BGS Scotland

In Memoriam – Brian Chapman

Former Consultant Geriatrician and Acute Physician, Royal Infirmary, Edinburgh (b 28th January 1956; q Edinburgh 1981; FRCPE) died from metastatic renal cancer on 9th February 2012.

Brian Chapman died peacefully at home on Thursday 9th February after a long battle against renal cancer.

Born in Edinburgh, he attended Daniel Stewart’s School where he was Dux, and then entered Medical School at the University of Edinburgh. There he met his wife Dorothy and they spent a memorable student elective in South Africa, narrowly avoiding being charged by an elephant. They became engaged on their return and he qualified BSc (2.1 in Biochemistry) and MB ChB in 1981.

After house jobs, he was appointed to a senior house officer rotation in Edinburgh and initially explored a career in Respiratory Medicine. However, after diagnosing an elderly patient attending a Respiratory Clinic with Parkinson’s Disease, he came to the attention of Roger Smith, a Senior Lecturer in Geriatric Medicine who persuaded him to apply for a post in the specialty. Brian’s subsequent contribution has been immense.

After training posts at the City and Longmore Hospitals in Edinburgh, Brian became the first Consultant Physician in Geriatric and Acute Medicine at the Royal Infirmary of Edinburgh in 1989. At that time, Geriatric Medicine was regarded with deep suspicion by many of those in other specialties.  However Brian quickly gained the respect of his specialty colleagues due to his superb clinical skills both within the specialty and on Acute Receiving.  He became the Clinical Director of Medicine of the Elderly services in 1996 and under his leadership, the specialty became the largest in the hospital, and he also set up an Acute Stroke service. That he achieved this without alienating the other specialties is a tribute to his outstanding negotiating skills and the respect in which he was held. He worked tirelessly on endless committees and working groups to put the case for services for older people at a national and local level and contributed enormously to the expansion of Geriatric services across Edinburgh. He inspired many trainees to join the specialty along the way, and was a mentor to many consultant colleagues. His advice was always consistent, considered and invariably sound. Colleagues in all specialties sought out his clinical opinion and frequently asked him to care for their older relatives. He gave his time freely to patients, their families and colleagues in need.

He also found time to contribute as Chair of the Symposium Committee of the Royal College of Physicians of Edinburgh, was a regular Host Examiner in the PACES exam and latterly Assistant Registrar of the College. He was a recent Secretary and Treasurer of the Scottish Branch of the British Geriatrics Society, and was awarded the President’s Medal by the British Geriatrics Society in 2010. He also worked as Principal Medical Officer at Scottish Widows.

He was devoted to his family and enjoyed travelling the world with them on holiday. He enjoyed many sports but was a rugby fanatic, managing to land the job of ‘Crowd Doctor’ at the Scotland rugby international games at Murrayfield.  He was very active within his Church, contributing as Session Clerk for a long period. Latterly he developed an interest in contemporary Scottish art.

In 2006, he was diagnosed with renal cancer. He accepted this with equanimity and was remarkable for the open and dignified way in which he dealt with the many adversities that subsequently befell him.  He drew great comfort from his faith. He continued working despite considerable pain and fatigue until he was forced to take early retirement in 2010. It is a tribute to him that so many colleagues continued to visit and share current issues – his advice continued to be relevant and considered. This advice continues to guide others charged with developing future Medicine of the Elderly services in Edinburgh.

He is survived by Dorothy, and his children Fiona, Andrew (both Foundation Doctors) and Gavin (a medical student). He was immensely proud of their achievements. He will be greatly missed by his colleagues throughout Scotland.

 

Annual Report of BGS Scotland – 2011/12

The Scottish Council has met formally on 3 occasions over the last year – with an increasing proportion of BGS Scotland’s business being done by e-mail.  

Meetings – The past 12 months have seen 3 successful BGS Scotland meetings.  A special one day meeting on “Community Geriatrics” took place at the Royal College of Physicians and Surgeons of Glasgow in June 2011.   This event masterminded by Dr Brendan Martin was highly successful with thought-provoking challenges identified for our speciality.  The Autumn meeting held at the Royal College in Edinburgh had almost 100 delegates and included a high quality CPD session on orthogeriatrics.  Today’s Spring Meeting in Fife continues the flavour of high quality Scottish meetings – with specific CPD focus on delirium and cognition. As the NHS in the 4 nations continues to diverge it is crucial that our speciality maintains its regular Scottish meetings to highlight service developments and promote networking of new ideas.  The trend to incorporating a high quality CPD session on a specific topic within the meetings is a welcome development.

