ArticlePDF Available
BRITISH
MEDICAL
JOURNAL
VOLUME
284
TALKING
POINT
A
new
form
of
community
hospital
service
for
the
elderly
D
L
BEALES
The
implications
of
the
Short
Report'
on
medical
education
are
slowly
being
appreciated.
The
main
problem
of
a
distorted
career
structure
and
surfeit
of
junior
hospital
staff
has
existed
for
many
years,
whereas
mandatory
training
for
general
practice2
and
the
increasing
competition
for
three-year
vocational
training
posts
are
relatively
recent
phenomena.
The
Short
Report
recommends
that
the
hospital
practitioner
grade
should
be
fostered,
but
there
is
much
misgiving
about
whether
the
main
recommendation,
which
would
mean
a
large
increase
in
consultant
posts,
can
be
in
the
long-term
interest
of
the
Health
Service.
Perhaps
a
new
partnership
between
hospital
practitioner
and
consultant
might
be
a
workable
solution
to
this
overloaded
career
ladder.
For
vocationally
trained
general
practitioners
the
pressure
for
practice
vacancies
will
become
more
intense
as
the
numbers
entering
such
schemes
increase
in
parallel
with
the
growing
output
from
medical
schools.
It
would
therefore
seem
logical
for
doctors
in
vocational
training
to
expand
a
special
interest
to
a
registrar
equivalent
or
hospital
practitioner
level.
This
would
be
particularly
appropriate
in
specialties
where
patients'
psychological
and
social
requirements
need
to
be
assessed
and
where
the
general
practitioner's
special
skills
and
knowledge
relating
to
the
community
may
be
used
to
the
full.
This
paper
describes
a
service
to
the
elderly
where
co-operation
between
hospital
and
consultant
has
led
to
considerably
improved
efficiency
and
a
service
able
to
respond
to
the
patients'
needs
in
a
defined
community.
In
Cirencester
the
general
practitioners
take,
as
hospital
practitioner
or
clinical
assistant,
an
intermediate
role
as
registrar
equivalent
at
the
Memorial
and
Querns
Hospitals.
These
two
hospitals
cover
a
population
of
about
45
000
with
18°'
aged
over
65
and
7'",
over
75.
The
nearest
district
general
hospital
is
16
miles
away,
and
Cirencester
is
the
market
town
for
the
predominantly
rural
area.
The
Memorial
Hospital,
with
62
beds,
has
a
complement
of
three
SHOs,
part
of
the
general
practitioner
vocational
training
scheme.
Though
the
beds
are
consultant-
designated,
all
the
work
at
registrar
level
is
carried
out
by
general
practitioners.
This
linkage
of
general
practitioners
in
all
specialties
means
that
close
relations
are
maintained
between
consultants,
general
practitioners,
and
SHOs
with
benefit
to
all.
When
the
SHOs
move
into
the
community
to
do
their
trainee
year
they
have
already
begun
to
form
a
liaison
between
the
hospital
and
the
local
community.
Policy
At
the
Querns
Geriatric
Hospital,
with
68
beds,
built
to
an
Oxford
design
in
1975,
there
are
two
two-person
teams
of
GPs,
"on
take"
alternate
days
and
weekends.
One
doctor
has
responsibility
for
continuity
of
care
to
patients
in
half
the
beds
of
the
unit.
On-call
cover
coincides
with
days
on
for
the
practice.
Patients
admitted
"on
take"
remain
the
responsibility
of
the
admitting
team
throughout
their
stay
in
hospital.
Each
patient
is
carefully
investigated,
and
there
is
full
access
to
pathology
and
radiology
services
at
the
Memorial
Hospital.
One
of
the
general
practitioners
has
undergone
special
training
in
gastroscopy,
and
a
consultant
opinion
in
other
specialties
is
readily
obtainable.
The
consultant
geriatrician
attends
the
hospital
and
is
available
to
give
an
opinion
on
any
admission
but
does
not
play
an
executive
role.
Weekly
case
conferences
are
held
in
which
all
those
concerned
in
treatment
meet,
with
patients
and
relatives
often
taking
part
in
discussions
of
aims.
