either in an acute admission or their GP contacting secondary care and asking, ‘Come out and see xxx’

If you take the entire population of ‘older people’ (an ill-defined group, but you know who they/you are), using this approach we are only meeting the needs of a tiny proportion.

Maybe 10 per cent if we are lucky.

An element between primary and secondary care aka GP and hospital is the requirement for either a referral – ‘Please see’ or an admission. Without this the two groups (old folk who frequently have multiple long-term conditions, frailty, dementia, falls, weight loss) are managed in the community; mostly very well but GPs and their teams but without the focus that someone like me – who you might call a pseudo-specialist can provide.

It is hard as a GP to see patient 1, 18-year-old with acne, patient 2, 35-year-old with bad back, 3, 2-year-old with cough, four, 99-year-old with rash and finally, 28-year-old six-months pregnant. (Within the hour).

Having this breadth of knowledge, ability and experience is phenomenal, but, only in certain circumstances can anyone know lots about everything (the odd polymath excepted).

And what is my first?

Well, I am joining a GP practice as a partner and supporting the older people across that practice area.

So, I am not a GP, I can’t be a GP and I don’ think that is something I would be able to pull-off. (I did apply back in the day to become a GP but was unsuccessful – I guess, you could call me a failed GP with FRCP after my name).

Now, I can call-up a patient and either invite myself into their home or bring them to the surgery on the basis of their medical complexity and perhaps frequent admissions to hospital; I can address polypharmacy and one of the most pressing issues – the creation of Advance Care Plans; these being documents that function to provide the best for our most vulnerable patients, often, supporting them to stay-away and out of A&E departments and admission units.

All of this is a work in progress.

I think this step which I am taking is one which will help liberate others within health and social care to do things differently.

I have met so many doctors who wish they had taken a different course. For those who are young and enthusiastic enough, you can re-train and do something else; for those like me, who actually love what it is they do, but struggle with the context, this is an alternative.

Imagine, you want to work with children, but as a doctor can’t face becoming a paediatrician (exams, relocation, hospital rotations); this could be an alternative. I know many people who enjoy supporting, caring for and treating older people but have opted-out of hospital practice because the idea of organisational life is not what they want; that and the on-calls, and the processing – the obsession with flow, bed capacity, accountability, command and control.

I am not giving-up on hospitals; I just think they need to change, and perhaps this might help them in their transition – in particular, to becoming more person-centred; not just in how they treat their patients, but in the experience of outpatients, relatives, carers and staff.

Small is beautiful. Yet, how do we maintain small in this world of bigger and better? Of mergers and networks? GP practices are facing the biggest change, which some see as a threat in a generation; pressures of workforce and recruitment are driving some to shut, some to become bigger and bigger, with, the risk of the loss of the jewel in the crown of primary care – continuity.

The NHS Long Term Plan seeks to fix this.

I see it more as a cry for help.

This I am hoping to support.

So, I don’t know if I am the first;

Multiple Google searches and conversations with colleagues leave me to think I am, which if the case, cool;

If not, please give me a call; I would love to hear what you are doing, how you are doing.

Here is to the next ten-years of change and growth!

I’ll end with a quick shout-out to some people who have helped keep me going through all of this – Annie, Maisie and the kids, Jane Pightling, Clare Gerada and George Briggs.