Health Service Initiatives – BGS Scotland has continued to engage, to a degree, with “Reshaping Care for Older People”.  This government policy has multiple strands and we have representation on several of the more relevant ones – including their stakeholder group, care home group and the polypharmacy group.  The overall strategy is liked to “Change Fund” developments – designed to try to shift care from secondary to primary care.  The “Change Fund” finances have had a patchy impact for the speciality – with new consultant posts or sessions funded by some areas – but little or no impact in other regions.  The “Reshaping Care for Older People” meetings appear to have diminished in the last year – perhaps effected by the Scottish elections and subsequent review of policies by the new government has been disappointing.  The other important initiative in the last year has been “Improving Care for Older People in hospital”.  This was triggered by several adverse reports of care in 2011.  The Cabinet Secretary ordered a programme of visits to acute hospitals to reassure the public that elder care in all departments of our hospitals is at the required standard.  The visits started in November 2011 and are ongoing.  The visitors are focussing on direct “hands on” care – with specific interest in capacity, cognition, delirium, medicines management, and falls assessment.  BGS Scotland had representation on the Stakeholder Reference Group and is taking up a seat on the longer term Stakeholder Review Group.  The latter group is intended to review the results of the visits and recommend areas for improvement.

Training – Geriatric Medicine’s establishment remains unchanged after last years review by Scottish Government – with up to 85 trainees permitted across the country.  The speciality continues to attract high calibre doctors from core medicine with 31 applicants for the 13 ST3 post this year.  Overall trainee satisfaction as judged by the GMC survey remains high.  The Scottish Trainee meeting was held in Perth and was deemed to be very successful.  Trainees continue to gain consultant posts relatively easily on gaining their CCT – although there continue to be concerns over a “bulge” of trainees in the next couple of years.  Both junior representatives on Scottish Council demitted office during the last year (Dr Claire Steel and Dr Jo Ford) – our thanks for all their efforts and good wishes for their future career.  The 2 new representatives on Council are Dr Sarah Alder and Dr Zoe Muir.  In order to protect the training establishment, it is crucial that BGS Scotland maintain an accurate database of our consultant establishment, existing vacancies, and future developments.  Please respond to the periodic requests for information in this area.

UK Perspective – Everybody should be aware of the substantial changes to the UK governance structure of the British Geriatric Society – as suggested by President Elect, Prof Paul Knight.  The Chair of Scottish Council remains part of the new Trustee Board.  The new Executive Board, where much of the regular business will be done, has no formal regional representation.  Most positions on the Executive Board will be appointed using a UK recruitment process based on merit.  The Trustee Board is responsible for overseeing the Executive Board. Scotland will have a strong position in the near future, when Prof Knight takes on the Presidency.

Finances – Finances remain healthy with autumn and spring meetings continuing to generate a profit.  However, engaging the pharmaceutical industry is becoming more challenging.  The costs of Council meetings have fallen due to their reduced frequency.

Congratulation – This year has seen a very large number of new consultant appointments – these included Claire McKay (Hairmyres), Laura Peacock (Hairmyres), Alison Craig (Monklands), Sarah Coutts (Edinburgh Royal), Susan Shenkin (Liberton), Rachael Murphy (Edinburgh Royal), Claire Copeland (Crosshouse), Elizabeth Kean (Fife), Marie Williams (Fife), James Shaw (Tayside), Deepa Sumukadas (Tayside) and Dirk Habicht (Perth).

We awarded several prizes over the year.  Dr Louise Burton won the Kate Johnston Prize.  Mr Jim Zhong won the prize for the Ferguson Anderson essay.  Dr Andrew Breckinbridge won the EBM prize and Dr Eilidh Hill won the Taylor Brown prize.

Acknowledgements – I am now finishing my 2 year period as Chair of BGS Scotland and I would like to acknowledge the assistance of every one on the Scottish Council over this period.  The Officer Bearers – Dr Sandip Ghosh, Dr Brendan Martin and Dr Stuart Johnston have worked diligently to support and enhance the aims of the Society.  I wish Dr Martin and Dr Johnston well for the next 2 years.

