Changing hearts and minds

BMJ 2002; 324 doi: (Published 15 June 2002) Cite this as: BMJ 2002;324:1416

Ian Philp, the national director of services for older people, tells Lynn Eaton how he is trying to redesign the NHS through the eyes of older people

The trouble with Ian Philp, if there is any at all, is that he is so terribly nice. Maybe it's the winning Scottish accent, but he reminds you of a modern day Dr Finlay who has somehow held on to that bedside manner often forgotten in today's high pressured NHS. You can't help wondering, though, whether perhaps he is just a bit too nice for the difficult job he has ahead of him.

Professor Philp's appointment as the national director for older people's services (the older people's tsar) 18 months ago caused a few ripples—some of jealousy, no doubt—among certain quarters of the medical profession. How could one so young (Philp is only 42) win such a high profile job? Now the question is less about his age, more about his ability to win friends and influence people—not just in the medical profession and among older people's groups, but in the corridors of power.

Philp is director of the Sheffield Institute for Studies in Ageing and professor of health care for elderly people at the Northern General Hospital in Sheffield, where he still works as a clinician one day a week. He trained at Edinburgh University and almost gave up at one point, but he was persuaded to stay by his tutor, who told Philp he would be good for medicine. So he stayed.

Philp finally published his eight point national service framework for older people in March last year. But he doesn't judge its success so far on statistics alone, by trying to calculate, for example, how many strokes it may have prevented. He hopes that the framework is beginning to change attitudes. “The main achievement is engaging a large number of people who will be affected by it so that there is a common understanding of what we are trying to achieve.”

Philp comes over as politically correct and “on message”—though he denies any political affiliation. He rightly picks me up for saying “bed blocking” (“many older people find it offensive”), describes himself as a “value based” person (“I am sure most good doctors are”), and remains unruffled when I ask him about the criticisms made by Professor John Grimley Evans (BMJ 2001;322:807-8) that he was one of the “in-crowd.” After a long pause, Philp bats it back—“I don't know what the term means.”

When his framework was published, many doctors struggled with it. It is less specific about clinical targets than some of the other national service frameworks and more holistic in its approach to changing attitudes to older people in the whole of the NHS and social care services. Philp is a little amused that doctors find the language so alienating.

“I was talking to some people from the King's Fund recently who said the response from the social care community was that it was written by a doctor. I said, well actually the medical community think it was written by a social worker!”

But he accepts responsibility for the framework being so broad and all-embracing. “We are dealing with a redesign of the NHS and social care through the eyes of older people.”

But there are three areas that are clinically based, he says, pointing to the standards on stroke, falls, and dementia. “The bits the doctors like are the clinical service models. But this framework is not written to promote the interests of professional groups. It's written to promote the view of what older people need from the service. It's not a professional manual.”

It can't be easy, though, to face an audience of doctors and ask them to do something without the carrot of extra earmarked cash. No doubt failure to secure such funding was one of his low points in the last year, and publicly at least, he is still fighting. But he points out that following the Budget announcement, there is extra cash for the NHS as a whole, which is bound to have a considerable effect on services for older people.

“Older people's services are receiving more money for improving services than all the other frameworks put together,” he says, in what is becoming a well used phrase on his part. “What there isn't, is the earmarked funds around the clinical standards, which upsets people.”

He acknowledges that clinicians in his area are expected to meet certain targets on stroke and mental health, with no extra earmarked funds, whereas doctors who are asked to meet the targets on coronary heart disease and adult mental health have been given extra cash.

“But older people consume 40% of the NHS budget and 50% of the personal social services budget. It does not make sense to earmark 50% of the budget.”

With clear targets and service models set out in the framework, he argues, they can progress without earmarked funding.

So the lack of earmarked funds is not a constraint at all, then?

He ponders. “I think there is a constraint. If people think that the signal from lack of earmarked money means there is less importance attached to older people, that is a problem.”

But he is reluctant to accept that, given conflicting priorities, education of staff might lose the battle. “There will always be trade-offs between short term quick fix and the longer term sort. I'm working backwards from 2005—I'm not talking about getting good headlines for the next three months.”

He has avoided being too much in the media spotlight, preferring to measure his success by solid achievements, rather than column inches.

“Liam Donaldson, the chief medical officer, advised me on my first day in post to avoid the celebrity aspects of the job. He said ‘Ian, the day after you leave this job, you are going to be forgotten about.’”

Embedded Image

When Ian Philp published his framework, doctors struggled with it

The national service framework for older people aims to:

  • Root out age discrimination in the NHS

  • Provide person centred care

  • Provide intermediate care to prevent unnecessary hospital admissions and to ensure timely discharge from hospital

  • Ensure older people receive the specialist help they need in hospital

  • Reduce the incidence of stroke

  • Reduce the number of falls

  • Promote good mental health

  • Promote health and active life in older age

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