Regular
attenders
are
the
sisters
and
nursing
staff,
together
with
occupational
therapists,
physio-
therapists,
and
a
social
worker.
Visitors
may
include
home
help
organisers,
the
patient's
own
GP,
the
district
nurse,
the
domiciliary
occupational
therapist,
and
the
pharmacist.
The
advantage
of
having
one
doctor
co-ordinating
these
multi-
disciplinary
case
conferences
is
that
he
is
able
to
bring
patients
forward
for
discussion
at
the
right
time.
One
doctor,
therefore,
has
an
overall
view
of
all
the
patients
in
his
ward.
It
would
be
difficult
for
all
the
GPs
in
this
area,
now
numbering
22,
to
look
after
their
own
patients
in
the
hospital.
The
case
conference
system
of
review
would
then
be
immensely
complicated,
and
not
all
general
practitioners
wish
to
take
a
special
interest
in
the
elderly.
The
emphasis
is
on
rehabilitation,
and
a
close
relation
exists
with
the
staff
responsible
for
general
medical
beds
at
the
Memorial
Hospital.
Patients
are
transferred
at
an
early
stage
if
they
require
extended
rehabilitation
and
resettle-
ment.
The
senior
house
officer
at
the
Memorial
Hospital
attends
our
case
conferences.
Since
the
full
implementation
of
these
policies
our
admission
rate
has
increased
by
more
than
one-third
(figure;
table).
Any
patient
discharged
for
follow-up
in
the
Querns
Day
Hospital
is
delegated
to
another
two-man
GP
team,
who
also
hold
regular
multidisciplinary
case
conferences.
Jones
and
Ramaiah
have
described
a
similar
effective
use
of
a
day
hospital
co-ordinated
by
general
practitioners.3
Numbers
of
admissions,
discharges,
and
deaths
of
geriatric
patients
at
Querns
Hospital
1978-81
1978
1979
1980
1981
Admissions
280 304
282
466
Discharges
197
206
221
341
Deaths
88
96
66
120
Discussion
Participation
by
general
practitioners
can
offer
advantages
over
the
traditional
hospital-based,
career-centred
approach to
staffing
units.
The
links
between
general
practitioners
and
the
geriatric
consultant
make
this
hospital
an
ideal
introduction
to
the
concepts
of
geriatric
care
for
doctors
in
GP
vocational
training
schemes.
Our
opinion
is
that
most
patients
do
not
need
the
full
facilities
of
the
district
general
hospital;
selected
patients
are
transferred
if
necessary
and
prompt
return
ensured.
The
real
advantage
of
this
arrangement
accrues
from
the
presence
of
an
active
unit
serving
its
own
local
population
and
concentrating
its
efforts
on
the
team
approach
to
rehabilitation
and
resettlement
Cirencester,
Glos
GL7
lYX
D
L
BEALES,
MRCP,
MRCGP,
general
practitioner
840
13
MARCH
1982
BRITISH
MEDICAL
JOURNAL
VOLUME
284
13
MARCH
1982
841
in
the
community.
Relatives
or
appropriate
support
can
be
brought
in
at
an
early
stage
after
admission,
and
the
patient
does
not
suffer
separation
from
his
"natural
area."
This
may
be
a
key
factor
in
reducing
the
demand
for
long-stay
or
residential
care.
Thus
there
is
an
early
dialogue
between
community
and
staff
familiar
with
local
resources
and
sources
of
help.
Day
visits
and
shared
care
with
relatives
for
patients
with
stroke
can
be
planned
almost
from
the
first
day
of
admission.
Evidence
suggests
that
the
long-term
benefit
of
stroke
rehabilitation
in
a
specialised
unit
is
lost
with
time.4
We
think
that
part
of
this
loss
of
effectiveness
is
the
breaking
of
links
between
hospital
and
home
and
the
time
it
takes
for
patients
to
reacclimatise
when
discharge
comes.