 

Spring BGS (Scotland) Meeting

The spring scientific meeting of the Scottish British Geriatrics Society was held in April in the Queensferry Hotel in Fife. The views across the Firth of Forth provided a beautiful background to what proved to be an educational and inspiring event.

The meeting commenced with an evening symposium entitled ‘An Inspector Calls’, with Ros Moore (Chief Nursing Officer), Hugh Masters (Policy Lead for Older People) and Donald Lyons (Chief Executive of the Mental Welfare Commission) providing an insight into current and future initiatives to improve healthcare services for older people in Scotland. This included an overview of current programmes including ‘Re-shaping Care for Older People’, Health Improvement Scotland’s ‘Standards of Care for Dementia in Scotland’ and forthcoming inspections focussing particularly on nutrition, falls, pressure care and assessment of capacity. This provoked a lively debate regarding how these initiatives can best be met given the current challenges of limited available resources.

The following day, the first session focussed on delirium starting with an excellent talk from visiting Dutch Professor Sophia de Rooij to share her ongoing studies into the pathophysiology of delirium. Areas of research include use of bedside wrist worn sensors to measure patients’ movements (with disruption of normal circadian patterns), use of diagnostic rating scales and increased serum biomarkers such as IL6 and 8. An intriguing area of interest is in the role of melatonin in both delirium treatment and prevention. This was followed by an outline of Dr. Andrew Teodorczuk’s qualititative research into delirium education. His vivid patient video describing the experience of delirium is available for all to use on the internet as an educational tool, and his work has resulted in delirium becoming a local Trust priority in his area. To conclude this session, two audits were then presented, the first from an FY1 outlining how implementation of a standardised treatment plan has improved their completion of AWI, the second looking at whether elderly patients would like copies of their clinical letters (in line with DOH good practice guidelines). The majority of surveyed patients were in favour, although this provoked much division of opinion amongst the audience.

The next session on Geriatric medicine and cognition began with an overview of vascular cognitive impairment and its relation to small vessel disease (SVD). With data from the PROGRESS trial, perhaps in patients with clinical evidence of SVD (including cognitive impairment), there is benefit in treating vascular risk factors although the aims of treatment are unclear. This was followed by an excellent overview of the ‘Cholinergic Effect of Medication’, outlining how a higher score on the Anti-cholinergic Cognitive Burden (ACB) scale relates to an increased risk of cognitive impairment and mortality. Current evidence suggests that prolonged use of drugs with significant anti-cholinergic burden (beyond sixty days) is more likely to have a lasting impact on cognitive function. There is an update of the ACB drug scale in progress.

The afternoon session started with a series of talks on the oldest old. The first presentation looked at multi-morbidity, expansion of this population group and the survivor effect. This led to excellent discussion about geriatric medicine being very little to do with age and everything to do with frailty and comorbidity. There was an interesting discussion about the risk of even geriatricians exhibiting paternalism toward the oldest old. There was then an excellent trainee presentation from the Northern Deanery looking at their oldest old and indeed a very clear case study highlighting the survivor effect and high functionality at extreme old age with limited comorbidity.

Dr Martin Wilson from Inverness entertained us all with a clear, precise and astute talk on pragmatic prescribing in the elderly. Given that an estimated 25% of older adult acute hospital admissions are felt due to adverse drug events topics such as this can never be covered enough.

The penultimate talk from Dr. A Breckinbridge, winner of the best presentation at the trainee Evidence Based Medicine day in Glasgow, outlining the evidence behind treatment of HIV infection in patients aged over 65. This is of increasing relevance as it is estimated that by 2015, half of those with HIV will be over the age of 50.

The day was concluded with a talk from Michael Matheson, the MSP Minister for Public Health, outlining the Public Health strategy plans for increasing longevity. Following on from the publication in June 2011 of the Standards of Care for Dementia in Scotland, a consultation document will be coming out in May 2012 addressing integration of health and social care. Looking to the future, he outlined a government proposal that from 2013, all those post diagnosis of dementia will receive at least a year of formal support – further details will surely follow.

With many thanks to Professor Reynish and colleagues from Fife for organising a very enjoyable and successful BGS Spring meeting.

