Our ageing population will naturally lead to an increase in age-related illnesses and greater numbers of frail, older people to be cared for in the community. Soon people over 65 years of age will out-number those under 16 and the oldest of the old, the over 85s, are the fastest growing sector of our population.

With the continuing emphasis on care for those with long term illnesses to be as close to their homes as possible, such responsibility will rest initially with primary and community care teams, although help will undoubtedly be required from our specialist secondary care colleagues in geriatrics and old age psychiatry.

However as the nature of primary care has changed dramatically over the last 10-15 years, so too has the acute care of frail older people.

Previously, much of the acute care and rehabilitation of older people was delivered in acute hospital settings. Now, acute care is delivered predominantly in acute medical units (AMUs), often over very short time periods, with on-going rehabilitation provided in a variety of community settings, including intermediate care schemes (home based or residential) and community hospitals.

Some older patients with complex needs, who would previously been managed in hospitals by geriatricians, may not receive the specialist geriatric component of comprehensive geriatric assessment (CGA), even though they may still access other aspects of care (physiotherapy, occupational therapy etc). The consequence of this change in health care delivery is unclear, but in some centres the outcomes for frail older people attending AMUs and being discharged back into the community setting are worrying - up to 55% are readmitted and 26% die in the following 12 months.

While there is renewed interest in community geriatrics, it may be difficult to persuade both hospitals and primary care trusts to invest in such services. Why would an acute hospital want to fund a scheme which ultimately might lead to a reduction in ‘business’? And why would a PCT want to invest in a post when the post holder will be spending half their time in working in the hospital. One solution would be to develop services which are jointly funded by the PCT and the acute hospital trust and which can jointly benefit both parties.

Such is the rationale behind interface geriatrics; geriatricians working at the front door (either the emergency department or the acute medical unit or both), identifying who needs to be admitted and for how long and who would be better served by a community-based multidisciplinary team. These same geriatricians should be part of this team to ensure an integrated approach.

An Australian trial has shown that a CGA approach spanning primary and secondary care can reduce readmissions by about 25%; similar UK studies are underway.

The community role of the geriatrician, working within a multidisciplinary team, can not only be linked into early expedited discharge support from hospital. More importantly, they may be able to decrease the need for access to acute care settings and unnecessary admissions, as has been shown by several of our colleagues in recent years. Of course, avoiding admissions or readmissions is fine, but the real aim is to improve the quality of care for frail older people. Appropriate resource utilisation and allocation is more important than reducing resource use. These arguments are the currency of the day and may be helpful to colleagues trying to develop services in this challenging economic climate.

So maybe a fusion of community and acute geriatric medicine - the interface geriatrician, is one way by which care for older people can be improved, whilst keeping both commissioners and providers happy!

A British Geriatrics Society conference on Interface Geriatrics will be held on the 5 March 2010. Relevant to all health professionals involved in the care of older people in the community, the event is being supported by the RCGP and the College of Emergency Medicine. Read the details here.