1 Introduction

The nature and type of care provided to older people has re-emerged as a key topic of concern for government, professionals, and older people alike. In the UK, this has been stimulated by debates around the pace of demographic change, the crisis in standards of residential and hospital care, and the rebalancing of support from public to private care provision. A report from the House of Lords, Ready for Ageing (1), concluded that while the UK population was ageing rapidly, ‘both Government and society were woefully underprepared’. The report expressed the view that ‘longer lives can be a great benefit, but there has been a collective failure to address the implications and without urgent action this great boon could turn into a series of miserable crises’ (1). The report set this within the context of major demographic and health changes, including 51% more people aged 65 and over in England in 2030 compared to 2010; over 50% more people with three or more long-term conditions in England by 2018 compared to 2008; and over 80% more people over 65 with dementia (moderate or severe cognitive impairment) in England and Wales by 2030 compared to 2010 (2).

Such developments raise major issues both for the organization of services and for the relationship between the different disciplines concerned with the care of older people. The aim of this chapter is to explore the relationship between two of these: geriatric medicine on the one side, and social gerontology on the other. The argument to be explored is that fostering a closer relationship between them will be essential for developing new approaches to supporting older people within the community and for improving well-being in older age.

To develop this theme, the chapter will examine:

  First, the way in which geriatric medicine emerged, noting its links with research on the social context of ageing.

  Second, the subsequent loosening of this connection will be explored and the reasons assessed.

  Third, the emergence of factors making the case for linking geriatric medicine with social gerontology will be reviewed.

  Finally, the paper will conclude with a number of illustrations of a socially informed care of older people drawing together the various disciplines represented in geriatrics and gerontology.

2 Geriatrics as ‘social medicine’

The development of geriatric medicine (taking England and Scotland as examples) was forged in a social context which itself had a direct impact on practice and clinical interventions (Box 2.1). The modern history of the discipline has been documented in accounts from the late John Brocklehurst (3) and Barton and Mulley (4, 5). An important connecting theme in the evolution of geriatrics—at least from the 1930s—was the battle of the early pioneers against the ‘warehousing’ and neglect of older people. Thompson’s (6) research in the 1940s, summarized in articles entitled ‘Problems of Ageing and Chronic Sickness’, published in successive issues of the British Medical Journal, illustrated this to powerful effect in an analysis of hospitals in the city of Birmingham. Thompson (6) noted that the words ‘medical treatment’ could only be used in a narrow sense relating to the ‘therapeutic use of rest and drugs, because in the infirmaries no other form of treatment was generally possible’. Similar observations had been made in West Middlesex by Warren who had earlier pioneered the concept of rehabilitation applied to the care of older people.

However, the emergence of geriatric medicine also took place in a context of growing awareness of ageing as a ‘social’ as well as ‘health’ issue. This was reflected in research sponsored by the Nuffield Foundation (7) as well as in reports concerning the implications for pensions and related issues of the changes associated with ageing populations (e.g. Phillips Committee (8)). This awareness of the social context of ageing was influential in shaping many of the approaches taken by geriatric medicine in its early phase of development. Indeed, it might be argued that geriatrics, over the period from the late 1940s to the 1960s, drew strongly upon what might be termed sociological observations in developing approaches to the care of older people. This was especially the case in respect of those geriatricians who helped transform the profession in this period.

The previous point can be illustrated through examples from the work of Sheldon, Isaacs, Ferguson Anderson and Williamson and his colleagues. Sheldon’s (9) Social Medicine of Old Age was based upon 447 home interviews in Wolverhampton (conducted by Sheldon himself), where the health of older people was placed within the context of the families and neighbourhoods in which they lived. Sheldon drew a conclusion from his interviews still highly relevant today: ‘To regard old people in their homes as a series of individual existences is to miss the whole point of their mode of life in the community. The family is clearly the unit in the majority of instances, and where such ties are absent they tend to be replaced by friendships formed earlier in life’ (9).

Isaacs and his colleagues in their study Survival of the Unfittest, based upon fieldwork conducted in the 1960s (10), explored reasons for the admission of older people to a geriatric unit in Glasgow, highlighting social issues—such as the strain on what came to be termed ‘informal carers’ and inadequate care in the community—as major factors. Anticipating debates in the 1990s around ‘informal care’, the researchers (10) concluded: ‘No one could work with the relatives of the geriatric patients of Glasgow, as we did, without developing a profound admiration for their devotion and self-sacrifice… . No one could retain for a moment the absurd, oft-refuted, but still prevalent belief that people don’t care what happens to old folk. But still one can ask whether the Health Service … should have to depend so much on its unsung heroes and heroines, the middle-aged and elderly housewives’.

The idea of geriatrics as embedded in a community context was further developed through the ‘preventive’ approach in geriatrics. Examples of such approaches are the drop-in health centre for older people developed by Anderson and Cowan (11) in Rutherglen in Scotland in the early 1950s and the ‘case-finding’ model of Williamson and his colleagues (12). The latter approach demonstrates what Williamson et al. described as the ‘iceberg’ of unreported illness and the need to seek out disease in apparently healthy older people—an observation subsequently confirmed in longitudinal studies of ageing (e.g. 13).

This development of a community approach ran parallel with early sociological investigations into ageing populations, notably those by Townsend (14, 15) in studies of family life and residential care. In The Last Refuge, Townsend (15) identified social factors precipitating admission to a residential home similar to those subsequently reported by Isaacs et al. (10): for example, ‘financial insecurity, social isolation and the absence of subsidiary or secondary sources of help on the part of those living with or near a relative’ (15). And sociological research in the 1950s and 1960s on the impact of loneliness (e.g. 14, 16) was also influential in raising concerns about the implications for medical practice of changing family structures (e.g. the rise of single-person households).

3 Geriatrics and social gerontology: divergent paths

The strands so far identified suggest the possibility of a geriatric medicine which might have developed strong links with emerging research on social aspects of ageing. Yet the period from the 1970s saw geriatrics and social gerontology take divergent paths as each attempted to gain professional and academic respectability (Box 2.2). Geriatric medicine underwent significant expansion in the UK (all four countries combined): from just four consultant geriatricians in 1947 to 335 in the late 1970s to approximately 1,100 by 2010. However, this was in the context of a continuing need to ‘defend’ geriatrics given negative views within the medical profession, these surfacing at regular intervals in the period from the 1950s onwards (4, 17, 18). This was reinforced through the steady growth of the welfare state and the treatment of ageing as a form of what Townsend (19) referred to as ‘structured dependency’ arising though the impact of poverty and ‘passive forms of community care’. These elements pushed the emphasis in geriatric medicine towards a more exclusive biomedical approach at odds with emerging sociological or social science perspectives on ageing.

At the same time, social gerontology began—from the 1970s—its own period of expansion where it sought to carve out a distinctive space around which issues relating to ageing could be researched and discussed (20, 21

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