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The government in England is proposing to unite the various pieces of law on equality and discrimination under the umbrella of one “Equality Bill”.

It might seem surprising that older people are currently not protected in English law from age-based discrimination in the “provision of public goods and services” (such as health and social care). The Parliamentary Inquiry into the human rights of older people in health care has already highlighted that prisoners for instance, currently have more rights than elderly nursing home residents. Even where explicit age based policies have been rooted out (for instance as a result of the 2001 NSF for older people, we have all seen examples of covert and overt ageism in the attitude of professionals or the public to frailer older people or in the prioritisation of services, resources and performance frameworks, as well as in clinical decision-making.

I recently attended a workshop on behalf of the BGS, along with other stakeholders from medicine, nursing, charities and government bodies to examine this issue. Several examples of services felt to be inherently ageist were highlighted. The issue also arose of cases in which age might be a legitimate exemption as a valid factor in clinical decision making (for instance around the probability of success of IVF, as a factor in prognostic scores for Intensive Care Unit patients or in the utility of bone densitometry as a technology). Even here, it is surely the patient’s overall physical status, co-morbidity and individual outlook which is more material than their chronological age, used arbitrarily and in isolation. As some of the participants pointed out in a discussion about whether NIHCE with its use of cost per QALY might be inherently ageist, we do also need to be critical about what we mean by “evidence-based” practice when so often the participants in clinical trials do not reflect the complex older patients with whom we deal daily. Nor do the existence of NIHCE guidelines or NSF targets guarantee that older people will be adequately addressed or treated, as major recent audits on continence, falls, bone health or delirium indicate and as the dementia strategy have highlighted. Judicial review has tended to focus on access to treatments proscribed/restricted by NIHCE such as herceptin rather than the lack of provision of those recommended by it.

Our relationship with the media and other charities
The BGS has been developing stronger formal links with Help the Aged (to merge with Age Concern on 1 April. They haven’t decided on what to call themselves yet). The charity has been lobbying the government hard to push the agenda around age discrimination in healthcare - the concern being that unless we also have the detailed regulations in place to make the aspiration in the equality bill a reality and before the next election, the whole cause will be put back by a couple of years. There is now a petition for an early day motion to push for this. And as part of this, Help the Aged has worked closely with the BGS – an example of win/win with their high profile and our clinical credibility. A survey was commissioned of BGS members in 2008 with over 200 members replying). The results of this survey were used in a joint press release from the BGS and Help the Aged, on 26 February and I was on hand as the official BGS media contact the following day. The first call I got was from the health correspondent of a national daily who was fairly sceptical about the validity of a survey of specialist geriatricians with a fairly low response rate. I pointed out that these were nonetheless the views of frontline professionals working in the service and that there was lots of other objective evidence of a raw deal for older people, from the Dignity In Care Reports, the audits and parliamentary inquiry mentioned above. Nonetheless, news values being what they often are, he chose to lead with a story entitled, “masturbation good for the over 50s.” I also gave lots of a copy to a well known “mid-range” national paper, with several examples of inadequate care for older people around continence, fractures, falls, dementia, dignity and the labeling of people with legitimate medical illness as “social admissions”. For the second time this year, said newspaper (which always insists on using the blanket term “the elderly”) didn’t consider these facts newsworthy enough – there being no individual story or scandal of abuse or neglect on which to hang them

Did the press release work?
In my time as Deputy Secretary and Secretary of the BGS, I have done various bits and pieces about geriatric medicine on radio/tv and in the papers, but this was my first taste of working with the highly professional and polished PR machine of Help-the-Aged. I had taken a day’s annual leave to clear the decks which was just as well. I decided right at the outset that there was a handful of key messages I wanted to convey - essentially: a) older people are the biggest group of service users – not a minority (hence my dislike of “the elderly” as a term), b) common conditions in older people tend to be less well recognised, managed and funded, with less training, research funding, resource of performance targets, c) where conditions affect young and old in equal measure, they tend to be treated very differently in the two groups, d) presentations of illness in frailer older people with loss of function tend to be written off as “acopia” or “social” when an actual diagnosis is required as would be expected in a younger patient, e) the current lack of protection in equality law. In the event I found myself talking about the issues non-stop starting at 6:05 on Radio Five Live, through to appearances on Radio Bristol, Cornwall, Ulster and London and a trip to BBC TV centre for an item on News 24. The interest had died down by teatime in favour of kebabs are unhealthy” and “octuplets in America”, which tends to be the way of things with the news media, but we did get a lot of coverage for the cause and stir some debate. It was pretty surreal talking to people whom I usually listen to or watch and even more surreal doing the local stations interspersed with phone-ins about “left handedness”, “farming”, and “filthy lyrics in songs your kids listen to”. I would say that throughout the day, I was generally asked intelligent and serious questions. The commonest issue which came up (including from the BBC TV people after we had gone off air) was “isn’t it all about money/finite resources?” I pointed out repeatedly that whilst money was finite, it wasn’t down to individual practitioners to make arbitrary decisions based on age alone and that it would be better to have an honest political debate about age-based rationing rather than covert or unwitting prioritisation and that some things such as better attitudes, caring and knowledge didn’t always cost. This point was re-inforced on the BBC later by Joan Bakewell, who made the point that few older people would ever take recourse in law and that inculcating more caring and patient attitudes in staff didn’t always cost.

