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EDITORIALS: Iona Heath Long term care for older people BMJ 2002; 324: 1534-1535 [Full text]

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Issues of Perceived Value

Ned Hoke   (29 June 2002)

Older than old

Michael O'Donnell   (29 June 2002)

Long term care for older people: dementia is the main issue

Tom R Dening   (29 June 2002)

full funding from what source is long overdue?

Stephen F Hayes   (1 July 2002)

Re: Long term care for older people: dementia is the main issue

John C Campbell   (5 July 2002)

Long Term Care

Kalman M Kafetz, London E11 1NR UK   (12 July 2002)

All NHS HEALTH CARE IS NOW FREE BY LAW

Stephen Squires   (13 May 2003)

Issues of Perceived Value 29 June 2002
Ned Hoke, Ecological Medicine/private Western US Send response to journal: Re: Issues of Perceived Value	Ione Health's perceptions seem both just and humane. Treating a human individual as increasingly unworthy while headed into increasingly older age or greater neediness has complex roots and provenance. In ages of scarcity leaving the old to die without support was in some cultures the expected doorway. Within the immediate present this is no longer presentable but an intermediate way has emerged that banishes the person from the rings of full human value while holding their bodies alive with modern medical marvels and warehousing. Reinventing conceptions of life that see the whole time-strand of human living as emergent mystery full of endless value to the last breath and beyond might be the only way overcome the amortized machine replacement principles that lurk beneath the surface of such issues as this.
Older than old 29 June 2002
Michael O'Donnell, Writer and broadcaster Handon Cottage, Markwick lane, Loxhill, Godalming, Surrey GU8 4BD Send response to journal: Re: Older than old	Older people, indeed. I was taught at school that in the absence of a comparative object – “I am older than you” – the adjective older means older than old, mid- point on a scale that runs old, older, oldest. I may well be frailer than I think but I resent the implication that I’m even more ancient than old. The patronising euphemism “older people” as used in this editorial, and by the jargonists who create entities like the National Framework for Older People, is a neat – and, in this case, ironic – illustration of what the author calls “the solid core of ageism within the English healthcare system”.
Long term care for older people: dementia is the main issue 29 June 2002
Tom R Dening, Consultant psychiatrist Cambridgeshire & Peterborough Mental Health Partnership NHS Trust, Box 311, Fulbourn Hospital, Cambr Send response to journal: Re: Long term care for older people: dementia is the main issue	Iona Heath (1) makes a convincing case for abandoning the distinction between personal care and nursing care in England, and therefore for following the Scottish example of providing free personal care for older people in need of it. Frank as this editorial is, it does not however go to the root of the issue. There is not a single mention of the importance of dementia in determining the levels of care needed by older people. Moreover, there is a curious general reluctance to acknowledge just how fundamental dementia is to the whole question of long term care. Instead, euphemisms like 'frail' or 'vulnerable' are used, which do not reflect the real picture. Yet we know from several studies (2,3) that the majority of residents of all types of care homes, even those that do not purport to care for people with dementia, do in fact have this condition. Because of the invalid and unreliable division of care homes into residential and nursing, 'EMI' and 'non-EMI', there are perverse incentives not to even recognise that older people may have dementia when they are being assessed (4). So the real reason why there is no sense in separating 'personal' from 'nursing' care for older people is that most older people in long term care have dementia. They require care which is sensitive to the needs of people with dementia, and in that sense is specialist dementia care. They do not particularly require nurses to provide their care, nor however should we pretend that their needs do not exist or do not require to be met. Until this issue is made overt and firmly grasped, we will make little progress. (1) Heath I. Long term care for older people: increasing pressure for change. BMJ 2002; 324:1534-1535 (2) Macdonald AJD, Carpenter GI, Box O, Roberts A, Sahu S. Dementia and use of psychotropic medication in non-'Elderly Mentally Infirm' nursing homes in south east England. Age Ageing 2002; 31: 58-64 (3) Matthews FE, Dening TR. The prevalence of dementia in institutional care. Lancet (in press) (4) Macdonald A, Dening T. Dementia is being avoided in NHS and social care. BMJ 2002; 314: 548 Declaration of interest: I have just completed a secondment to the Department of Health as a Senior Professional Adviser. These views are entirely my own and not necessarily those of the Department of Health.
