Editorials

Medicine must change to serve an ageing society

Eradicate age discrimination and increase resources

Doctors and those responsible for commissioning and shaping health services have failed to acknowledge the rapid ageing of most societies. This worldwide phenomena is unprecedented, leaving us ignorant, fearful, and reluctant to tackle it face on. A conference in London last month examined how medicine and its institutions must change to serve a growing older population while still meeting the needs of younger people. Two issues dominated: age discrimination and resources.

Currently 20% of the population of the United Kingdom is over 6012 million people. By 2031 this proportion will be nearly a third18.6 million people.¹ Most will lead healthy and rewarding lives, but the numbers of people needing acute and long term care will inevitably increase. Rates of cardiovascular disease, dementia, and osteoarthritis among elderly people in the next century will be greatly determined by success or failure now in preventing such disease.

Health care is ill suited to perform well in a world with many more elderly people because it is ageist. Older people face arbitrary discrimination in their encounters with health professionals,² and this probably reflects a wider ageism within society. Older people are excluded from research and many beneficial interventions, some of which would be lifesaving, and are insensitively managed.³

Recent changes in acute medical services in Britain have created an environment where ageism flourishes. More and more older people are admitted to fewer and fewer beds for shorter and shorter stays. Nearly a third of beds for acute cases are now occupied by people over 75, and the throughput per bed has more than doubled over the past 10 years in the geriatric sector.⁴ General practitioners are also under pressure, caring for increasing numbers of disabled elderly people in nursing homes.

The health needs of most older people are the same as for everyone else, but the oldest old, and those with chronic diseases or disability are characterised by multiple pathology, non-specific presentations, a high incidence of secondary complications, and the need for intensive rehabilitation. They need a generalist approach to assessment and treatment and are poorly served by a superspecialist profession. Even doctors who specialise in caring for elderly people often prefer curing acute illnesses to using their skills in chronic disease and rehabilitation.⁵

To combat age discrimination health professionals and their institutions must acknowledge and document it and then act to eradicate it. These actions need to go on at all levels of the service, including hospital departments and general practices. The General Medical Council, the royal colleges, and specialist associations can all guide their members through the process and must recruit older users of the health service to help them. The charity Age Concern continues to lobby for legislation to outlaw age discrimination ^{3 6} and also campaigns for a government inquiry into ageist practices in the NHS. Steps have already been taken to redress the imbalance of research in older people. The major research funding agencies now refuse to fund trials with an arbitrary age limit for recruitment. Longer term measures will begin at medical school, where modern teaching methods can be used to foster enthusiasm among medical students for older people and their problems. Partnerships with older people will enhance core teaching, as well as empower older health service users to shape the curriculum. Later on, all doctors could acquire the necessary skills by doing six months in geriatric medicine during training.⁷

Reshaping the health service around older patients need not be painful and can start now. Even small adjustments to the ward, clinic, or surgery can make a difference. For example, admission wards with access to a breadth of expertise are better for patients with multiple problems than direct admission to a specialist (say orthopaedic) ward. Individual doctors can also make a difference by seeking out and removing their own prejudices. More sweeping changes will have to follow, however, including: engaging older people in the commissioning and design of services; accepting that undergraduate and postgraduate training produces doctors whose aspirations don't match the needs of their patients; finding and protecting money to pay for care of older people; returning to an emphasis on rehabilitation and convalescence; and changing the way we think. If the health service could be made fit for older people, it would be fit for everybody.

But there is no escaping the conclusion that a health service that will serve an ageing population well will need substantially more money than is available now. Older people probably bear the brunt of rationing within the health service. Many of those who fought in the second world war, rejoiced in the creation of the welfare state, and paid for it throughout their working lives now feel let down. Many are bitter that the government has failed to produce any response to Royal Commission on Long Term care for Elderly People that was published in March. It recommended that the personal care element of the package should be free and funded by taxation. ⁸

There is still no consensus on where extra money for the health service should come from, but Professor Sir John Grimley Evans, a gerontologist from Oxford, who closed the conference, said there should be no further discussion of rationing until NHS funding is brought in line with other comparable European countries. The yearly average spend per head in the UK is 25% lower than the European average. If the government does not increase expenditure on the NHS substantially and if the health professions do not manage to counter ageism then the NHS may fail to meet the challenge presented by an ageing society.

Alison Tonks, assistant editor. 

BMJ

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