I am pleased to report that many callers on stations told positive stories about their experiences in the NHS or denied that they had ever experienced ageist attitudes. This is a constant tightrope that the BGS has to walk. We can campaign for dignity in care, we can highlight deficiencies in funding, training or service provision, but we also need to remember that most hospital units receive far more spontaneous thanks and gifts than complaints and most patients are satisfied with the service they receive. So we also want to celebrate good services and caring staff and avoid scaring the bejesus out of potential service users or their relatives. (See Paper by Iliffe et al in the JRSM 2008). I therefore found myself repeatedly using the end of life care strategy as an example of an initiative backed by real “must-do’s” and resource which was already beginning to make tangible improvements to palliative care for older people.

More of the same?
In addition to our growing relationship with allied charities, I am pleased to report that the BGS has recently advertised for a media and publicity officer and that there has been a strong field of applicants. This is a welcome development. Whilst we are often excellent at responding to consultations and enquiries behind the scenes, we have not always been the most pro-active at securing coverage or raising awareness around older people’s healthcare issues, nor have we always been seen as a “go to” organisation. With over 2,500 members and the largest of all the physicianly specialities in the UK we perhaps need to start punching our weight and this initiative may help. When I was speaking to various journalists they seemed uniformly surprised when I gave them basic statistics about the prevalence of falls, osteoporotic fractures, incontinence or dementia, or the percentage of bed days occupied by patients over 65. Several were almost unbelieving when I explained the phenomenom of delirium of physical illness manifesting with functional loss. But then lets face it, even within the medical profession, we could be more proactive considering what a huge chunk of adult medicine and surgery involves patients with geriatric syndromes of multiple long term conditions. As a “for-instance”, go into any medical admissions unit in the UK and the junior doctors will be aware of BTS guidelines on pneumonia, asthma or chest drains or BHS guidelines on hypertension management. But how much general awareness is there of our own guidelines on say delirium? Some of this may of course be down to how much we bang the drum in our own hospitals – perhaps our speciality has tended to attract doctors who are sometimes too “reasonable”. Perhaps we really need to acknowledge that the basics of good geriatric medicine should be everyone’s prerogative in adult medicine (for further discussion see article by Dr Thompson ).

Academic Geriatrics
One way to lever up the profile of our speciality and that of the older people we look after is by academic profile, including research and teaching. Although there are some pockets of very high profile research around the UK and there are around 50 people with the title of professor in the UK and Ireland, there are a number of established medical schools with no academic department or with un-replaced chairs, or with chairs who have no clinical background in our speciality. Whilst we all know that much of the teaching of undergraduates is led by NHS consultants, this fact does suggest that our position in ensuring geriatrics is at the heart of thinking in medical schools might be weakened, not to mention our ability to generate a better evidence base for what we do. It is also inescapable that a high number of presidents of medical colleges or specialist societies, or others in senior leadership positions in the NHS, are drawn from the ranks of clinical academics. This issue contains a lively debate about the current state and future of academic geriatrics in the UK.

Jed Rowe
A theme of this editorial has been the need for high quality teachers, mentors, role models, campaigners and opinion leaders in the our field and Jed was one such individual. I met Jed when I was a Senior Registrar and went to give a talk at his beloved Moseley Hall Hospital. I was immediately taken with his knowledge and passion and his outspoken and deliberately challenging views. He clearly cared deeply about the welfare of older patients, was not afraid to stir things up on their behalf and as many would attest, took a keen interest in mentoring and developing up and coming young doctors, including my own career even though I was nowhere near his deanery. He was an inspired and frequently mischievous lecturer and a deeply original thinker about the speciality. He will be missed by many of us. At the recent national conference of the falls and bone health section I was reminded that he called his falls clinic “the well-balanced clinic” a decade ahead of the data showing that older people who fall respond better to positive messages than the “F” word. For those who haven’t seen it, the letter in January’s Age and Ageing by Paula Nenn would strike at chord even with those who never met Jed and certainly tells of a career which made a real difference to the care of older people. Most tellingly, she says that “I have seen countless young doctors arrive as physicians and leave as geriatricians after 6 months working with Jed”. Evangelism isn’t always a bad thing, especially, as in Jed’s case, it is backed by logical arguments and a clear understanding of the evidence and we could all take something from his example.

National Dementia Strategy
The Strategy has now been published and we hope to have comment in our May issue.

David Oliver

BGS Newsletter, March 2009
Issue 19 ISSN 1748-6343 20