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Ageing again, but this time it's about how we and our patients see it. The study on page 404 explores women's views of breast cancer risks. Some felt that age doesn't matter; others that it is commoner among women in their 40s and 50s; very few answered (correctly) that the risk continues to rise into the 9th decade. This may not surprise many readers. Our own preoccupations with cancer when it affects younger women is reinforced by advertising campaigns designed to raise awareness that use young, improbably beautiful bodies for the eye-catching photographs (the latest example is a campaign using young women in the public eye to publicise domestic violence). We do, however, have to consider where this sits in our attitudes towards ageing and what we should do about it. We know, for a start, that the record is not one that we can be proud of. Ann Bowling's leader on page 347 reviews studies of ways in which older patients have been discriminated against in the past. She quotes the NICE guidelines supporting decision making based on age ‘where age is an indicator of benefit or risk.’ But that doesn't seem like much help. Age is often an indicator of risk (always? — after all, death rates rise with age), but much of the risk is likely to be the increase in prevalence of long-term illness with age. Some of the participants in the study on page 352 felt that being offered flu vaccination simply because they were over the age of 65 was ageist, and failed to acknowledge their own good health. The obvious answer, that in this instance the ageism works to their advantage, offering them a beneficial service that they wouldn't get if they were younger, won't quite do either. The beneficent intentions of the profession may not be met with gratitude from recipients who feel they are being incorrectly labelled. The participants in the study were doing what, everywhere else, we would applaud: trying to assess the balance of risks and benefits as they apply to themselves individually and taking their own decisions. Like the participants with asthma on page 359, who underline the importance of health beliefs when taking such decisions. The clash is with the public health imperative, which dictates maximising vaccine uptake. And do we know whether the increase in risk to the over-65 age group from influenza is really about age, or is it the higher prevalence of chronic respiratory and cardiac illness in this age group? Answers on a postcard, please. Target payments to practices for flu vaccination are simply another element in the mix. On page 423 Mike Fitzpatrick shares his thoughts about the way in which general practice is funded in the UK. I too can remember arguing in the 1980s that the independent contractor status of GPs was a curious anachronism, holding back the development of primary care, and like him I now look with surprised horror that we might be creating something worse. In this month's Back Pages there is a fascinating account of a GP's life in the London of the 1939–1945 war (page 418). It conjures up the sense of common purpose and shared experience out of which the NHS was created. It's easy to take universal coverage for granted, but on page 424 John Frey describes one of its aspects that I, for one, had never thought of before.
The worries about GPs' under-diagnosis of depression also started in the 1980s, and they haven't gone away. From the outset those with chronic physical illness were seen as being particularly at risk. The worry also works the other way round — that those with recognised mental health problems may have unrecognised or untreated physical problems. Not so for those with rectal or postmenopausal bleeding (page 371), and for patients with headaches more emotional content brings more treatment rather than less (page 388). The leader on page 348 argues that, where depression is concerned, our whole approach to the problem misses the point. For many it is a long-term illness and only by recognising it as such will we start to adopt helpful approaches to the problem. Certainly we don't seem to have got very far since the 1980s, and are still looking for better approaches. One such is described on page 364, where again what older patients seemed to appreciate was face-to-face contact with someone who would listen and give them time.
Which brings us back to ageism. After ‘Honour your father and mother’, the commandment continues ‘so that your days may be long and that it may go well with you …’. Of course our older patients deserve just as high standards of care as the younger ones, as a matter of principle. But if we hope to be well cared for as we get older, we had better set a good example now.