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Perhaps this issue’s editorial should be re-titled “news round-up”. Only a few weeks into 2008 and already, issues affecting our speciality have been in the news repeatedly.

Many of the topics highlighted are linked directly to BGS work or to health care of older people in general and some will be linked to articles in this and future newsletters. So where to begin?

Stroke
Well, for starters, we had the announcement from the Department of Health of the National Stroke Strategy (see Ajay Bhalla's comment). This attracted a great deal of media interest and has resulted in many hospital trusts rushing to set up rapid referral pathways for thrombolysis, so as not to be left behind in the commissioning race. The focus on stroke is welcome. There are over 200,000 people per annum in the UK suffering stroke and TIA. Mortality rates have not dropped over the past decade (unlike those for coronary artery disease). Our outcomes fall below those of many European countries. Though nearly all district hospitals now have stroke units, many patients still never receive the specialist care they provide. Stroke care remains patchy and inconsistent. The Stroke Strategy does emphasise rehabilitation, primary and secondary prevention, stroke unit and post-discharge care. There has been major input from BGS members. If I have a reservation it is that the focus on acute thrombolysis pathways and rapid access TIA clinics which might divert attention away from equally important but low-profile and “low-tech” areas of care, which have traditionally been neglected (not least by some neurologists). I find it instructive that the moment stroke moved from the Older People’s to Cardiac National Service Framework and a pharmacological “high tech” and curative treatment became available, interest seemed to increase exponentially, (even though most patients with stroke will never benefit from thrombolysis even with “Rolls Royce” services); another example of covert discrimination against geriatric medicine and frailty? With moves to make Stroke medicine a separate speciality, the evolving relationship between geriatric medicine and stroke care will be an interesting one and hopefully one the BGS can continue to influence.

Darzi Report

Since our last edition, we have also seen the publication of Lord Darzi’s Interim Report Our NHS Our Future, (see Deborah and Finbarr’s commentary). This report is ostensibly a draft for comment (though I am bound to wonder how much is already cast in stone and how much was actually prepared by Lord Darzi himself – as an academic surgeon from a London tertiary referral centre). The report contains significant content on preventative medicine; case-management for long term conditions (despite the current poor evidence-base for community matrons and other forms of case-management and reservations expressed by the BGS); and devolution of care from secondary care to “the community” (i.e. PCTs) with a series of performance metrics to assure that this is happening. Though as Gerry Robinson pointed out in his recent TV programme when visiting the excellent rapid assessment service for older people in Rotherham, what is a general hospital if not part of the community? And why disband a popular hospital-based assessment service for older people, merely on ideological grounds? The report is supposedly at consultation stage currently, and the Society will be one of many stakeholders to comment. It will be interesting to see how much the final report differs from the draft or whether the consultation is more for show. We hope to have an article in the next Newsletter summarising the implications of the report for our speciality. In the meantime, you can find the details (along with Lord Darzi’s blog and comment from his “listening roadshows”. The editor of the BMJ, Fiona Godlee also interviewed Lord Darzi about the report and was able to include some specific questions we had suggested around older people and the shift to primary care. There is useful comment and debate on Darzi on the Kings Fund Site .

Gordon Brown and Heath Promotion
Since our last edition, the Prime Minister has made his first major speech on the NHS and set out his vision. For a summary of the speech there is a good piece by Rebecca Evans in the Health Service Journal 10th Jan. For pithy expert commentary, it is well worth reading Chris Ham’s Piece in the BMJ 12 January www.bmj.com (Vol 336). As he points out, “the government has willed the ends, but will it provide the means and the mechanisms for effective prevention and improved outcomes” (a theme I will return to). Beyond the emphasis on health promotion and preventative medicine, the speech also echoed Darzi in highlighting the need for better management of long term conditions and an expert patient programme. Brown also discussed personal direct payments or “health” budgets - which in reality largely concern social care. All these themes were short on operational detail which might transform the visions into reality and public-health benefits. A provocative opinion piece by Julian Tudor Hart (BMJ Jan 2008 336) mischievously suggested that there was too much emphasis on extending the kind of “screening” currently demanded by the middle class worried well to less advantaged members of society, rather than majoring on screening that would produce genuine public health benefits.

