Medicine and books: Health care for older people
Authors: David Griffith
Journal: BMJ (1998)

Steve Iliffe, Linda Patterson, Mairi Gould 

BMJ Publishing Group, £17.95, pp 177 

ISBN 0 7279 1192 9 

Community care of older people

Ed David Beales, Michael Denham, Alistair Tulloch 

Radcliffe Medical Press, £17.50, pp 224 

ISBN 185775 032 2 

Problems in the care of elderly people are often “messy.” That is to say they are not straightforward, unidimensional issues but involve complex interplays of factors, often with more unknown factors and irreversible elements than in other branches of medicine. “Clean” problems—does treatment x help condition y?—are less commonly encountered and usually form only part of an overall scenario. This lack of clean problems is just one of the difficulties bedevilling the development of evidence based medicine in the care of elderly people. 

Just as the problems are messy so are the solutions. Professor Grimley Evans has emphasised the place of both “therapeutic” and “prosthetic” approaches—the former being an attempt to cure or modify the biological problem, the latter accepting that this may not be possible but seeking to modify the environment to help the person cope with the disorder. A combination of these two approaches may be necessary. Both, but especially the prosthetic, require a high degree of multidisciplinary involvement, and this is in any case usually de rigeur in the care of older people. How successful is the structuring and synthesis of such multidisciplinary care? 

Conscientious readers of the BMJ will have seen recent reports that the Clinical Standards Advisory Group has found that care in the community is not working well for elderly people, with community health and social services being described as fragmented, confused, and underfunded. There are reports of unacceptable variations according to where people live. The British Geriatrics Society in a submission to the House of Commons Health Select Committee has suggested the creation of a single purchasing authority responsible for all aspects of social and health care of elderly people in the community. Other organisations such as Age Concern are working in different ways to improve access to and coordination of services. Nevertheless, a considerable degree of optimism would be required to imagine that there is likely to be any major improvement in the near future. Trying to retain and expand diversity and flexibility in the system while improving accessibility and a degree of uniformity of quality is a major task. 

Users of services include not only elderly people themselves but, in a different sense, general practitioners. They have an important, possibly pivotal, role in knowing how and where to marshal help in the most appropriate way to support elderly people. I suspect that much of this knowledge is best gained in practice with the help of a good general practitioner trainer, but a handbook to help guide doctors also has a useful place. Health Care for Older People is ostensibly aimed at a wide audience and indeed contains sections that may be of interest to people in many disciplines, but I think those training in general practice would find it of particular value. The authors have backgrounds in primary care, primary care nursing, and hospital based care of older people and have put together a readable, cohesive set of pieces to direct people to available resources. Practical details are combined with digestible amounts of background and contextual material as well as critical appraisals. Among many topics covered are sections on carers and their needs, community health services, and the hospital-community interface. This works well, and I can highly recommend this book. 

I am not so happy about Community Care of Older People. There is an impressive list of contributors from many subjects, but it is rather a “curate’s egg” of a book, being good only in parts. I think it tries to achieve too much for a relatively short book, attempting to skim briefly, and necessarily selectively, through the whole of geriatric medicine. This inevitably leads to some problems. Its title is therefore a little misleading as the community care of older people is only one of a number of issues it tries to address. Readers wanting a volume on this topic would be better directed to Health Care for Older People. A small, specific complaint relates to internal consistency. In a good chapter on demography the important point is made that it is fallacious to think that the elderly population is rapidly expanding, yet just this same fallacy is repeated elsewhere in the book. 

I note that two of the book’s editors have been examiners for the diploma in geriatric medicine (DGM) examination, and it might serve most usefully as a guide for people studying for this examination. One of the chapters is actually directed specifically at this topic. Even here recourse to other texts for information on clinical topics would be advisable. Despite these reservations, for those who are prepared to be selective in their reading this book contains useful material on how to implement care in the community.