Abstract
On reading the recently published Health Ombudsman's report Care and Compassion, 1 I surprised myself at how pleased I felt. Not the response that author Ann Abraham intended, I am sure. The report concluded that the most basic standards had not been met in the care of 10 elderly patients in different NHS trusts. This was not a scientific paper, but it contained powerful information. The formal support for the care of older people by the Health Ombudsman felt empowering and leads me to reflect on elderly medicine and its place in the delivery of health care.
Directives such as the Department of Health National Dementia Strategy 2010 and the National Service Framework 2001 state clear objectives to ensure high-quality health and social care for older patients. However, the reality of providing care in a stretched NHS often results in a mismatch between these standards and what can be provided on a day-to-day basis. The reasons for this are complex and challenging to address but with an ageing population must not be ignored.
Since the days of Marjory Warren, a pioneer in the treatment of elderly patients, the aim of elderly medicine has always been to address the specific and complex needs of elderly patients. Sadly, the specialty has often been burdened in clinical and academic arenas with a ‘Cinderella’ reputation. While I believe this has largely improved, a shadow of it does still appear. How can this be? Elderly medicine physicians truly practise general medicine, addressing every system, multiple acute and chronic problems, with challenging ethical, therapeutic and management decisions. For this reason, elderly medicine physicians often have a central role in the delivery of the undergraduate curriculum in our medical schools. It is always of interest to me how, at the beginning of the third year, no hands are raised by the students when asked if they would consider a career in elderly medicine, and how surprised they are with how much they learn and how much they enjoy the specialty. Many of their opinions are changed by direct experience rather than the presumed image of what elderly medicine is.
I was delighted to hear at a recent meeting in our trust that Professor Sir John Took, Dean at University College London and Chair of the Medical Schools Council, very much supports the importance, and the core position, of elderly medicine in the teaching of our future doctors. However, I am mindful of my own experience as a trainee of needing to refer to myself as a medical registrar, not an elderly medicine registrar, to gain a fair hearing on referring a patient to a tertiary centre. I recollect my irritation (some 15 years ago) on being asked by a coronary care nurse if I was a geriatric senior house officer or a medical senior house officer, and her confusion when I answered that I was both. I remain perplexed as to why, in many trusts, elderly medicine colleagues have had to fight, and some are still fighting, for elderly medicine jobs to be considered part of the core medical training rotations. Surely, when over a third of the acute admissions to hospital are elderly patients, it should be compulsory? Interesting still, that our specialist colleagues such as the cardiothoracic surgeons and nephrologists actively manage patients well into their 90s, but that many health-care professionals often begin the discussion regarding management with ‘how old?’ When there is a shortage of resources, the elderly care wards are often the first to feel it, and so morale is affected and recruitment for nursing staff can be understandably difficult.
On a more positive note, the development of stroke medicine over the last 10 years is a fine example of how a clear identity and true team-working can improve patient outcomes. As a house officer 17 years ago, I realized that the patient with a stroke was often seen last with variable standards of care. The development of stroke units since this time has seen this previously truly ‘Cinderella’ condition become a priority within the health service, with the highest standard of team-working and consistent improvements in global patient outcomes as a result. I am sure that this is the direction in which elderly medicine should move. From one trust to another we call ourselves different names – geriatrics, elderly care or elderly medicine. We are often forced by resources to define the patients we able to look after by age (older than 80 years, older than 85 years) while in some centres by need. A structure where wards provide truly subspecialty care, such as dementia, falls, rehabilitation and acute short-stay wards, could replicate the successful model of stroke care. Striving for this universal patient-centred approach, where age is not a variable in the standard of care received, might allow patients to be truly assessed with regard to their individual needs with no reference to whether they are fit for a haircut or not! With many new initiatives planned, I am hopeful that those who are key figures in the delivery of health care in the NHS will be able to ensure that the mismatch between standard and practice that the Health Ombudsman reported is not something we read about on our newspaper front pages again.