Preventing Falls and Fractures
Moving from the rhetoric on prevention, screening and case-finding and the major current focus on Obesity (see BMJ debate “is the obesity epidemic exaggerated” BMJ  2008;336:244); what could be a better example of a pressing public health issue of relevance to our speciality than the prevention of falls and fractures? This issue also illustrates again the fact that standards and aspirations for improving care mean little without earmarked investment, a willingness to invest in the short term for medium term gains and binding performance targets. Fragility fractures affect around one in two women and one in twelve men over a lifetime and accidental falls, in addition to causing such fractures, are one of the leading causes of hospital attendance and admission in older people. Despite the targets in the NSF and NICE guidelines promoting secondary prevention of falls and fractures, we know from our own national audits in conjunction with the RCP that services for these conditions are patchy and poorly integrated and that many patients still receive no assessment. One of the reasons behind this is the sheer scale of the problem means that whilst secondary care has a fighting chance of “catching” patients who attend hospital following falls or fractures, there needs to be better input from primary care to realise whole population gains rather than pockets of good practice. Because of this, a consortium of NOS, BGS and Help the Aged have tried for a second time to incorporate falls and fracture prevention into the Quality and Outcomes Framework for the GP contract. I am afraid that the falls standard has been rejected on the grounds of being too difficult to record or measure, but negotiations are still ongoing around fragility fractures. An appeal has also be upheld against the NICE guidelines on secondary prevention of fragility fractures in view of the fact that so many of our own patients are unable safely to take Bisphosphonates.

Whilst all this was going on, the BMJ issue 19th January contained two reviews suggesting that the key to secondary fracture prevention lay in preventing falls, and a further systematic review (the first since 2005) suggests that the evidence for falls-clinic-style multifaceted falls interventions might not be as strong as suggested in earlier guidelines. See the BGS Falls Section response to this. Finally, in Feb 2 BMJ published a further systematic review suggested that Calcium Supplementation (widely accepted in the treatment of bone fragility) increased cardiovascular risk with those risks outweighing the effects in fracture prevention. Interesting times for the Falls and Bone Health section.

Better services for dementia care
An increasing feature of my day to day job (I am sure echoed by colleagues around the country) is the sheer number of patients arriving in the acute sector for whom dementia is in reality their main problem (even if they present with acute medical illness) See Martin Curtice’s parliatmentary round up on page 30. It is also clear when these patients default to or become stuck in hospital, that our investment in community services for dementia is grossly inadequate, however hard our colleagues in old age psychiatry may work. Previous reports in which the BGS has been a key player such as “Who cares Wins”; “Delirious about dementia” as well as standards in the original 2001NSF re-iterated in “A New Ambition for Old Age” have highlighted that such patients often get a raw deal from the system. It was therefore pleasing to see an announcement from Ivan Lewis following the Junior Health Minister, endorsed by the Alzheimer’s Society, that dementia services should be central to service planning in the future. And the public accounts committee called for the appointment of a dementia “tzar”. (See Downs and Bowers BMJ February 2nd and rapid responses for comment). Again, whilst this emphasis is welcome, the sceptic in me wonders where the money is to accompany this initiative.

Investment in services for older people
One of the reasons for the failure of so many of the original NSF targets to be met in full was a lack of earmarked funding or binding performance targets for issues specific to older people. In a recent survey of 1,600 health service managers commissioned by the Health Service Journal to commemorate the 60th anniversary of the NHS, the groups identified to have “benefited least from NHS reforms” and “received the least investment” were overwhelmingly older people and those with mental health problems. Going back to the National Stroke Strategy, it has been noticeable that when such an initiative is accompanied by “must do’s” things happen quickly. Other recent examples of radical change achieved in short order are the welcome expansion in palliative care services for older people and the focus on infection control or on critical care outreach. But for the “geriatric giants” we still have a long way to go. Beyond falls, fractures and dementia, we know that delirium is still under-recognised and badly managed (Ref BGS Compendium or Young and Inouye BMJ 2007). And the recent joint continence audit with the RCP, led by Adrian Wagg and reported in this month’s Age and Ageing (Vol 37, No.1 p32) – tells a similar tale – neglected even within our own speciality and again, despite the existence of NICE guidelines.