Jane Rimer

Trainees Update

 

The annual Evidenced Based Medicine day has recently taken place at the RCPSG.  This year a cash prize as well as the chance to present at the BGS meeting in Fife was up for grabs.  Competition was tight with 8 trainees presenting topics from cost effectiveness of Dabigatran for stroke prevention in AF to the use of “early warning scores” in the elderly.  The prize was won by Dr Andrew Breckenridge, ST5 in the West of Scotland, for “What is the evidence for the treatment of HIV infection in patients aged over 65?”  A number of presenters converted their reviews to posters for the recent BGS meeting in Fife.  The EBM day is held annually in Glasgow in the Spring and the prize will continue to be sponsored by BGS Scotland.

Our annual trainees meeting will be held on the 14th September 2012 in the Queens Hotel, Perth.  The programme is now complete so please keep a note of the date.  We will be looking to elect a new trainee representative at this meeting – please get in touch if you would like to consider standing for this.

Please be aware of the Start-up Grants offered the Scottish BGS branch to support research in Geriatric Medicine. They are intended to provide immediate financial assistance to support new (sometimes a pilot project) research that may not yet be developed sufficiently to warrant support from other sources. Grants up to the value of £2000 will be supported.  The application process is described on our website under the Trainees/Research section.  Jo Ford has now gone on maternity leave before moving to a Consultant post in Norwich.  Many thanks for all her hard work over the last 2 years.  She will hopefully return for the trainees meeting in September.

Zoe Muir zoe.muir@nhs.net and Sarah Alder sarah.alder@nhs.net

 

Ferguson Anderson Prize – 2011

The Ferguson Anderson Prize is awarded annually, and offers 3 prizes of £300, £200 and £100 to medical students studying at Scottish Universities for an essay covering any topic relating to ageing or care of older people. The essay must not exceed 2500 words, excluding references.

Prize winners this year were 1. Jim Zhong 2.Laura Hughes and 3 Carys Morrison.

Jim’s winning essay was entitled ‘The difficulties of care in Alzheimer’s Disease: a student’s perspective’. Congratulations to him and to everyone who entered last year. For 2012 we are changing the entry qualifications slightly. BGS Council is aware that a lot of students do work together in groups during their training period, so for 2012 we will accept a group entry as well as pieces of work from individuals. Please see our website for more details.

The National Institute of Health Research

The National Institute of Health Research (NIHR) has set up a series of clinical research networks and specialty groups. The UK Age and Ageing specialty group is chaired by Professor Marion McMurdo, and offers specialist advice and guidance to assist with the delivery of research studies.  

The aim of the UK Age and Ageing specialty group is to bring together researchers from across disciplines, to foster new collaborations, to signpost researchers and clinicians to sources of NHS support for research and to stimulate the development of high quality ageing research proposals which will lead to improvements in the care of older patients. In addition, the group oversees the NIHR portfolio of clinical studies, monitors recruitment to studies, and helps researchers overcome barriers to research.

Each of the devolved nations and each region in England has its own lead clinician. Dr Gillian Mead was appointed as Scottish Lead for the Group in September 2010, and Dr Carolyn Greig was appointed as scientific coordinator.  We held our inaugural meeting in January 2011. Our speakers included internationally recognised experts, who provided a most stimulating series of talks, focusing on key areas for new research, including falls, incontinence and delirium.

Since the launch meeting in January 2011, members of the Scottish group have been successful in obtaining substantial grant funding for new studies. The size of the NIHR portfolio has increased; there are now 23 Scottish studies listed on the portfolio.  We are delighted to report that we now have over 250 members in Scotland which represents a critical mass of researchers and clinicians committed to improving the health and well being of older people through research.

We held our second annual meeting in Dundee in January 2012, which was hosted by Professor Marion McMurdo. It was attended by over forty delegates, including researchers from Taiwan and China, who are currently studying in Scotland.

The focus of the meeting was a stimulating set of excellent lectures delivered by leading researchers in their respective field. Professor David Stott explained how to obtain European funding for a large clinical trial, Professor Peter Davey described how to use routinely collected clinical data for clinical research, Dr Helen Frost discussed the evidence for interventions to prevent functional decline in older people-including exercise, comprehensive geriatric assessment and telecare, and Professor Martin Dennis explained how to obtain funding from the NIHR Health Technology Assessment for large clinical trials. Dr Miles Witham, Ms Caroline Brett and Dr Susan Shenkin described their exciting new research projects.

