Dr James Williamson was a highly regarded young consultant in chest medicine who, in 1959, decided to change specialties. His colleagues reacted with disbelief. Chest medicine in Edinburgh was doing well, and Williamson had played a big part in its greatest triumph: the irrefutable proof that, at last, TB could be cured.
But Professor John Crofton, who led that study, was sympathetic towards his young colleague’s plans. The population was ageing, and the still-young specialty of geriatric medicine faced great challenges. Over the next 25 years Williamson – along with colleagues such as Ferguson Anderson in Glasgow, Norman Exton-Smith in London and Ben Isaacs in Birmingham – became a leading figure in the development of geriatric medicine as a mainstream clinical and academic discipline. It is now Britain’s largest medical specialty, with a diaspora around the world and a continuing international reputation.
Jimmy Williamson was born in Wishaw and educated at Wishaw Academy. At Glasgow University he was a prize-winning medical student, graduating in 1943. After junior jobs in Glasgow and two grim years in pre-NHS general practice in England he returned to Scotland to train in chest medicine, with time at Hairmyres hospital where, in 1944, he looked after George Orwell.
In his first consultant post he joined Crofton’s team, taking charge of Edinburgh’s central chest clinic, the Royal Victoria Dispensary, in 1954. If TB was to be eliminated, good case-finding was essential, and sometimes this involved carrying portable x-ray equipment into lodging-houses and up the stairs of slum tenements – not for the unfit for the fainthearted, but all in the line of duty in the “battle against the bug”.
From 1959 Williamson, now an NHS consultant geriatrician, brought to his new specialty much that he had learned from that battle: a research training, organisational skills, and an appetite for big challenges. In 1964 he published a landmark paper in the Lancet, documenting the many unreported medical needs of older people at home. A pioneering longitudinal study of the health of older people followed. His reputation grew, and in 1973 he went to Liverpool as the first professor of geriatric medicine appointed there. In 1976 he returned to Edinburgh, once more a first professor of geriatric medicine.
Ascertainment studies such as the above were only a preliminary. There followed in Edinburgh a remarkable series of service development initiatives that established first a national then an international reputation. While most geriatricians simply worked within the specialty, Williamson took a more strategic view: they could achieve far more by collaborating with the major specialties.
General medicine was an early target. Traditionally, the physicians in the Royal Infirmary viewed the role of the geriatrician simply as one of removing patients who blocked their beds: as Williamson later put it, “that morning if possible, and in a wheelbarrow if necessary.”
Instead, he helped them to look after older people better. With younger geriatrician colleagues, he took an early and close interest in their older patients on twice-weekly ward rounds, and led the wards’ multi-disciplinary teams. This substantially reduced length of stay: far more patients were able to go straight home; far fewer became “bed-blockers”. Another landmark paper, in the BMJ in 1979, prompted a senior colleague to call from London to congratulate him: “This is the first evidence we have that geriatric medicine actually works!”
At a time when old age psychiatry was in its infancy, Williamson, who realised that some of the most challenging patients of all were those with both psychiatric and medical needs, established wards where geriatricians and psychiatrists worked together. Orthopaedic surgeons too were helped. Williamson had visited the orthopaedic unit in Hastings, where a geriatrician friend, Bobby Irvine, worked closely with the surgeons in the acute unit, dealing with the many medical problems seen in older patients with fractures. That model was quickly replicated in the Royal Infirmary. Thirty years on, ortho-geriatrics is now a flourishing and effective subspecialty of geriatric medicine.
By basing his department in the City Hospital, Williamson was able to offer an ideal service to the GPs of Southwest Edinburgh and their patients, with prompt home visits on request and immediate advice by telephone or, preferably, by dropping in on the practice on the way back to base. This was much appreciated, and paved the way for another collaborative initiative: an augmented home care scheme.
Patients who might require admission would be seen by a geriatrician within two hours, and if suitable for care at home would be looked after there by GP and geriatrician, and a team from health and social work: nurses, physiotherapists, backed up by “gold-star home helps”. A pilot scheme succeeded, averting unnecessary hospital admission and showing that home treatment and rehabilitation worked well.
For various reasons, a proposed randomised controlled trial proved difficult. But Williamson recognised that health and social care working well together could provide for the frail elderly what he called a spectrum of care: covering everything from early frailty, intermittent sub-acute illness, and even palliative care. Close working could maintain frail older people at home, where they wanted to be; and costly, unnecessary and possibly risky hospital care could be avoided. In the late 1970s, this was an idea far ahead of its time. Now it is being taken very seriously, with integration of health and social care as a policy goal both North and South of the border.
What mattered most to Williamson was improving the care of older people by any means necessary. His political sense was acute, and his methods effective. A crucial victory was his campaign, opposed by many, to set up an academic department in Edinburgh. Eventually he prevailed and Edinburgh medicine, somewhat to its surprise, acquired a centre of excellence in something it had largely disapproved of only a few years previously.
His achievements there brought widespread interest. His department’s visitors’ book in the early 1980s was an international Who’s Who of geriatric medicine, as people came from all over to find out more about his clinical research, his service initiatives, his undergraduate teaching, and his thoughts on the many challenges of setting up services for older people. Soon he was organising two-week residential international geriatric medicine courses in Edinburgh. These have continued to this day.
His intellect, determination and work-rate were impressive, and his memory was phenomenal. In 1985 he was introduced to Bernard Crick, who had just published a definitive biography of Orwell. They discussed his TB and its treatment, with Williamson closing his eyes, clutching his brow, and reporting in detail a chest X-ray he had last seen in 1944. Then they went through the other patients on the ward, one of whom Williamson did not remember. Shortly afterwards I talked to Crick. “All the Orwell contacts are hopelessly suggestible,” he said. “So I always chuck in some bogus information. Your man did well. He spotted it.”