If
relatives
are
actively
concerned
in
the
rehabilitation
process
and
supported
through
their
initial
sense
of
shock
and
panic-often
followed
by
mixed
emotions
of
anger,
guilt,
and
depression-the
staff,
relatives,
and
patients
can
work
together.
If
there
is
a
genuine
need
for
residential
care
or
long-term
care
then
this
will
become
apparent
to
the
relatives,
who
may
accept
it
more
readily
because
they
have
been
taken
into
the
doctors'
confidence.
It
is
not
then
seen
as
abandonment,
and
relatives
or
the
community
can
then
work
together
positively.
We
think
that
we
can
most
effectively
prevent
patients
needing
this
very
expensive
form
of
care
by
concentrating
rehabilitation
and
the
range
of
health
and
support
systems
close
to
the
patient
and
his
community.
This
policy
differs
from
the
recommendations
of
the
British
Geriatric
Society'
given
in
its
answer
to
the
Royal
Commission
on
the
National
Health
Service.6
The
Society's
suggestion
was
that
an
eventual
target
of
half
of
district
general
hospital
beds
was
appropriate
for
the
elderly.
Our
experience
seems
to
show
that
these
poilcies
can
be
made
flexible
and
so
take
account
of
the
natural
boundaries
of
small
communities.
In
our
area
there
have
been
considerable
gains
from
concentrating
a
com-
prehensive
geriatric
service
co-ordinated
by
general
practitioners
with
a
special
interest
in
the
subject
in
a
relatively
small
unit.
If
the
system
described
here
has
been
applied
successfully
in
other
areas
then
it
is
probably
opportune
to
consider
its
more
general
adoption
throughout
peripheral
hospitals
in
the
country.
Apart
from
the
benefit
the
elderly
derive
from
closer
participation
with
general
practitioners,
this
enlarged
range
of
practitioner
activity
would
inevitably
increase
the
scope
of
general
practice.
Furthermore,
the
problems
besetting
medical
training
in
50
0't
40
^E
401
Change
of
regimen
0
30P\
c
10"
La
E
~20
0
0
z
10.
0
1*
Dec
1978
Dec
1979
Oct
Dec
1980
Dec
1981
Admissions
to
Querns
Geriatric
Unit,
Decemnber
1978
to
December
1981.
hospitals
at
present
might
well
be
alleviated
by
the
intervention
of
general
practitioners
and
trainees
in
this
sector
of
hospital
care.
I
thank
Dr
William
Wright
and
Dr
John
Grove-White
for
their
help
in
preparing
this
paper.
References
I
Social
Services
Committee.
Medical
education
with
special
reference
to
the
number
of
doctors
and
the
career
structure
in
hospitals.
Fourth
report.
London:
HMSO,
1981.
(Short
Report.)
2
Department
of
Health
and
Social
Security.
Vocational
training
for
general
practice:
the
National
Health
Service
(Vocational
Training)
Regulations
1979.
Statutory
Instrument
1644.
London:
HMSO,
1979.
3Jones
DT,
Ramaiah
RS.
Day
hospital
care
by
general
practitioners.
Br
Med
J7
1981;283:1441-2.
4Garraway
WM,
Akhtar
AJ,
Hockey
L,
Prescott
RJ.
Management
of
acute
stroke
in
the
elderly.
Br
MedJ7
1980;281:827-9.
5British
Geriatrics
Society.
Report.
London:
British
Geriatrics
Society,
March
1981.
6
Royal
Commission
on
the
National
Health
Service.
Report.
Cmnd
7615.
London:
HMSO,
1979.
(Accepted
2
March
1982)
From
the
Council-continuedfrom
page
839
should
not
be
supported
just
because
he
was
a
BMA
member.
It
was
more
important
to
take
note
of
what
people
stood
for.
The
BMA
had
failed
last
time
because
of
the
success
of
the
pressure
groups
and
a
lack
of
proper
publicity.
The
Association
should
put
up
a
slate
of
candidates,
but
it
had
to
have
a
policy
and
greater
publicity
was
needed,
particularly
in
the
BM7.
