Letters Primary-secondary care divide

Putting more specialist physicians into the community is not answer to primary-secondary care divide

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e4730 (Published 16 July 2012) Cite this as: BMJ 2012;345:e4730
  1. Roger A Fisken, retired consultant physician1
  1. 1Bedale DL8 2JE, UK
  1. daardon{at}yahoo.com

I agree with Hughes that everyone involved with caring for elderly people should be aware that “the urgent admission to hospital of a vulnerable old person in crisis must be questioned at all times.”1 However, putting more specialist physicians into the community may not solve the problem. This proposal might improve elderly people’s independence and quality of life, but it won’t stop them being admitted late in the evening when they feel unwell and a neighbour or concerned person isn’t sure what to do. I suggest:

  • The government puts more money (real money, not fudged budgets) into out of hours primary care, community physiotherapy, and occupational therapy.

  • Having done this (and not before), the government reimposes the obligation for general practice to provide 24/7 care for patients.

  • Commissioners encourage specialists to provide rapid access assessment clinics for elderly people, including domiciliary visits if needed.

  • The registration of all care homes should require that admission assessments of residents include an explicit agreement about what to do in the event of acute illness. Admission rates of patients from care homes should be monitored and those with rates well above average visited by the appropriate regulator.

  • Emergency ambulance crews are given explicit guidance about the admission of elderly people from care homes. In particular, crews should ask staff, residents, and relatives: “how do you think the person will benefit from being admitted to hospital as an emergency?”

Accusations of ageism may inhibit such conversations, but local health organisations and the NHS need to be upfront about why this discussion is necessary.


Cite this as: BMJ 2012;345:e4730


  • Competing interests: None declared.