Email your comments

Amid the recent celebrations of the NHS’ sixtieth anniversary, the Health Service Journal published a list of “NHS Heroes - the 100 most influential figures in the NHS”.

Marjory Warren was in at 18th place in the charts and one of the highest placed doctors. The HSJ credited her with “highlighting the needs of older people”, “beginning to improve services for them” and “inventing the speciality of geriatric medicine”. Though the BGS wasn’t mentioned specifically, it was good to see one our founders in the spotlight. And of course, Warren and other pioneers such as Amulree and Exton-Smith were able to use the newness of the NHS and the responsiveness of the Atlee government to new ideas, to push at an open door for investment in geriatric units. It did no harm to the cause that the “knock on” benefits for bed occupancy and length of stay from properly assessing the older long term sick were so impressive. [For more detail see Barton and Mulley PGME 2003; 79: 229-234]. One can only wonder what Dr Warren would think about the care of older people in 2008. After all, it was the same Health Service Journal in which 1,000 health service managers, when surveyed as part of the 60th anniversary celebrations, felt that older people were still the group most neglected in the new NHS. I am sure she would be pleased to discover a growing number of people surviving into independent and healthy old age; that there is a growing academic evidence to underpin our work; that we are now the most numerous physician’s speciality; that we have a presence in every general hospital; and that the membership of our Society now stands at over 2,500. Also, she might be gratified that there have been a succession of government guidelines, service frameworks and strategies to highlight the care of older patients.

I do wonder if the early leaders of our speciality, might be disappointed at our relative lack of access sixty years on, to primary, intermediate and long term care (see Young and Philp BMJ 2000 ). What of the relative imbalance between the daily activity of the NHS - where older people are the biggest service users, juxtaposed against the under-emphasis on teaching and training in geriatrics in undergraduate and postgraduate curriculae. The inaugural chairs of geriatric medicine might also be dismayed at the gradual retreat of academic departments from a number of our medical schools.
We must be careful not to dwell on negatives and to celebrate the excellent service the NHS still provides for many older people. There is a modern British tendency to reduce the reporting of healthcare to a series of “scandals” around issues such as undignified care and neglect or hospital acquired infection. [See John’s Starr’s piece on the folly of eyecatching but misguided initiatives around Clostridium for instance.] Yet behind the headlines, whatever their views about the NHS in general, most older people repeatedly declare themselves “satisfied” or “very satisfied” with their experience of care and spontaneous letters of thanks outnumber formal complaints by 3:1 in hospitals.

Too reasonable?
Nonetheless, we have to be honest as a speciality, that there is still a long way to go in improving the care of older people. In 2006, the Warren lecture given by Colin Powel, was entitled, “Whither geriatrics? Do we need another Marjory Warren?”. (Age and Ageing 2007; 36: 607-610 doi: 10. 1093/ageing/afm 115). I would argue that we need a whole army of Warrens. Whatever the BGS or the more “vocal”/”high profile” geriatricians might do at national level via the Royal Colleges, Departments of Health, or guideline groups, we surely all need to engage at local level to keep geriatrics in the spotlight - bypassed as it so often is, in targets or commissioning priorities. As Shaw said, “All progress is achieved by the actions of the unreasonable man,” and perhaps we all need to become a little more “unreasonable”, in highlighting the needs of older patients, though linking our lobbying to evidence and the potential win/win for the whole system if we get the care of older people right.

Lord Darzi’s report, “High quality care for all: NHS Next Stage Review final report” (see http://tinyurl.com/4t6uf8 and www.bgsnet.org.uk/mar08/ 1_darzi.htm) - released in the week of the NHS anniversary - does not say a great deal about the needs of older people, is currently longer on broad mission statements than detail and continues to push the “care closer to home” agenda (a double edged sword for older, frailer people who require specialist assessment). However, the focus on local solutions, on commissioning driven by quality rather than a narrow range of targets and on more integrated provision between health and social care does offer us opportunities to get involved with our PCTs and SHAs to influence commissioning. It is pleasing to note that several strategic health authorities now include specific goals in their five year plans, around the care of older patients.