full funding from what source is long overdue? 1 July 2002
Stephen F Hayes, GP Weston lane surgery, Southampton, SO19 9HJ Send response to journal: Re: full funding from what source is long overdue?	The demographic time bomb is certainly coming home to roost, pardon the mixed metaphors, as social and medical advances lead to long years of retirement, often with decling health, for the many. The belief that the old are "entitled" to full health, nursing and social care is very strong. However, what is the nature of this entitlement and how can it be satisfied? The founders of the British welfare state promised "cradle to grave" care paid for by National Insurance, but there was never any fund set up, all state funded care comes from current taxation. The promises made were unsustainable and at the expense of future generations. Things have changed. Young couples today are struggling to find the money to buy a home and are putting off childbearing because of the high cost of living. Must they be forced to pay yet higher taxes so that state care can be provided to 80 year olds who in many cases are sitting on capital gains from decades of fat years of stock market gains and house price inflation? By all means raise tax to pay for care of the elderly-but not income tax. The dead do not feel the pain of taxes-tax them by lowering inheritance tax thresholds. It is unjust that working people who are curently seeing their pension funds decline in value should be taxed more heavily so that the state funds the care of an octegenarian who, when they die, leaves £200,000 to his or her sexegenarian offspring. Where is the moral basis for the assumption that the state has the right to tax the working population to prevent a retired person spending their accumulated wealth on buying the nursing and social care that their children are unwilling to provide-and then to allow those children to pocket the value of the estate? conflict of interest-I stand to gain £100,000 or so on the passing of my parents, but I won't need it. However I am being bled dry by income tax.
Re: Long term care for older people: dementia is the main issue 5 July 2002
John C Campbell, Prof. of Political Science University of Michigan, Ann ARbor MI 48104-1608 Send response to journal: Re: Re: Long term care for older people: dementia is the main issue	Dementia is indeed a difficult problem. Perhaps the biggest problem with Japan's new mandatory long-term-care social insurance system is what many perceive as insufficient weight to dementia. Since the assessment is based on ADLs, and many with Alzheimer's can feed and dress themselves, they tend to be put in one of the lower categories (of six). Or even if not too low, the services available are for fairly intensive care (measured in mintues) while demented people often need quite unintensive supervsion (measured in hours). Japan is going to weigh dementia more heavily but it doesn't solve the problem. On the other hand, the fastest- growing program in Japan is Alzheimer's group homes, treated as residences rather than institutions, on the Scandinavian model. These are not too expensive and seem to meet the need very well for many people.
Long Term Care 12 July 2002
Kalman M Kafetz, Consultant Physician Department of Medicine for Elderly People Whipps Cross University Hospital, London E11 1NR UK Send response to journal: Re: Long Term Care	There is much sense in Iona Heath's article and the comments in the web responses on the importance of dementia as the principle factor in the need for residential care. However, if care is free, more money will pass to heirs, thus increasing the wealth difference between rich( with inheritances) and poor (without). It would be interesting if health economists could calculate the public health cost of this.
All NHS HEALTH CARE IS NOW FREE BY LAW 13 May 2003
Stephen Squires, Retired Scientific author/journalist Bridestowe. Devon. EX20 4QF Send response to journal: Re: All NHS HEALTH CARE IS NOW FREE BY LAW	This article overlook's the fact that the government has CONCEDED that all care i.e., ALL 'health' and ALL so-called 'social' care is now free 'at the point of delivery' See HSC2001/17: LAC(2001)26, page 31 "Where an individual's primary need is health care then the WHOLE PACKAGE of care must be paid for by the NHS" Also, see my response 'An Absolute Right to Free NHS Care' 28th. April. Learn more at WWW.nhscare.info Competing interests:   None declared