Over the forthcoming year, the group in Scotland will continue its work of supporting Scottish researchers, and overseeing the portfolio of Age and Ageing studies. It is becoming increasing important that patient recruitment is recorded monthly on the portfolio-the Scottish Lead and Scientific Coordinator will provide any necessary advice and support to researchers to help ensure accurate and timely ‘accrual’ data.  The Group wants to develop research utilising existing clinical data through data linkage, and continue to develop new research on delirium.

The group would welcome new members, particularly NHS clinicians with an interest in research to improve the care of older people. Currently only a small proportion of older patients admitted to hospital are given the opportunity to participate in clinical research; this is one thing that we would like to change.

We believe that there is enormous potential to build on existing expertise in ageing research in Scotland. If you want to improve the care of older people through research, we would be delighted to hear from you, and we would welcome new members to our group. Membership of the group allows access to a password protected site which currently includes a list of other researchers interested in ageing, as well as the excellent presentations from our January meeting.

For further information please contact mhardin1@staffmail.ed.ac.uk, Dr Gillian Mead (gmead@staffmail.ed.ac.uk) and Dr Carolyn Greig (cal.greig@ed.ac.uk).

Older People in Acute Care – the Inspection Process

As detailed in the last newsletter by Donald Farquhar, Health Improvement Scotland has been tasked with carrying out a programme of inspections of acute care across the country. Their remit was to drive improvement in care of older people and provide public assurance that NHS Scotland was treating the elderly with respect, compassion, dignity and care that they deserved. The inspections will take into account some of the standards assessed in 2002 by the Clinical Standards Board in their document, “Older People in Acute Care”. The standards have been revamped to take into account recent areas of concern such as medicines management, pressure care, nutrition, falls assessment, delirium and dementia.

Many of you will have been, or are about to be, visited by an inspection team for the new process looking at the care of older patients in the acute hospital environment. Perth Royal Infirmary, as part of NHS Tayside was one of the first to be visited back in early December last year. I thought it would be useful to reflect on the process and the positive view that although such visits have their faults and problems, they are useful for our key aim of improving the quality of care to our vulnerable patient group. Before the visit the board had received and returned a self assessment form that was long and filled in mainly by managerial staff with very little clinical input by medical teams. The visiting team was not made up of medically qualified personal, so there was a need to make sure that the visitors had the opportunity to meet senior medical staff – I suspect that ensuring such interactions take place will vary from hospital to hospital and from board region to board region across Scotland. Certainly in Tayside there was a continual need to ensure a loud and clear voice from appropriate Consultants on the pre visit work up as well as on the day of visit. The inspectors were primarily focussed on the issues of dignity in the ward areas, aspects of nutrition and meal times, the identification and care delivered to patients with cognitive impairment and the management of falls assessment.  They spent time talking to various staff groups and to patients and relatives in all the ward areas including acute receiving areas, mainstream medical wards, surgical and orthopaedic wards as well as geriatric assessment and stroke units. The visit lasted 2 days and then the visiting team met the senior managerial staff and gave initial feedback before the written report to follow later.

Much of what the inspecting team commented upon was expected and the hospital staff was prepared for most of the raised issues. Eg concerning the management of delirium and dementia there was attention brought to the need to improve signage and some of ward environment. The was much attention paid to how we could enhance the delivery of nutritional support to patients – with suggestions for 24 hour availability of snacks for patients and the need to have catering staff much more visible on the ward areas. Some of us are old enough to remember the 24 hour toast, tea and snack service in our wards of not too long ago! Issues around dignity were rightly highlighted where and when necessary. The visit did cause a lot of stress on our managerial colleagues, but it was a shade disappointing that, at least with this visit, more was not made by the inspecting team to analyse the ‘medical’ component of the care of frail elderly patients. No attempt was made to inspect either case notes or drug charts, and I suspect this was due to the backgrounds of the inspecting team and the very rapid manner in which the whole process was undertaken. Perhaps as the inspection process matures there will be opportunity to develop inspection tools that will carry more weight to the process. We wait and see.