So, why the need for us to rattle more cages? Well, we need look no further than audits by our own Society, in conjunction with the RCP (London) on the management of older people with falls, fractures, incontinence, stroke, delirium, or the care of older people with dementia, or the recent work around dignity in care. Older people - the largest users of secondary and primary care and suffering from medical conditions which are hugely prevalent and debilitating, still receive inadequate attention or funding, and are still often low priority, even when NICE guidelines exist and getting the care right would have benefits for the whole system. We regularly have posters at our own scientific meeting confirming that (even on our own specialist wards) many patients continue to receive inadequate assessment and care. And when teaching, I am constantly disappointed by the very poor knowledge and awareness among recently qualified doctors around the assessment and treatment of frail older people. I am sure Warren would say that we need to be a major part of the solution and grasp the initiative in her mould. Colleagues in, say, diabetes, cardiology, chest medicine, palliative care or microbiology are not shy about pushing hard to get the care of their areas right throughout the hospital or pressing commissioners for more investment. Perhaps as a speciality with strong service values we are sometimes just too, well, reasonable? Views please.

“Challenging”
Talking of being “challenging” (ghastly management speak I know), for the third issue on the trot, we are carrying a piece on the National Stroke Strategy – this time by Nigel Dudley, himself “challenging” some of the statements made in last month’s newsletter by Jenkinson and Boyle. I should emphasise that as a speciality and a Society, we welcome the stroke strategy and have been actively engaged in the stroke agenda for a long time, with a number of geriatricians driving stroke care and research, all the RCP (London) work on stroke, as well as engaging throughout with the development of the stroke strategy. We have always welcomed the range of standards in the strategy (and now appearing in SHA Plans) around rehabilitation and prevention - even though thrombolysis has attracted most of the coverage (in a striking parallel with the NICE dementia guidelines where memory enhancing drugs dominated the debate). However, it is also true that all change can introduce unintended consequences and that recent experience with, for instance, NSFs or NICE guidelines suggests that aspirations don’t always translate into better services.

It is therefore right and proper that we encourage robust debate around these issues – and the newsletter is the perfect forum. We are an independent Society and not an arm of the Department of Health. What would be welcome in the wake of the to and fro about stroke care would be views about the emerging relationships between stroke medicine, neurology and geriatrics and in particular, thrombolysis and rapid-access TIA clinics aside, which speciality will be overseeing most of the rehab and discharge planning – especially for frailer stroke patients with multiple co-morbidities.

Looking outside the Society, we are hoping that our new strategic links, with Help the Aged, (and its well grooved PR machine) - the “BGS/Help the Aged Health Advisory Panel” and our growing links with the media, will help raise our profile. The BGS had a stall at the RCP (London) open day on 5 July. It was pleasing to see so many sixth formers so interested in careers in medicine and we had numerous adult visitors (several well into retirement themselves), but there was a general lack of knowledge about what geriatrics was, why we needed a separate speciality for older people and a fair amount of “I hope I won’t be needing you any time soon” defensive jocularity (see box above). It also struck me that as a speciality whose main technologies and interventions don’t involve fancy bits of kit which one can show to people on the stand, it was much harder to get across to the public what we were about. There are external PR battles still to be won. And dare I mention it again...the “G” word can be a problem sometimes when you are meeting the general public.

A good example of elderly care in the media recently has been the well balanced and subtle series of reports on Radio 4’s Today Programme about long term social care of older people. This highlighted a number of issues dear to the BGS and we were able to help them with technical information and with expert advice on what the undercover care home worker and resident experienced. For those interested you can listen again on http://news.bbc.co.uk/today/ hi/today/newsid_7492000/7492986.stm.

Finally, can I take this opportunity to remind members of the Birmingham Meeting (12 - 14 November - see www.bgs.org.uk/Notices/bgsconf_autumn.htm). We had a great four years in Harrogate but one criticism was that it was geographically inaccessible for members in many parts of the country. Well one doesn’t get much more accessible than Birmingham, the programme looks packed with interest, so be there or be square.

David Oliver

BGS Newsletter, Aug 2008
Issue 17 ISSN 1748-6343 17