The number of people aged over 75 years is set to double in the next ten years and people over the age of 65 years are going to make up the majority of the population. It is a credit to the NHS that the reason we have this problem is that we have a healthcare system that is delivering. However, this ticking time bomb of the elderly population means that we need a debate about how we keep people healthy for as long as possible. Also what happens when they are not healthy.

When I worked in a practice in Tower Hamlets, a very elderly frail lady in a wheelchair came to see me one day with her family. Her only problem was that she was constipated. I went into her records and saw that she was on 17 medications and she had six or seven different comorbidities. Even though I had been practising for over 25 years, I didn’t know what to do to help her. I didn’t know where to start and which of these medications was causing the problem. An elderly care consultant might say start working through the drugs, but the side effects of 17 different medications is a pharmacological stew. By the time you get to five medications, you cannot make any valid predictions.

At the time I was chair of the Royal College of GPs and I was writing the vision for general practice and collecting the evidence for this. This patient made me have a light bulb moment. We might be putting our patients on all these fantastic medications to keep their quantity of life going, but what about their quality of life and those who were caring for the quality of their life such their GPs?

GPs do a lot for elderly patients from admission avoidance, follow up with secondary care, over 75 years health checks, and flu vaccinations. But are elderly patients too complex for a generalist?

When I started my training at University College Hospital, they developed a specialty called neonatology for the very young patients and took it away from the paediatricians. Perhaps as a GPs no matter how much additional training we have, maybe we won’t ever be skilled enough to manage the very elderly.

Many people might disagree with this and talk about the holistic care of the patient, but I actually think my profession is not ever going to be competent or confident enough to manage these patients.

Of course, I’m not saying that we don’t look after these patients. We also look after the very tiny babies, but the difference is that we don’t take responsibility for their care. Going forward, we need to be looking at new models of delivering care for this older population.

Some areas have started doing this with small multidisciplinary teams that include GPs and elderly care doctors working in a holistic way to deliver a different sort of care to these patients.

We also need to think about the role of the community in helping our elders and how the community can support them at the end of their life. Most discussions are always about what can the state do; what additional services can be added? The costs of supporting the ticking time bomb of this population are going to be astronomical and can we really expect the state to intervene at every level?

GPs have seen an enormous rise in consultation rates for this age group. An average patient over the age of 75 years will consult around 12-14 times a year and many of these are doctor initiated. Can a GP continue to absorb this workload?

Another issue is the medicalisation of old age. We sometimes spin this fantasy that death is something we can prevent with modern medicine. We are excellent at providing healthcare to patients, but we need a sensible debate about when prevention is too much and when death is the natural end to a fulfilling life.

The ticking time bomb of an ageing population is also us. We have to decide what we want as we grow older and how we won't be supported by our family and friends, communities and GPs.

 

Based on a talk by Dr Clare Gerada, Medical Director, NHS Practitioner Health Programme