He
would
support
candidates
who
favoured
a
more
careful
selection
of
medical
students
and
the
production
of
clinically
mature
doctors,
looked
after
the
interest
of
patients,
and
opposed
the
control
of
the
GMC
by
the
DHSS.
The
junior
doctors
could
have
swamped
the
GMC
if
they
had
voted
for
each
other,
Dr
Arnold
Elliott
claimed,
but
they
had,
he
thought,
voted
for
their
professors
and
so
a
large
number
of
academic
staff
were
elected
to
the
council.
In
Dr
John
Noble's
view
the
BMA-
sponsored
candidates
were
not
elected
because
the
divisional
and
regional
structures
were
weak.
He
criticised
the
single
transferable
vote
system
as
an
abomination
and
opposed
the
idea
of
BMA
leaders
standing
for
the
GMC.
The
minority
groups,
including
the
academic
staff,
had
been
successful,
Dr
Mary
White
said,
because
they
had
been
better
disciplined,
whereas
the
BMA
candidates
had
fought
each
other.
There
had
not
been
enough
publicity.
She
thought
that
the
Council
ought
to
be
able
to
select
more
than
11
candidates;
there
ought
to
be
a
few
extra
ones
for
the
Council
to
use
as
it
thought
fit.
The
chairman
of
the
GMC
Working
Group,
Dr
Brian
Lewis,
pointed
out
that
if
the
BMA
leaders
did
not
stand
then
the
leaders
of
other
organisations
would
get
on
the
GMC.
The
important
thing
was
to
educate
members
in
the
use
of
the
single
transferable
vote
system.
The
Council
agreed
to
recommend
the
sponsorship
scheme
to
the
Representative
Body
for
approval.
NHS
London
Weighting
increased
Agreement
has
been
reached
on
London
Weighting
allowances
in
the
NHS
for
1981,
backdated
to
1
July
1981.
Non
resident
Resident
staff
staff
London
zone
C722
(from
£200
(from
£679)
£189)
Extraterritorially
managed
and
£527
(no
£147
(no
contiguous
units
change)
change)
Fringe
zone
£149
(from
£38
(from
£L141)
£36)
Doctors
are
entitled
to
claim
their
back
pay
and
should
contact
their
former
employing
authority
if
the
authority
has
not
contacted
them.
Negotiations
are
now
taking
place
for
the
1982
settlement
due
in
July.
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Article
Follow-up of a controlled trial of the management of acute stroke in the elderly showed that the improvement in functional outcome at the time of discharge from hospital that had been achieved through establishing a stroke unit had disappeared by one year. Factors that might have contributed to this included overprotection by the families of patients who had been treated in the stroke unit, who were not permitted to carry out activities of daily living in which they were independent, and the early discharge from medical units of patients whose full rehabilitation potential had not been realised. Prolonging the benefits of short-term gains in functional outcome through the intervention of a stroke unit requires that all the links in the chain of stroke rehabilitation are maintained, including the proper orientation of patients' families before discharge from hospital.
Medical education with special reference to the number of doctors and the career structure in hospitals. Fourth report
  • I Social Services Committee
I Social Services Committee. Medical education with special reference to the number of doctors and the career structure in hospitals. Fourth report. London: HMSO, 1981. (Short Report.)
Vocational training for general practice: the National Health Service (Vocational Training) Regulations 1979. Statutory Instrument 1644. London: HMSO, 1979. 3Jones DT, Ramaiah RS. Day hospital care by general practitioners
Department of Health and Social Security. Vocational training for general practice: the National Health Service (Vocational Training) Regulations 1979. Statutory Instrument 1644. London: HMSO, 1979. 3Jones DT, Ramaiah RS. Day hospital care by general practitioners. Br Med J7 1981;283:1441-2.
Medical education with special reference to the number of doctors and the career structure in hospitals
I Social Services Committee. Medical education with special reference to the number of doctors and the career structure in hospitals. Fourth report. London: HMSO, 1981. (Short Report.)
National Health Service. Report. Cmnd 7615
  • on the, Royal Commission
Social Security. Vocational training for general practice: the National Health Service (Vocational Training) Regulations 1979. Statutory Instrument 1644
  • Department of Health and