| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
| ||||||||||||||||||||||
COMMENTARY |
Clinical Geratology, University of Oxford, Green College, England.
Address correspondence to John Grimley Evans, MD, Professor Emeritus of Clinical Geratology, University of Oxford, Green College, Oxford OX2 6HG, England. E-mail: john.grimleyevans{at}green.ox.ac.uk
Ignatz Nascher invented the word, Marjory Warren created the specialty; directly and indirectly, her work inspired the development of geriatrics in many countries of the world.
She set out principles of care for chronically disabled older people and recognized the importance of bringing geriatrics expertise into the training, practice, and thinking of both doctors and nurses. To achieve this, it would be essential, she averred, to develop geriatrics units in acute hospitals (1).
In the United Kingdom, geriatrics was established as a recognized specialty as soon as the National Health Service (NHS) was introduced in 1948. Geriatricians were immediately confronted with problems in medical politics. The NHS had merged the previous dual system of charity and workhouse hospitals into a single service with geriatrics departments based in the latter. Before the NHS, hospital consultants had given their services to the charity hospitals for free while earning their living in private practice. It continued to be assumed that NHS salaries would never be more than token honoraria. While members of the medical establishment were happy for other people to look after the workhouses, they were less enthusiastic about increasing the number of consultants competing for private practice. Geriatricians were therefore established as an underclass without access to acute hospital beds and with limited rights to private practice.
It rapidly became clear that Marjory Warren had been right. The key to a successful geriatrics service lay in the acute hospital where most of the mistakes that led to unnecessary disability among older patients were being made. The reasons why geriatrics needed to be based in acute hospitals rather than primary care were also clear (2). Geriatricians set about trying to influence the care of older people in acute general hospitals in a variety of ways, depending on local resources and support from colleagues. By the late 1970s, three basic patterns of geriatrics services had become established in England and Wales. The traditional model was restricted to a geriatrics unit that offered long-stay rehabilitation and day hospital facilities accepting referrals from acute hospitals or general practitioners. The age-defined model was established where geriatricians had, by one means or another, acquired sufficient beds in an acute hospital to provide full medical services for people above a defined age. The integrated model, aimed at "geriatricizing" the whole hospital service by placing Physicians with Special Responsibility for the Elderly (PSREs) on the staff of the acute hospitals, sharing in the acute emergency medical rotas but also providing the rehabilitation and long-stay services on the same or other sites. The PSREs shared the same junior medical and nursing staff with other physician colleagues, thereby contributing indirectly as well as directly to the care of older patients and to the training of professionals of the future.
For 20 years, debate continued over the relative merits of these three models. The traditional model was dependent on other doctors knowing when and about what to consult the geriatrics service; although continuing in Scotland, where hospital beds were plentiful, it became less prevalent in England and Wales where resources were more limited. The age-defined model indirectly fostered ageism in some centers by creating two parallel medical services—for young and for old patients—but with poorer facilities for the old. The integrated model depends on sharing of resources and a degree of collegiality that is not always attainable among doctors and nurses. However, at a time when recruitment of British medical graduates to geriatrics was essential to the development of the specialty, it seemed to be effective in attracting young doctors (3).
The NHS has always been seriously underfunded, and for years was only able to survive because its minimal bureaucracy allowed it to be outstandingly efficient at translating money into care. Politically, the NHS is vulnerable because of its funding from central taxation; lack of hypothecated funding means that government can divert money that might go toward health to other interests. In the 1990s, government policy led to the closure of NHS long-stay geriatrics beds in order to shift the costs of long-stay care from the NHS budget—free at the point of delivery—to the private and the means-tested social services sector (where costs fall partly to local rather than central taxation). Many rehabilitation units have also been closed to save revenue. Although the government has now started to inject more money into the service, too much of it is being soaked up in elaborate new management and information structures. While health professionals continue to see themselves as primarily responsible to the public, government-imposed "targets" leave the new breed of managers in no doubt that their jobs depend on loyalty to their political masters.
Government intentions for the future care of older people have been decreed in a National Service Framework, which some critics see as aimed primarily at reducing NHS expenditure on older people rather than enhancing their well-being (4). Geriatricians are still being actively recruited, but it is not clear what their future role will be. Academic departments of geriatric medicine, more successful in teaching than in research in the United Kingdom, are withering in an age of molecular medicine. But perhaps the specialty as originally conceived has served its purpose. In 1973, one newly appointed professor of geriatric medicine commented that, if at end of his career medicine had become sufficiently geriatricized for there to be no need to appoint a successor, he would rejoice rather than grieve. However, ageism is so deeply entrenched in British society that if geriatrics were to disappear, it would surely have to be reinvented.
References
| ||||||||||||||||||||||
| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
