The Major Influences in Geriatric Medicine
Three different groups, with different but complimentary agendas, challenged the neglect of elderly people in the United Kingdom in the mid 20th century. The first group, mainly doctors, had two aims: to discover the state of health of older people in hospital and the community, and to reverse the custodial care of the chronic sick. The second group, the Ministry of Health and its successors, had to solve the problem of 70,000 beds occupied by the chronic sick, which would impede the embryonic NHS. The third group, comprising philanthropic organizations, wanted to stimulate research into the ageing.
The Ministry of Health
The Medical Revolution (a) Hospital and community surveys
The health of the elderly in hospital was unknown in the early days of the NHS. Researchers in Birmingham surveyed regional chronic sick hospitals. They realised the inauguration of the NHS would trigger requests for the admission from older patients, which would add to the 14,000 people already on regional medical and surgical waiting lists. They believed elderly people blocked many local beds but lacked data. Their surveys showed that about half the patients inappropriately occupied a hospital bed. Other researchers in Oxford, Belfast, Lancaster, and Leeds found significant misplacement of older people in mental and geriatric hospitals.
The health characteristics of the elderly in the community were similarly unexplored and therefore surveyed. A Wolverhampton study found the majority were still mobile and living at home. Most illnesses were managed within a family using its own resources. A Sheffield investigation found one in five elderly people living at home were undernourished. A seminal survey of 173 local authority, private and voluntary residential homes in England and Wales showed much of the accommodation was of poor quality, some quite unsuitable for residential use, relationships between residents and care staff were uneven and the manner with which death was treated varied widely .
The Medical Revolution (b) Geriatric medicine
Starting in 1935 pioneering doctors led by Marjory Warren and Lionel Cosin, and followed later by Lord Amulree, Norman Exton-Smith and Sir Ferguson Anderson, began transforming medical management of the chronic sick. The problems they faced were medical, social, apathetic fellow consultants and management, and deficient education of medical students. The medical challenges included enormous workloads, many hundreds of inpatients, hundreds more on waiting lists for admission, very poor ward accommodation (some still had gas lighting), inadequate investigative facilities and a dearth of medical, paramedical and secretarial staffs. The social obstacles followed from the belief that long stay care was a matter for the State. Patients and relatives considered that admission to a chronic sick bed was a ‘bed for life’, perhaps as long as ten or twenty years, and therefore home accommodation was given up. Patients became institutionalized and relatives did not want them back. Home support from younger relatives weakened as family size decreased and more went to work. Indifference of local consultants and management committees towards elderly inpatients obstructed even minor developments causing geriatricians to resort to subterfuges to obtain heating on unheated wards, to repair leaky roofs, and even get basic washing facilities on wards.
It seems strange in these days to state that the first thing these pioneers did was to examine their patients and make medical notes, something at odds with then current practice. Investigations and treatments were organised. Very quickly doctors realized that medicine in the elderly could be quite different compared to younger people. Social factors could complicate discharge. The ethos of admission changed to medical need not destitution. A bed was no longer for life. Upgrading of geriatric wards was achieved but new building was very slow to materialize.
New approaches to medical services for the elderly were developed according to local conditions:
Unpaid home visits were used to assess the urgency for admission of patients on the waiting list and were later replaced by paid domiciliary visits to provide medical opinion.
Outpatient departments were increasingly utilised.
Progressive patient care became widely practised. Patients were admitted initially to a treatment ward and then moved to other wards as they improved or required further treatment. The disadvantage was that beds were not always used to maximum efficiency and nursing continuity was lost but, it was argued, it helped patients’ morale to be moved as they improved.
Day hospitals provided rehabilitation, physical maintenance, follow up care after discharge from hospital, and allowed minor medical procedures to be undertaken without the need for admission. Their efficiency became much debated with criticism targeting inadequate audit of their function, poor working policies and insufficient consultant input.
Continuing (long stay) care, once an integral part of the geriatric service, was largely transferred into the private and voluntary sectors.
Statistics of bed usage were published by geriatricians who showed that elderly patients, who had been confined to bed for many years, could be successfully rehabilitated and discharged. Length of stay decreased, bed turnover increased, many more patients were admitted and geriatric medicine became the fastest growing medical specialty.
Geriatric subcommittees were set up by the British Medical Association and the Royal College of Physicians.
Geriatricians deemed general practitioners pivotal in elderly care. They acted as first line of referral when an elderly person became ill and coordinator of support services. They were encouraged to learn about the modern management of older people and take the Diploma of Geriatric Medicine of the Royal College of Physicians of London. Unfortunately older people did not always consult their general practitioner about their symptoms because they felt little could be done for them. Case finding programmes for untreated disability showed that general practitioners were largely aware of the major disorders affecting the elderly at home but were less aware of minor problems with sight, hearing and care of toenails, which could impact on quality of life.
