Episode 2. Geriatrics

This week we are in conversation with Dr A, currently working within a Geriatric department, in Essex. They share their personal anecdotes as a junior clinical fellow within the NHS…

““Deprivation increases both disease severity and complexity of management “.

From your clinical perspective, what is the most significant unmet need amongst your patients?

The most significant unmet need is timely access to a doctor, which can be detrimental for an aged individual.

Geriatric patients rarely present with straightforward, early disease; often, they present late, repeatedly or in a crisis because they were unable to access clinical review when symptoms first appeared. This is especially evident in delayed cancer diagnoses, chronic conditions, and preventable emergency admissions.

Once patients enter the system, care pathways are generally effective. The difficulty lies on reaching a clinician early enough for preventative care. As a result, doctors spend much of their time managing avoidable complications rather than early disease.

A key contributor of this issue is workforce capacity – patients don’t always need new treatments, they need earlier access to clinical decision making.

What part of your job feels needlessly difficult due to the structure of the UK healthcare system?

A disproportionate amount of time in the clinical is spent on medico-legal documentation and administrative tasks. Consistent documentation is required for communication, continuity and legal defensibility – information needs to be entered, and re-entered across multiple digital platforms with a focus on liability management, rather than a simple clinical summary.

Understaffing intensifies this problem; when one doctor is responsible for multiple patients, documentation becomes an act of risk-containment rather than clinical reasoning. Whilst doctors are trained to assess and treat patients, they are increasingly becoming record-keepers.

How do social or economic factors show up in your day-to-day clinics?

Social and economic factors present in nearly every consultation. Geriatric patients frequently struggle to attend appointments due to physical insecurity, transport costs or housing challenges. Medical adherence is often limited due to challenging living circumstances (not always due to a lack of health literacy), and many admissions occur because patients lack social or familial support.

Deprivation increases both disease severity and complexity of management – exacerbated by workforce shortages as limited consultation times prevent addressing the underlying cause of repeated presentations. Unfortunately the system is better structured for episodic medical intervention, rather than sustained support.

In your opinion, what one change in policy, training or funding would have the biggest impact on patient care?

Increasing the number of doctors within the workforce through improved retention and meaningful recruitment expansion. There are simply too few doctors for the volume and complexity of patients. This affects emergency departments, wards, clinics, and discharge planning; until baseline staffing is improved, the NHS workforce will struggle. To do this, pay and working conditions need to be improved, and funding for training needs replenishing to compensate for speciality understaffing.

When doctors are responsible for an exceeding number of patients, care becomes reactive rather than preventative – consultations shorten, defensive investigations increase, and continuity disappears (which has multiple knock-on effects). And so I think most systemic NHS pressures are due to a mismatch between patient demand and doctor availability.

What do you wish policymakers understood about your speciality or your patients?

Healthcare capacity is determined by clinician time rather than infrastructure or targets. A hospital may appear adequately resourced, but can still function unsafely if each doctor is busy managing multiple patients. In these situations, provision of medicine takes priority over precision of care – focusing on immediate risk management whilst preventative and holistic management is deferred. Junior doctors are the key workforce here – providing the majority of patient care. So when working conditions and pay decline, the trust loses its core clinical workforce.

Many policy initiatives focus on pathways and performance metrics, but the limiting factor remains limited clinician availability per patient.

Where do you feel evidence or data is lacking in your field?

There is limited data measuring workload intensity and its direct relationship to patient outcomes. For example, the system routinely measures waiting times and patient mortality but less commonly measures:

• Average number of patients per doctor
• Number of interruptions and task-switching
• Time spent documenting vs examining patients
• Cognitive load and decision fatigue in doctors

Without adequately measuring workload capacity, any policy interventions risk addressing consequences rather than cause. The NHS has strong clinical research but comparatively little system-capacity research, despite capacity being the primary constraint on patient care.