The care of older people

(it's a time machine!)

The care of older people (with long-term problems)

Single organ therapy for medical specialties, general medicine and its subspecialties has increasingly failed a number of groups of people over the last 200 years or so. The largest group were elderly people who were summarily dismissed from the Infirmaries from the days of their building as 'vagabond beggars, incurables and elderly'[1].  The vagabonds at least were welcomed after 1948 when the NHS diverted attention from people's cheque books and onto their illnesses.  However other groups have continued to suffer from the tyrrany of single organ care, notably the 'incurables', young chronically sick people and those who were not capable of 'getting better' immediately. The lack of good consistent post myocardial infarction advice despite excellent research findings[2] [3]  and a lack of rapid admission[4] [5] and full rehabilitation services[6] for stroke victims remain a matter for concern in general medicine.

Is geriatrics the right model?

Geriatric Medicine “is that branch of general medicine concerned with the clinical, preventive, remedial and social aspects of illness in older people. Their high morbidity rates, different patterns of disease presentation, slower response to treatment and requirements for social support call for special medical skills”. The purpose is to restore an ill and disabled person to a level of maximum ability and wherever possible return the person to an independent life at home.[7]

General rules for deciding upon effective services have been put together by a large number of people. The one that appears to have stood the test of time was put together by Maxwell.[8]  These should be borne in mind, as well as the quality of the direct care provided by a doctor or nurse for patients.

·         Access to services

·         Relevance to the needs of the whole community

·         Effectiveness for individual patients

·         Equity.

·         Social acceptability

·         Efficiency and economy

Access to services

Services given in the home or near to people are likely to be more accessible to patients than those given at a point for a large population.  Smaller geriatrics hospitals have largely closed down in preference for a district general hospital site over the past 20 years or so. Where the geriatrics department has remained separate it has, usually, been in poorer premises with poorer physical access. especially to older premises.  Geriatrics appears to have lost out in this regard. Patients often have another type of problem with access to services when they try to find their way through the complex appointment systems to see a consultant. Geriatric care has been good at not developing waiting lists, though this is a function of the fact that most admissions are emergencies.

Geriatricians still occasionally do domiciliary visits and a few work out of health centres but this has not been common. In terms of access such approaches are to be desired. Access to services can mean other things.  One is whether people or the professionals know about the service in question.  There is little point in having a special clinic for a particular group of people if the publicity for it is bad. In the past such innovative schemes as night-sitter services and incontinence laundry services have foundered because of a perceived lack of demand when lack of publicity was the culprit.

Relevance to the needs of the whole community

UK general practitioners, as gatekeepers for the service, have been particularly effective in keeping down the demand for services, compared with countries where patients have open access to hospital care. Sometimes however there appears to be an inherent ageism in this parsimoniousness.

Effectiveness for individual patients

Scientific testing of the effectiveness of care for elderly people still lags some way behind that for the middle aged due to ageism among researchers. There is an increasingly expanding body of knowledge in this area, especially about the effectiveness of high tech medicine in older people and in the area of rehabilitation, lacking in good scientific research until quite recently.

Equity

Equity is a central concept for geriatricians for ageism is rife within the health service, as recent studies have shown. Such ageism may be subtle, such as the failure of a GP to refer for specialist care an elderly patient with renal failure, or perhaps more commonly, to wait until the disease is at a more severe stage than for younger people.

Social acceptability

Geriatricians should be aware of the social acceptability of the treatment that they give or purchase for their patients.  However they are not always as aware of their patient’s views on the acceptability of treatment or, for that matter, their social conditions as we might wish[9].

Efficiency and economy

The specialty of Geriatrics is not perceived as a pricy specialty. In fact high staffing ratios are important in geriatrics care which balance somewhat he faster turnover in non-geriatrics wards. Overall, as far as it can be measured, they probably cost about the same per patient.

In as far as some geriatrics departments are involved with cold orthopaedics they must share some of the ridiculously long waiting lists for assessment, operation and rehabilitation for an operation which, in terms of cost per QALY is one of the most efficient and effective in medicine. 

The Future

One of the problems within geriatrics is that the roles of geriatricians are often not clear.  There are a number of models which may cross over. A commissioner on a PCG, keen to get the best value might want to know more precisely what he or she is getting for their money. There appear to be five models, some of which cross over one another.

·         General physician for older people

·         Expert in complex pathology

·         Specialist in holistic medicine for older people

·         Expert at rehabilitation

·         Expert at assessment for community care

Geriatrics medicine has put on the agenda the differences between elderly people and younger in relation to acute inpatient care. I think geriatrics needs to make clear what their preferred sphere of influence is before purchasers, so that they can decide on how geriatricians fit into the treatment of ill people.  Geriatricians may say that they are expert in all of the fields I have mentioned, but there are two dichotomies to be faced;  the specialist versu the generalist and the simple care of the aged versus the care of complex problems at all ages.  I do not think a geriatrics service in one place can perform all of these functions. 

My personal preference would be for them to take over the general care of complex problems in all age groups.

References