Introduction
Old age has attracted the attention of writers and philosophers for centuries. They concentrated on the theories of ageing and how to increase longevity. While they were unclear about the cause of growing old, with theories ranged from incorrect diet to loss of heat and moisture, they considered that a healthy old age could be promoted by keeping active, eating sensibly and taking exercise. It was not until the 20th century that medical and social care of older people received attention, promoted no doubt by their swelling numbers.
Action in the USA
The impetus for change came from the United States of America in the person of Dr. Ignatz Nascher (1863-1944), the ‘father of geriatric medicine’. In 1942 the American Geriatrics Society was formed with a membership of physicians and in 1945 the Gerontological Society of America was created with a multidisciplinary membership. However the American momentum was not sustained and the leadership in modern geriatric medicine passed to the United Kingdom.
Situation in the United Kingdom prior to NHS: ‘As We Were’
Health care in the United Kingdom began with religious orders and lasted until 1536. The subsequent vacuum persisted till the 1601 Poor Law, which saw the creation of workhouses, alms houses and infirmaries. Because of the growth of the population and urbanisation, the Law was amended in 1834.
By the eighteen/nineteenth centuries, health care was mainly provided by voluntary hospitals and workhouses/infirmaries. The former had a high reputation for good nursing and medical staff but did not admit chronic sick patients for fear of bed blocking. Consequently, medical students never saw them and were not taught about the diseases of old age. Workhouses were grim buildings, which discouraged admission. Their infirmaries had to accept patients refused by the voluntary hospitals and gradually become long-stay institutions for the chronic sick.
Trenchant criticisms of conditions and care in Victorian workhouses and infirmaries surfaced in the mid-1800s particularly the Andover and Huddersfield scandals. The 1869 report of the Lancet Sanitary Commission stated: ‘The fate of the ‘infirm’ inmates of crowded workhouses is lamentable in the extreme; they lead a life which would be like that of a vegetable, were it not that it preserves the doubtful privilege of sensibility to pain and mental misery’. The 1905 Minority Report of the Royal Commission on the Poor Law advocated a need ‘to break up the present unscientific category of the aged and infirm’ and ‘to deal separately with distinct classes according to the age and mental and physical characteristics of the individuals concerned’. The 1941-1945 surveys of hospitals in England and Wales were equally frank, leading the Nuffield Provincial Hospitals Trust in 1946 to recommend a complete review of care of the chronic sick.
By the early 20th century care of an aged relative was regarded as the concern of the State. Relatives came to view admission of an older relation to a chronic sick bed as ‘a bed for life’, and the patient’s home was given up. Consequently, if they become well enough to be discharged they had no accommodation to return to. Relatives made every excuse for keeping their old folk in hospital. All too often patients became institutionalised and did not wish to be discharged.
Advent of the NHS
In the mid 1940s three events took place, two of which directly followed the creation of the new NHS. All had different but complementary agendas. Firstly, pioneers in geriatric medicine, such as Drs. Marjory Warren, Eric Brooke, Lionel Cosin and Trevor Howell aimed to reverse the poor quality of care and accommodation provided for the chronic sick by applying modern investigations and treatment. They faced the challenge of hundreds of inpatients often in widely separated hospitals, hundreds more on waiting lists for admission, inadequate resources, lack of staff, derisory investigative facilities, poor quality patient accommodation and antipathy, even antagonism, from the medical profession and hospital authorities. In those early days the emphasis was on rehabilitation but as new drugs became available, geriatricians admitted and successfully treated many acutely ill elderly people. Secondly, the Ministry of Health had to tackle the problem posed by 70,000 hospital beds in England occupied by chronic sick patients whose presence could seriously impede the progress of the embryonic NHS. Furthermore, it knew that the numbers and life expectancy of older people were increasing and predictions indicated this would continue. Thirdly, major charitable organisations began supporting research into the ageing process (gerontology) and created national councils for the ‘care and comfort of the aged poor’.
Achievements
Geriatricians, by changing expectations and applying modern methods to their chronic sick patients, discharged many, increased bed turnover and reduced bed requirements significantly. Ward accommodation slowly improved. The Ministry supported geriatricians and took measures to improve recruitment, establish geriatric units in general hospitals and develop a range of community services. The study of ageing was supported: organisations such as the Nuffield and Ciba Foundations encouraged the work of Drs. Alex Comfort (The Joy of Sex) and Vladimir Korenchevsky (The Father of Gerontology), who became director of the Oxford Gerontological Institute. Ciba helped to found the International Association of Gerontology, whose Third World Congress was held in London in 1954. A 1984 report from the Nuffield Provincial Hospital Trust concluded that geriatric medicine had established its expertise and had had notable success in raising the standards of services for the old. The UK had become the ‘Mecca’ of geriatric medicine.
Where are we now?
The political will in the UK to produce an effective coordinated hospital and community service for older people with clearly defined objectives remains lacking. Governments are more concerned about the costs of caring for the elderly. The rising numbers, longevity and morbidity of older people are increasing pressure on all health/social services. In the 1980s the NHS began withdrawing from long term care leaving this to the private and charitable sectors. Consultant geriatricians are now more involved with acute adult medicine, have withdrawn from continuing care and retain only limited commitment to rehabilitation, although community geriatric medicine is gaining influence. The pressure remains on patient turnover and rapid discharge. Local social service departments are hard pressed, often lack resources and are frequently targeted for financial cuts. Psycho-geriatrics is the new NHS Cinderella service. Ageism remains widespread.
Quality of care of elderly patients remains a core criticism in spite of numerous reports and commissions in the past 20 years. We should remember the words of David Lloyd George, PM 1916-1922:
‘How we treat our old people is a crucial test of our national quality. A nation that lacks gratitude to those who have honestly worked for her in the past while they had the strength to do so, does not deserve a future, for she has lost her sense of justice and her instinct of mercy.’
Further reading:
Boucher C A (1957). Survey of Services Available to the Chronic Sick and Elderly 1954-1955. Ministry of Health: Reports on Public Health and Medical Subjects No 98.
Crowther M A. (1983). The Workhouse System 1834-1929. The History of an English Social Institution. London, Methuen.
Denham M J (2006). The Surveys of Birmingham ‘Chronic Sick’ Hospitals 1948-1961. Social History of Medicine 19, 279-293.
Department of Health (1991). On the State for the Public Health for the Year 1990. London: HMSO. pp 68-95.
Sheldon J H (1948). The Social Medicine of Old Age, London. Oxford University Press.
Townsend P (1962). The Last Refuge. London, Routledge and Paul Kegan.
Warren M W (1948). The Evolution of a Geriatric Unit Geriatrics, 3, 42-50