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At the time of writing, we are awaiting the launch of the government’s Green Paper on potential approaches to funding long term care.

We are also expecting the launch of the government Strategy for the Ageing Population - which includes the Prevention Package for Older People. I hope to be able to report on these in detail in our next issue, by which time we might also know who is to succeed Ian Philp as the National Clinical Director for Older People - an appointment in which the BGS has an important stake.

Levers to Improve services for older people
We know that from 2011, the additional investment made over the past few years in public services will dry up and there will potentially be some pain. It also seems (in England, and we would welcome perspectives from the other nations) that the era of “targets and terror” which was used to deliver on priorities such as waiting times and National Service Frameworks with national “must do” timelines, is gradually being replaced by a National operating framework and quality framework with only a handful of “must-do” targets and “vital signs”. The focus is moving towards quality (outcomes, safety and patient satisfaction) and towards more joined up local commissioning to meet the needs of the local population. This poses potential risks that providers will focus even more on those conditions for which targets exist, but also potential opportunities to commission services that really do address the needs of older patients with complex needs or with common conditions of old age. However passionate and informed we are about the clinical needs of older people, we need broader skills and knowledge to influence this process in our own patch. And it helps to have an understanding of the thinking and priorities of the non-clinicians. To complement last issue’s feature explaining commissioning and the general piece on payment by results, this month, we have the second enlightening piece on PbR as it affects geriatricians. This could be a useful tool to improve quality and redesign services, but it helps to understand the fundamentals. Such technical knowledge is crucial to our role, but it needs to be aligned to good leadership skills. Way back to Marjory Warren and the other early pioneers, the history of geriatric medicine is peppered with examples of inspirational and transformational leaders and campaigners.

Leadership
Of course, leadership isn’t just at national level. Good leadership is crucial to delivering, leading and transforming services in every unit and - in conjunction with partners in primary and social care, mental health and the voluntary sector, to every locality. Small changes in small services can still make a big difference to patient care. We all have the potential to deliver leadership but it does mean sometimes challenging orthodoxies, or going outside the comfort zone of day to day patient care. For that reason, the articles in this newsletter on leadership are a great way to stimulate some thought and debate. There are a number of formal leadership training programmes around. A few years ago I gained a great deal from a 3 year work based MSc programme called “Leadership London” which improved my insight and changed my approach to leadership. I know that some of our members are currently undertaking similar programmes with the health foundation. There are several programmes and courses out there and we would love to hear from other members undertaking them. A useful document in this context is the NHS Leadership Framework available at www.nhsleadershipqualities. nhs.uk/

Geriatrics beyond our shores
Colleagues in other countries are often amazed to discover that we are the most numerous hospital-based medical specialty in the UK. In many nations, geriatrics has struggled to gain a foothold – either as a concept within the medical profession, or in health service priorities. Population ageing and the growing number of patients with frailty or complex needs who defy categorisation by organ/procedure and who need a different approach are resulting in a greater need and more awareness of our specialty. Several of our members attended the International Association of Gerontology Meeting in Paris and the BGS is actively involved with the IAGG committees. In recent issues, we published work on the BGS’s contribution to training the first wave of Taiwanese Geriatricians. Now, I am delighted to carry Neela Patel’s piece on population ageing and geriatric medicine in India in this month’s edition. I would welcome perspectives – especially from first or second generation Indian and Pakistani geriatricians who now work in the UK. Neela and other pioneering overseas geriatricians, often working against the odds, clearly embody leadership in a way we can all respect.

Outlawing Age-Based Discrimination in Health and Social Care
As mentioned in Newsletters past, the Equality Bill seeks for the first time to outlaw age based discrimination in the provision of public goods – such as health and social care. On becoming an Act, such legislation needs to be backed by a code of practice and a consideration of the practical elements of implementing it. (Think by analogy, of the Mental Capacity Act). Because of this, there is a major enquiry, involving many stakeholder groups, so the implications of implementation can be thought through. South West Region (chaired by Sir Ian Carruthers from the SHA and Jan Ormondroyd from Bristol City Council) are leading on this with initial findings to be reported in the autumn, but there will also be a nationwide enquiry. It does seem a shame that when by far the biggest group of service users is older people, we still need law to prevent them being treated like a disadvantaged minority, but there it is.

I cannot over-emphasise how important an opportunity this is for us to improve services. It is without doubt the most important policy development in my time as BGS Deputy Hon Secretary/Hon Secretary. We have a golden opportunity to influence the process and one which must not be wasted. The law will apply to the whole of the UK and once enacted, whilst individual older people might not often resort to the courts, the lobbying organisations will be able to use it (and are already discussing doing so). We need to bear in mind that discrimination refers to the arbitrary use of a person’s chronological age to deny them treatment or access when this is irrelevant to clinical outcomes/likelihood to benefit. Clearly, taking age into account, where it is a relevant part of clinical decision making, is not inherently discriminatory and there are examples (e.g. bus passes, NIHCE guidance on secondary prevention of fragility fractures or influenza vaccination) where older people are prioritised over younger people.

With the exception perhaps of mental health services, we won’t find too many explicitly age- based policies in the system. However, it does seem clear that at organisational level, there has often been greater investment in interventions that affect younger patients. A recent report from the North West Cancer Registry found that there was ageism in the provision of cancer care and outcomes in older people could be improved. And we know that despite NICE guidelines on for instance falls, fragility fractures and incontinence, national RCP audits have shown that most patients are not receiving the evidence based interventions set out. The Dementia Strategy has highlighted deficiencies in investment in dementia services. And there is little in the GP Quality and Outcomes Framework around the needs of patients with conditions of ageing. Despite talk of services being “age-proof and fit for purpose” we still have a long way to go.

Of course, age discrimination is also inherent in the attitudes and knowledge of individual staff. And there is still a mismatch between the content of education and training of professionals, and the fact that for many, their careers will increasingly be spent in the care of older people. We also often fail to value or reward those staff working in the “unglamorous” area of older people’s care.

Enquiry Work streams
I will make the details of the enquiry publicly available on the website, but in a nutshell, the work streams will be:

• Behaviour (of individual staff and how it could be influenced)
• Resource allocation and systems (and whether these inadvertently lead to age discrimination and how they could be altered to combat ageism).
• Services (examples of services where age-based differential treatment arises and whether it is reasonable or discriminatory).

I sit on the national working group for the BGS (contact me). Tarun Solanki from Taunton Hospital is leading for us in the South West Region. England council has also submitted some evidence. Any views, personal accounts or empirical evidence you have around age discrimination, either where you work or nationally, would be welcome. And if you have any good news to share on services which have improved the lot of older people and helped tackle age discrimination, please contact press@bgs.org.uk so we can help showcase them.

David Oliver

BGS Newsletter, July 2009
Issue 22 ISSN 1748-6343 22