An effective social service department was an essential component of a geriatric service, since it provided a range of domiciliary care, such as home helps, meals on wheels, occupational therapy, appliances, residential homes and day centres. Social workers liaised with voluntary organisations such as Age Concern, old people’s clubs and church organisations.
The geriatricians’ cri de coeur was improving the teaching medical students about the diseases and treatment of old age. Attitudes of medical students were initially sympathetic towards the sick elderly but changed to indifference on qualification. Factors blamed included the prejudice of universities and medical teachers against geriatric medicine, poor image/role of the geriatrician and poor working conditions. Lord Amulree was appointed as geriatrician to University College Hospital in 1949, the first and only London teaching hospital to have such an appointment for many years. The first UK Professor of Geriatric Medicine, Sir Ferguson Anderson, was not appointed until 1965. Further progress was slow but responded to pressure from Sir George Godber, Chief Medical Officer 1961-1973, and Sir Keith Joseph, Secretary of State 1970-1974, who encouraged the foundation of professorial posts (Charing Cross, St. George’s and University College Hospitals in London and Birmingham University). Postgraduate research courses were set up leading to the degrees of MSc and PhD. By 1998 almost all the London teaching hospitals had a professorial chair in the speciality but since then recruitment into academic geriatric medicine has fallen away.
The Ministry of Health
In 1946 the Ministry had two years to create the NHS. It realised the programme would be seriously impaired by the 70,000 hospital beds occupied by the chronic sick. Furthermore it knew that the number and life expectancy of the elderly was increasing and would continue to do so. More effective use of existing beds and improvements in community services were essential.
The Ministry set the ball rolling with a presentation to the Parliamentary Medical Committee in 1947, which stated that the vast majority of the chronic sick were elderly people who were inadequately classified. Four groups occupied hospital beds inappropriately – those with diseases which had become chronic because they had not been treated soon enough; those with disabilities who could not be sent home; those admitted with preventable diseases; and those who could go home but had no home to return to.
General physicians were encouraged to treat the chronic sick but failed to do so, which convince the Ministry that a speciality of geriatric medicine was required.
It organised surveys, supported pioneering geriatric physicians, encouraged recruitment, persuaded health authorities to create more geriatric units and consultant posts in the main hospital, promoted modern management of sick elderly people, improved ward design and stimulated research.
It considered geriatric medicine was effective and the number of existing geriatric beds was sufficient provided they were used efficiently. The Hospital (later Health) Advisory Service was created by the Secretary of State to act as his ‘eyes and ears’ regarding elderly care services.
Community services were supported. Case finding and screening of older people was encouraged. Community accommodation increased but arguments raged about who should pay residential/nursing home costs. While health care, such as nursing, was free, social care, such as assistance with washing and dressing, was means tested. Those with above threshold savings had to contribute to their support and felt penalised for saving for their old age.
Unfortunately the Ministry/Department was not helped by new political administrations, which were more concerned about health service costs and which introduced almost yearly reorganisations and centralisation. Policy-makers shied away from specifying targets for elderly care for fear of being held accountable for failures, and denied rationing of health care. Many policies were considered little more than statements of good intent. An attempt to create a Minister for the Elderly was foiled by lack of government support.
Voluntary and charitable organisations
These philanthropic institutions appreciated that the ageing process and the diseases of old age were ill understood and therefore supported research. In 1943 Viscount Nuffield founded the Nuffield Foundation, one of whose objectives was the care of the aged and poor, and set up the National Corporation for the Care of Old People, (later the Centre for the Policy on Ageing) whose chairman was Seebohm Rowntree. The Foundation created a Research Committee, which gave grants to geriatricians and gerontologists. The Nuffield and Ciba Foundations supported Vladimir Korenchevsky, a Russian biologist and a student of Pavlov, who became director of the Oxford Gerontological Institute. The Ciba Foundation helped to found the International Association of Gerontology, which held its third World Congress in London in 1954. The first meeting of its clinical section was held in Sunderland in 1958, and another was organised in Manchester in 1974. The Ciba Foundation established special colloquia on ageing in London, which were attended by many international experts. The King Edward's Hospital Fund supported research into aspects of ageing.
In spite of the powerful personalities and organisations pressing for improvements in the medical and social care of the elderly, serious defects remain to this day. Age discrimination continues, older people are not always nursed with dignity, quality of care is questioned, no comprehensive review of elderly services has been held, and whenever financial cuts in services are required elderly care is an early target.
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