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Now that the festive season is over, let me start off by wishing all our readers a happy and successful New Year, wherever they may be.

We arrive in 2007 in thoughtful and reflective mood with a year of momentous change ahead of us in the National Health Service including, Modernising Medical Careers; moving to community delivered services; contestability with competition to provide services coming from the private sector and more assertive commissioning by Primary Care organisations, leading to reconfiguration of Accident and Emergency, Maternity, Paediatric and Outpatient care. The latest target for Modernisation is the Emergency service as outlined in the two NHS documents which arrived in the Christmas post, entitled “Emergency Access” by Professor George Alberti (National Director for Emergency Access), and “Mending Hearts and Brains” by Professor Roger Boyle (National Director for Heart Disease and Stroke).

So what is the future?
Readers of the lay press may well come to this debate with the notion that the agenda is closure of smaller Accident and Emergency Units and maybe, hospitals as well. To some extent I fear that they are correct as Modernising Medical Careers and involvement of the Private sector deplete smaller hospitals of staff or income under Payment by Results, (in England), but the National Directors have a point and are supported by the Royal Colleges. While we are naturally distraught at the dog bite suffered by Prof Alberti, the proposal is to establish regional networks with specialist centres to offer thrombolysis for stroke patients, primary

angioplasty for appropriate cases of myocardial infarction, major trauma and vascular surgery, all with a view to offering the best possible care for these seriously ill patients 24 hours a day - a laudable aim.

What does it mean for older people?
Now, while as geriatricians we welcome the emphasis being placed on the hyperacute management of stroke in particular, we must temper our enthusiasm just a little. Can we be sure that our patients with acute neurological symptoms are going to reach the regional centre and have their CT scan within the 3 hour window? Data from Newcastle suggests that we can, using the ambulance models described in the document, but what about all those referred to the regional centre subsequently found to be unsuitable for intervention? Will they be transferred back to a local unit, after stabilisation for 72 hours in the Acute Stroke unit? Our hospital takes part in a regional rota for vascular surgery which recently led to me being asked to repatriate a patient 6 days post aortic aneurysm repair, with renal failure. There will need to be clear arrangements for transfer of these patients at an appropriate time in order to prevent deterioration in Clinical Quality.

All the time though, there is a shadow looming. The Emergency Access document again talks in terms of preventing admissions, particularly of older people who have fallen, by offering a reassuring word from an Emergency care practitioner and an early appointment with a GP. For some patients this may be satisfactory, but on my ward at the moment I have at least five patients with so called mechanical falls, recently turned away from MAU or the Accident and Emergency department, only to be readmitted with urinary tract infection, vertebral fractures, pubic ramus fracture, Stroke, sinus node disease and in one case MRSA septicaemia. Why, as geriatricians are we failing to get this message across to policy makers? Acute loss of function means acute illness and needs specialist clinical assessment – unless, of course, you’ve been bitten by a dog.

A fairytale of New York
My wife and I recently spent some time on holiday in New York, enacting out our own version of the seasonal Christmas hit, with me playing Shane McGowan’s uglier older brother. Nonetheless I was rather taken with one or two contrasts with this side of the Atlantic. I rather liked the references to older people as “Seniors”, as in “Retirement Home for Seniors”, implying a degree of status and respect. Compare this with the misuse of the word “geriatric” which constantly occurs in this country. Secondly, we spent some time with an “older” person who remains very active in the art world and who was astonished to hear of my plans to retire at sixty and watch football on the television. Apparently people across the pond keep working in some capacity for as long as they are able, because they need the income – a sign of things to come maybe.

Drifting off at the BGS Conference
Our freelance journalist, Liz Gill, who provides such excellent reports of our scientific conferences, recently contacted the office with some observations about these events. As an experienced journalist and observer of human behaviour , not to mention being a veteran of some three of our conferences now, Liz offers an interesting lay perspective on an otherwise rather esoteric event. She pointed out that the evening of the first day often falls a bit flat after the sponsored symposium, with some solitary delegates “drifting off into the night, looking slightly disconsolate.” Where are they going? Best not ask I suppose… Anyway Liz’s suggestion is that we need an icebreaker event on the first evening, perhaps a quiz to allow colleagues to get to know each other and socialise. We could use questions from the SpR knowledge test, (only joking) and offer a prize. Come on then, what do you think?

Final word - Dermatology update
A retired physician in these parts tells of coming across a young woman one morning, admitted to MAU with acute alcohol poisoning. On closer inspection, he identified a florid periorbital and butterfly rash on the patient’s face. He immediately started asking questions about joint pains, myalgia, kidney problems and family history of Lupus or Dermatomyositis. After a few minutes, the indignant Geordie lass interrupted and demanded to know why he was asking these questions. Our colleague explained about autoimmune disease and the significance of the rash, only to be rebuffed with, “Why, naw, that’s the CS gas the Police sprayed in me face to quieten us doon.”

Final final word – more ego deflators
As we are just starting a New Year I thought I would add a second Final word.

Patient to mygoodself in clinic; “Eee, you’ve got the sort of face that makes me want to laugh.”

…and, I realised my attempts at dressing down had gone too far when, walking down to the quayside one winter’s night, I was grabbed by an earnest student who insisted on dragging me off to a nearby Salvation Army soup kitchen. Worse, none of the volunteers queried it.

Have a prosperous and enjoyable 2007.

Dave Beaumont