Pathy's Principles and Practice of Geriatric Medicine - Группа авторов

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was that medical students rarely saw them and, therefore, were not taught about the diseases of old age or how to manage the mixture of medical and social problems they would meet after qualification.

      Workhouse infirmaries were funded by local rates. They gradually became long‐stay institutions for the chronic sick. Examples of unsatisfactory conditions and poor care in workhouses and infirmaries surfaced in the 1860s and resulted in visits by the Lancet commissioners and the inspectors of the Poor Law Board. The 1869 report of the Lancet Sanitary Commission was damning, stating, ‘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’.2

      In 1929, the Local Government Act came into force, which aimed to correct the existing bipartite system of health care of ‘one part for the pauper and the other part for the non‐pauper’. However, Charles Webster concluded that health services between the two world wars were ramshackle and uncoordinated, with hostility between sections of the service, increasingly chaotic funding, and a hospital service that was unevenly distributed and limited in rural areas.3

      Further reform came in 1948 with the creation of the National Health Service (NHS), which rearranged British health care into a tripartite system. First, there was the hospital service, which was formed by the nationalization of 1143 voluntary and 1545 municipal hospitals. It became the dominant partner in the Service. Second, there were the general practitioner and the ophthalmic, pharmaceutical, and dental services. The third arm, which was managed by the local authorities, included health centres, health visitors, and ambulance services. Their immensely valuable home help and meals‐on‐wheels services did not really ‘take off’ until some years later. Importantly, health care for all became free of charge.

      Voluntary and charitable organizations made important contributions to the care of the older person and research into old age. In 1943, the Nuffield Foundation was created, one of whose objectives was the care of the aged and the poor. This support led to the formation of the National Corporation for the Care of Old People in 1947. The Foundation also stimulated major research into the causes of old age (gerontology). These moves to assist older people became increasingly important as the proportion of older people in the population steadily increased. In 1841, the over‐65‐year‐old people made up 4.5% of the population, which rose to 4.7% by 1901, 7.8% by 1921, 9.6% by 1931, and 10.5% in 1947.

      These newly appointed post‐war consultants in geriatric medicine had to embark on a steep learning curve. In the early days, they had the responsibility for very large numbers of inpatients, sometimes many hundreds, who were often kept in bed for no discernible medical reason, which could ultimately lead to a totally bedridden state. Generally there was a massive waiting list for admission, often precipitated by the death or illness of the carer or the person’s inability to prepare meals for him/herself. These new consultants learnt that illness and the presentation of disease in the older person differed from those in younger people, that more time was required to recover, that prescribing drug therapy required great care, that extensive teamwork was needed for successful rehabilitation, and that local social service support was usually essential to provide alternative accommodation or domiciliary support services. They had to provide a service although they lacked adequate resources and staffs, had poor ward accommodation and inadequate investigative/treatment facilities, and were not always based on the main hospital site. They had to fight antagonism and resistance from their fellow consultants and some hospital management committees. One chairman of such a committee refused a consultant geriatrician the use of empty beds in general medical wards: ‘Over my dead body’, he said. When he died, the geriatrician got the beds. Another consultant had to fight for proper washing facilities in the wards and for curtains to be placed around the beds of elderly patients. Yet others had to struggle to get heating installed in the wards and repairs made to the leaking ward roofs.

      Important studies of the elderly living at home or in residential homes appeared shortly after the war. Dr Joseph Sheldon, a general physician, published The Social Medicine of Old Age in 1948, which was the result of his research into the health of the elderly living in the community in Wolverhampton. In 1955, Professor William Hobson and Dr John Pemberton published The Health of the Elderly at Home, which was a study of older people living at home in Sheffield. In 1962, Professor Peter Townsend published The Last Refuge, a seminal study of old people living in residential homes.

      The British Ministry of Health, which was created in 1919, and its medical officers supported the newly emerging style of medical care of the sick elderly patient with official circulars, memoranda, meetings, and documents. These highlighted its firm belief in modern management of elderly patients and the drive to establish a geriatric unit in every health district. The Ministry organised surveys of hospitals in England and Wales, which were to be the basis of the forthcoming NHS. The reports, published in 1945, were generally very critical of services and accommodation for the chronic sick. ‘The worst and oldest buildings were set aside for the chronic sick’.5 ‘The buildings are old, dark, devoid of modern sanitary conveniences, death traps in the case of “fire”, and unfit for the nursing of the chronic sick’.6 ‘The first essential is that every patient should be thoroughly examined and treated with a view to restoring a maximum degree of activity’.7 Later, Lord Amulree and Dr Edwin Sturdee, both medical officers of the Ministry, presented a paper on the care of the chronic sick to the Parliamentary Medical Committee in 1946.8 In it, they stated, ‘Not only is the problem of the treatment of the chronic sick not being met, but also most people do not realize there is a problem’. In 1957, Dr Christopher Boucher, a Principal Medical Officer at the Ministry, published the result of an important survey of services available to the chronic sick and elderly.9 However, the Ministry realised that it could not force change but could only use persuasion to improve proper medical services for older people.10 Perhaps this was why even in 1978, 42 health districts in England still lacked geriatric beds in general hospitals.

      The British Medical Association played its part in planning the medical care of older people with a series of very specific reports. A coordinated geriatric service was recommended to the newly created Regional Health Authorities, supported by a wide range of domiciliary services, which would be needed by the infirm elderly to enable them to stay at home for as long as possible.11–13

      However, commentators looked back to the old Poor Law and the new NHS with mixed feelings.14–17 They pointed out that whereas the old Poor Law system had given a coordinated personal service to its clients, the tripartite structure of the NHS service led to lack of cooperation and coordination between the arms of the service. Chronic and mental services received a smaller share of capital and revenue, and clear guidelines for the treatment of old people were lacking. The political will to produce a nationwide effective geriatric service was lacking. On the other hand, the new service did provide the less well off with forms of care to which previously they had only limited entrée, and the elderly now had access to consultant services.

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