Introduction

The growth in life expectancy at birth in much of the Western world reflects an ongoing revolution in longevity. This revolution encompasses both survival of individuals to older ages and changing age profiles of the entire population. In particular, the growth of the oldest old has resulted in significant healthcare changes, both on an individual and at societal level. Developed nations across the world have approached the ageing population and need for expanded health services in a variety of ways. Home health, hospital-based and nursing home care have experienced a profound increase in complexity of care needs over the last quarter century. This complexity of care is reflected in the expansion of funding arrangements, number of service providers and geographic service areas. Governments have expanded healthcare spending and broadened the scope of medical care. The development of health insurance programmes in some countries has allowed a greater number of individuals to access medical services. Institutes of higher learning have evolved to support the growing fields of gerontology and geriatric medicine. Educating the medical providers, workforce and community on the needs of older adults has become a major area of interest within and outside of the academic environment. It is important to draw older people into the processes of developing the services and new technologies that they themselves and others of their generation will use. By developing these new healthcare opportunities, the greatest gains may be made in health, independence and quality of life (QOL) in old age.

Overview of Healthcare Demographics

The proportion of UK citizens aged >80 years is set to increase from 2.7 million in 2008 to 6.7 million in 2050; at the same time the proportion of younger citizens will fall, with the result that the dependency ratio 1 will rise from 25% today to 38% in 2050.1 By 2060, healthcare spending will take up 8.3% of gross domestic product (GDP), and long-term care 0.7% of GDP.1 The rapid growth in the oldest old, with the associated frailty and the apparent failure to compress morbidity into the final year or two of life, means that the health and social care of frail older people will continue to be a major challenge for the UK Government.

Healthcare spending in the United Kingdom has grown more quickly than other economic expenditures, reaching 8.1% of the gross domestic product (GDP) in 2007. Even in the harsh climate of post-recession Britain, healthcare spending remains an important part of the overall UK budget, which continues to support publicly funded health and social care. Public healthcare expenditure increased by £5.1 billion (8%) in 2002 compared with £700 million (5%) in private health expenditures. All individuals residing in United Kingdom are entitled to receive treatment from the National Health Service (NHS), which is free at the point of delivery. The NHS, established in 1948, is the third largest employer in the world after the Chinese Army and Indian Railways respectively.

Development of Geriatric Medicine

For various historical reasons, specialist geriatric services developed as an integral part of the NHS in the United Kingdom earlier than in any other area of Europe. Marjorie Warren established geriatric medicine in Britain in the late 1930s. Her message was the need for assessment and rehabilitation of older disabled people, education of medical students, and research into the problems of ageing and old age.2, 3 This derived from her work in the workhouse infirmary associated with the West Middlesex Hospital in London. Her methods (careful medical and social assessment, medical treatment and rehabilitation) were described in a series of publications.2–4 The general conclusion was that older patients should be treated in a dedicated area of general hospitals because:

geriatrics is an important subject to teach medical students;
geriatrics should be an essential part of the training of student nurses;
general hospital facilities are necessary for correct diagnosis and treatment;
research on diseases of ageing can only be undertaken with the full facilities of a general hospital.

These were visionary proposals in 1943 but continue to resonate in current discussions about managing older people. The emerging recognition of the needs of older people in an ageing society led to a number of major surveys and resulted in the collection of planning data for the introduction of new healthcare services. Curran and colleagues (1946) published data on about 1000 males over age 65 and females over age 60 and who lived in poorer areas of Glasgow, all of whom received home visits. A social and medical survey of people in England over age 65 was also performed by the Nuffield Foundation in 1943. The results were published in two reports: Old People (1947) and the Social Medicine of Old Age (1948).5, 6 The British Medical Association (BMA) set up a working group in 1947 to review care of the elderly and infirm and to make general healthcare recommendations.7 Of the 21 BMA members, four were active in the new speciality of Geriatrics (Amulree, Brooke, Cousin, Warren). Dr Trevor Howell, originally a general practitioner (GP), became interested in geriatric medicine after becoming responsible for Chelsea pensioners. He was appointed consultant physician at Battersea and subsequently opened one of the first geriatric units.8–10 In 1947, he called a meeting to bring together physicians who had a special interest in older people and skills in rehabilitation, incontinence management and domiciliary assessment. This meeting launched the Medical Society for the Care of the Elderly, the society was renamed the British Geriatrics Society in 1959. These pioneering physicians persuaded the Minister of Health to appoint more geriatricians as part of the hospital consultant expansion of the new NHS. Dr Tom Wilson was appointed the first consultant geriatrician in 1948 at Cornwall, which marked the introduction of this new medical speciality. By 2008, there were 1111 consultant geriatricians in the United Kingdom, but increasing subspecialization (for example into stroke medicine) and the feminization of the workforce means that the long-term aim of having one whole time equivalent geriatrician per 40 000 of population is still some way off.

The NHS has recognized the value of Geriatrics, now the largest medical speciality in the UK, and has invested significant time and resources to improve services and standards of care for older people. During the 1980s and much of 1990s, the trend in United Kingdom was for geriatric practice to become more closely identified with acute general internal medicine and to be less involved with rehabilitation and long-term care. The improved access to acute diagnostic facilities for older people was welcomed. The rise in consumerism and desire for choice have resulted in the public having a higher expectation of all services. Inadequacies and inequalities in the healthcare of older people have had a major influence on current heath policy, now in part being addressed by the National Institute for Heath and Clinical Excellence (NICE—http://www.nice.org.uk/). A campaign started by a national newspaper and an older people’s charity (Help the Aged) led the government to commission an independent inquiry into the care of older people. As a result of the finding, a National Service Framework (NSF) containing standards of care for older people was published in 2001 in order to apply to the NHS for implementation. The NSF was a 10-year healthcare improvement programme implemented through local health and social care partners, and national underpinning programmes. It was the first framework to establish standards for social as well as healthcare. The NSF established new national standards, service models and social services for all older people, whether they lived at home, in residential care or in hospital. This was achieved through the single assessment process, integrated commissioning arrangements and integrated provision of services. Ten years later, whilst there is still much to be done, the NSF has facilitated major improvements in the care of frail older people. In response to older peoples’ demands for care close to home,11, 12

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