interest in narrative based practice in medicine, and its coverage in such prestigious publications as the British Medical Journal under the editorship of Richard Smith. He is moving on to work in the increasingly focused area of Chronic Disease Management.

Medical education and training is also undergoing radical change (modernising medical careers, M.M.C.) as we cover in this issue.
With these themes flowing about, I watched Panorama on BBC1 on the 18th July 2004. The title of the programme was “Fighting for Care”. Andy Davies went on to succinctly fly across the tectonic plates of health and social care for older people in England, and slowly zoomed in on the edges and the cracks. From a great height can be seen the topography of policy, procedure and bureaucracy. However as the lens focussed closer to earth, it was possible to witness the movements, actions and challenges of our fellow human beings.

Panorama’s report used three cases of patients with irreversible cognitive decline at various stages of illness, to illustrate the efforts that carers were making on their behalf, to get what they considered adequate care for their loved ones in their time of need. The love, dignity and respect by the carers’ for the person in their charge was abundantly clear, as was their despair and fatigue.

The shock of diagnosis, the realisation of an inevitable decline, the loss of activities of daily living and the carers’ stress were poignantly illustrated.

Accessing the appropriate knowledge, as always, is the key to solving problems. It is salutary to be reminded what it must be like to deal with the policies, procedures and assessments required for people with acute and chronic physical and mental disability for the first time.

As professionals we are lucky if we master the maze of health and social care entitlements to which our patients should have access. A shift in nuance and subtle changes in criteria and interpretation can happen quickly, almost it seems, randomly.

After so many major reviews of care systems in the last few years, the most vulnerable, frail older people are still suffering. Having a good advocate is crucial, both in a personal sense, but also in a broader sense when the messages of the health ombudsman report into NHS Continuing Care in 2003 are studied closely.

However the take home message from this programme was as clear as it has been for some time now – care costs.

Come the election, the UK’s citizens will have to decide to elect a government who will raise the monies to fund care centrally. The alternative is to find extra resources from their own social networks – family, friends, neighbours and health professionals.

The former prospect does not have currency these days. For this reason “Fighting for Care” is a useful benchmark for the next decade. Increased self-reliance seems inevitable.

Letter to the Editor:

Dear Editor,
I welcomed the fact that representatives from BGS special interest groups have met with colleagues from the Faculty of Old Age Psychiatry to consider care homes and PCTs, as reported in July’s newsletter (p14-15) but write to express my concerns regarding the product of their deliberations. I was saddened to find the term “lost tribe” in print, this joins “bed blocking” in my lexicon of medical misnomers and begs the uncomfortable question, how did they become lost?

It is some 4 years since I contributed, with others from the Society, to the report of an RCP working party entitled, The health and care of older people in care homes - A comprehensive interdisciplinary approach (published by the RCP June 2000). The Society’s “standards of medical care” updated in 2003 refers to this RCP report to provide further detail. The report is contemporary society policy and I would suggest it has much value in the PCT led, Evercare tinted world of 2004.

The RCP report identified ten statements for action, that were used to structure the report. Their central theme was to call for an ‘integrated interdisciplinary approach’ for health and care services for care home residents. The report’s introductory summary identified the need for:

• a standardised interdisciplinary approach to assessment, care planning, and care delivery.
• development of the nurse as the lead practitioner in care homes.
• comprehensive systems of service delivery to engage general and specialist aspects of medical practice.
• all practitioners engaged in care home practice to have appropriate education and training and for relevant programmes of research.

It would be helpful for joint working with colleagues from old age psychiatry to build on previous work, perhaps critically reviewing developmental progress against policy documents using simple surveys may prove effective.

It might even be worth revisiting aspects of the roles our forebears, the Medical Superintendents, a suggestion made in the wake of modern matrons. I am not recommending the institution of a bygone era, or expressing any desire to inhibit the development and access to modern medicine for the most frail. I do however sense from “Googling” around, medical superintendents were very much more “in the loop”, respected, able to influence care, and indeed, more held to account than presently seems the general rule.

Yours sincerely

Clive Bowman FRCP
Chair, The Continuing Care Conference
Medical Director BUPA Care Services
Email: bowmanc@bupa.com