Intended for healthcare professionals

Editor's Choice

Not for wimps

BMJ 2006; 332 doi: (Published 18 May 2006) Cite this as: BMJ 2006;332:0-f
  1. Fiona Godlee, editor (fgodlee{at}

    What can we expect in old age, assuming we are lucky enough to make it that far? We may hope for physical and mental well being, independence, fun, dignity, and a peaceful death, but what are the prospects?

    Based on current trends, it's hard to say. There will be more of us, with proportionately fewer younger people to finance our longer lives. The expansion of private provision in health care (p 1172) raises fears that the old and chronically ill will be increasingly poorly served. And yet recent reports and initiatives suggest that new targets are improving outcomes and changing attitudes.

    Jacqueline Morris and colleagues give a cautious welcome to the latest report on the standards of health, treatment, and social care of older people in England (the National Service Framework (NSF)), but they think good care is still too patchy in the NHS (p 1166). Too many elderly people in hospitals suffer routine indignities, such as having to use commodes in mixed sex wards behind wholly inadequate curtains. Too often old people become, in Colin Douglas' words, “souls in cages” (p 1221). “In the rush and glamour of acute care, in the busy system that is designed to cure and doesn't like to lose, there are priorities that may take insufficient account of the worse-than-death outcome that so many of us dread.”

    And we have clearly lost the plot when elderly people in long term care are asked to order their meals as much as two weeks in advance. Kristel Nijs and colleagues compared these long range forecast meals served on a tray at the bedside with more sociable meals, sitting at a table with a choice of foods and members of staff to talk to and provide help (p 1180). Their randomised trial found significant improvements in quality of life, health, and body weight. Anne Milne and colleagues highlight limitations in the study but confirm the need to tackle social factors such as isolation that can contribute to the “anorexia of ageing” (p 1165).

    Both the NSF report and our editorial (p 1166) acknowledge that real transformation won't be achieved by simplistic targets. But targets can bring better priorities. Diana Jelley questions even that (p 1221). By the time her 90 year old patient died her care fell short of many of the Quality and Outcomes Framework (QoF) targets against which GPs are paid. But, says Jelley, other things, such as continuity of care from a practice where everyone knew her, were highly valued but are harder to measure. She says these aspects of care may suffer in the new patient led NHS, where priorities are set by middle aged, middle class people living in middle England.

    As someone once told me, old age is not for wimps. We can hope things will be OK when our time comes. Or we can work towards better attitudes, provision, and priorities for elderly people now. Call it enlightened self interest, or just the right values for a civilised society.


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