One thing I think we probably can all agree on (and as Cohen et al explicitly mention in their rapid response [1]) - lack of effective communication does no-one any favours.

This occurs in all parts of the system: within primary care (between usual care & out of hours care); between primary and secondary care (as detailed in Hughes' original paper); and within secondary care (continuity of care has been decimated by juniors' shifts, compounded by patient moves between specialty teams, wards and hospitals).

Ironically, the changing landscape of practice was beautifully summarized in Mangin's editorial [2] published only the day before Hughes' paper. The evidence shows that the response to these multi-domain (medical, social, psychiatric and functional) problems is comprehensive geriatric assessment [3].

However, this depends critically, among other things, on investigative modalities currently only available in hospitals. Unfortunately, at the moment, our historical model usually depends on admission (through the aforementioned inefficient system) to allow access to these resources. Despite geriatricians playing a significant role in the acute medical take, we all know what only too commonly happens next to the patients. As Mangin summarises in her strap line, this problem 'urgently needs radical shifts in research, evidence based guidance, and healthcare.'

Cohen et al [ibid] have shown a creative response to this challenge, as have Kannah and colleagues in SE Wales [4]. Sadly, the Government (whichever hue) and DH have let us down massively in two ways: they have signally failed to deliver a system-wide information infrastructure that is fit and necessary [5] for purpose; and they do not follow the medical profession they employ in basing system changes on evidence rather than ideological policy [6,7].

Having undertaken the largest reorganisation of the NHS since its inception, and delegated the organisation of the service to local level, they have neatly found an easy scapegoat if things don't improve! Since Kizer found that in reorganizing the VA to provide the best medical care in the US “We reduced staffing but the proportion of caregivers increased. You have to restructure your assets, but hospitals are major employers in every community and when you talk about cutting jobs it causes elected officials’ sphincters to tighten because hospitals are part of a community’s identity.” [5], I think sadly we can work out the likelihood of the necessary complex changes being undertaken at this local level.

I sincerely hope that I am proved wrong, and world class leadership (akin to Kizer's) triumphs in each local commissioning group.

Refs
1. Re: The primary-secondary care divide fails older patients
Cohen MAH et al.
http://www.bmj.com/content/344/bmj.e4009/rr/591609 (accessed 1 Jul 12)
2. Beyond diagnosis: rising to the multimorbidity challenge
Mangin D. BMJ 2012;344:e3526
http://www.bmj.com/content/344/bmj.e3526 (accessed 1 Jul 12)
3. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials
BMJ 2011;343:d6553
doi: 10.1136/bmj.d6553 (accessed 1 Jul 12)
4. The Gwent Frailty Programme
http://www.gwentfrailty.org.uk/ (accessed 1 Jul 12)
5. Healthcare Reform - How Kizer healed the VA
Payne D
BMJ 2012;344:e3324 doi: 10.1136/bmj.e3324
http://www.bmj.com/content/344/bmj.e3324 (accessed 1 Jul 12)

6. Test, Learn, Adapt: Developing Public Policy with Randomised Controlled Trials
Haynes L et al,
http://www.cabinetoffice.gov.uk/resource-library/test-learn-adapt-develo... (accessed 1 Jul 12)

7. The Big Society, Norman J. 2010 1st ed. University of Buckingham Press. Chapter 4. Rigor Mortis Economics, pp59-77

Competing interests: I am employed as a geriatrician, but have no party political affiliation

I was greatly concerned to come across what I consider a most 'ageist' article in a leaflet inserted in my parish magazine by a local GP practice. This was written as a justification in the name of "patient safety" for the recent doctors' 'Day of Action'. I quote:

"In a modern and fast changing NHS, we do not feel it is desirable for patients to be looked after by doctors in their late 60's. Long gone are the days when GP's could potter on until into their 70's. Medicine is far more complex and we are asked to manage patients who are far more ill, in the community than in the past. It simply isn't possible to stay up to date and work at the current required pace at that age. We would not want to be looked after by elderly GPs ourselves so don't see why our patients should have to be either."

My late husband, Ben Bennett (obituary BMJ Vol. 296 4 June 1988), was one of an increasingly rare breed of GPs who provided total care for his patients, including being on call for home visits evenings, nights and weekends. Had he lived, he would have undoubtedly followed in the footsteps of the many GPs, including his own grandfather, who have continued to care for their patients competently and devotedly well into their 70's and sometimes even 80's.

In my view, not only does the quoted article unjustifiably impugn the capability of those GPs (past and present) who choose to work beyond the official age retirement, but it also betrays a more general perception of people in their 60's and over as being increasingly unfit to carry out exacting and responsible work. Are magistrates (who do not retire until they are 70) and judges who frequently work on well beyond that, automatically incompetent? What about professors, politicians and other distinguished people who remain productive into old age? Should our own Queen discontinue her daily perusal of weighty affairs of state? Indeed, maybe this letter should be dismissed as senile ramblings, coming as it does from someone of 69 who continues to work as a freelance research psychologist.

I hope I am wrong. I hope that the GPs who wrote this article were seizing on this as an argument to excuse their taking industrial action, which is bad enough. Far worse though, to have to feel that an increasingly large proportion of the population is now viewed by the medical profession as automatically incapable after reaching a certain age.

Competing interests: None declared

There is much to commend in Dr Hughes' article, in particular we should make everyone involved with the care of elderly people aware that "the urgent admission to hospital of a vulnerable old person in crisis must be questioned at all times". I'm not sure, however, that his suggestion of putting more specialist physicians into the community will necessarily solve the problem; there is a lot to be said for this proposal as regards making elderly people more comfortable and improving their independence and quality of life, but it won't stop elderly people getting admitted late in the evening when they feel unwell and a neighbour or some other concerned person isn't sure what to do. I would suggest:
1) the government needs to put more money (real money, not fudged budgets) into out-of-hours primary care and into community physiotherapy and OT;
2) having done this (and not before) the government should re-impose on general practice the obligation to provide 24/7 care for their patients;
3) commissioners should encourage specialists to provide rapid-access assessment clinics for elderly people in their specialty, including domiciliary visits where appropriate;
4) it should be a condition of the registration of all care homes that their admission assessment of residents includes an explicit agreement about measures to be taken in the event of acute illness. The admission rates of patients from care homes in a locality should be monitored and those which have admission rates well above average should be visited by the appropriate regulator;
5) emergency ambulance crews should be issued with explicit guidance about the admission of elderly people from care homes. In particular, the crew should ask the care home staff, the resident and/or his relative the question: how do you think the person will benefit from being admitted to hospital as an emergency? Accusations of ageism may well inhibit this sort of conversation but local health organisations and the NHS as a whole need to be upfront about why this sort of discussion is necessary.

Competing interests: None declared