Professor Ian Philp
After 8 years in post, the National Clinical Director for Older People has recently moved on from the Department of Health. I hope to twist his arm to write something on his experiences for a future issue. For now, I would like to thank him on behalf of the Society for doing so much to put the care needs of older people in the spotlight. Despite being “one of us” he had to be careful not to be partisan in pushing a doctor-led agenda and also had a tightrope to walk between his corporate role within the DH and his advocacy role for older people. There is no question in my mind that the publication of the NSF led to an increased focus on older peoples’ services and a stimulus to better joint working with primary and social care organisations. His own 2006 document “A New Ambition” highlighted the gains but also pointed out that we still had a long way to go in delivering joined up, dignified or “age-proof” care. Again, within the unwritten hierarchy of NHS performance targets and structural re-organisation, the lack of dedicated funds and binding targets, and almost certainly some covert discrimination against the needs of older people by commissioners, may have been partly to blame for some of the failures but I believe we would have been a great deal worse off without Ian’s contribution. Finbarr Martin remains as the deputy clinical director, as does Deborah Sturdy (a member of our nurse consultants group), as the senior nursing advisor. But the future role of a clinical director is uncertain.

Restrictions and Rationing in Social Service Provision
Talking of politics and resources, the government’s own recent report on provision of home care, the third annual report of the Commission for Social Care and Inspection shows that despite an increase in the proportion of people over 75, fewer were receiving home care services. Services are being increasingly rationed – with priority given to those with “substantial care needs”. Denise Platt, the chair, said in an interview with the Guardian that “People who only five years ago qualified for council-arranged help are today excluded by the system and left to fend for themselves. The poor experiences of people and their carers trying and failing to get sufficient help contrast starkly with those people who do qualify for council-arranged care.” Also, that there was an “urgent need to create a fair and equitable social care system, which is sustainable and affordable.” The report stated “it is striking that critical decisions over who was eligible for care were not carried out by staff with a professional social work background, in the six councils it studied in depth”. A parliamentary enquiry has been announced and Ivan Lewis was quoted as saying “the rationing of services for vulnerable and frail older people has become inconsistent and unfair” And that applying a “vulnerability test” to restrict services only to the most frail flew in the face of the government’s own focus on promotion and prevention.

Resource to the fore again
Meanwhile, north of the border, the news emerged in February from an Audit Scotland report that the Scottish decision to allow free personal care for all, non-means-tested had resulted in a spend four times that originally projected with an overspend of £63m. Equity, universality and needs based provision are seemingly irreconcileable goals in any resource limited system.

Useful Articles
We had a recent discussion at the Policy Committee on the implications for staff “at the coalface” of implementing the Mental Incapacity Act and lessons from the Scottish experience. We plan to have something in the next newsletter on this. However, two recent useful articles on practical application of the act can be found in BMJ (Nicholson et al BMJ 2008; 336:322-5) and in Clinical Medicine (Muckherjee E et al 2008; 8(1):65). Finally, as we all deal day to day with malnourished inpatients, there was a recent very useful review on this subject (Lean M, BMJ 2008;336:290) - which is in turn, a key part of the dignity agenda.

Campaigning and Naming
All of this leads me finally, to the issues I raised in my December Editorial. In response to the question of whether or not we should campaign, I have received no responses. As a busy DGH doctor myself, I realise that this lack of response may simply reflect how busy members are. What it doesn’t leave me with though, is a sense of what BGS members think about this issue. You may all be very opinionated one way or the other or you may be supportive of the committees in making decisions on your behalf. Again, views please.

On the allied issue of whether a change in our name would help us in a campaigning role, we have received three replies on this issue. How representative they are is hard to say. However, it would seem that the issue of our name has been raised and shelved repeatedly. Time for a referendum of the members perhaps? If we do change, I do believe that the new name should reflect our specific focus on better health assessment and health care for older people. But as things stand there doesn’t seem to be a groundswell in favour of change of any kind.

Until next time.
David Oliver

BGS Newsletter, March 2008
Issue 15 ISSN 1748-6343 15