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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 November 24; 335(7629): 1059.
PMCID: PMC2094193
What's wrong with the NHS?

Well, if you are old and frail . . .

David Oliver, senior lecturer, geriatric medicine

The personal view describing deficient care of the author's ageing mother with mental health problems was harrowing.1 Although many service users do not experience such poor care, there is much objective evidence of “undignified and indifferent care” and “deep rooted and persistent attitudes by hospitals and staff to older people.”2 The old and mentally ill suffer discriminatory attitudes considered unacceptable in other groups.

Some of the problems described are down to lack of professionalism. Ageist attitudes in society infect clinical professionals. Patients with legitimate medical illnesses are labelled as “social admissions” or “bed blockers,” rather than being diagnosed and treated. Even though much hospital and primary care work involves older frailer patients, most medical and nursing students don't want to work with older people. Specialist training for care of the elderly and mental health is inadequate for future needs. A 2001 national service framework recommended education and training for all professionals caring for older people, but no funds were earmarked and it hasn't happened.3 The Healthcare Commission's plan to use inspection and performance management to improve these aspects of care provides some hope.4 But we still have a system with a clear hierarchy of performance targets, and the “basic care” clearly lacking in this case1 is well down the list.

The recent report on the Maidstone and Tunbridge Wells scandal showed how external targets distort priorities.5 The whole performance framework for the NHS encourages a view of unselected acute older patients as a loss leader. Experienced nurses who should act as mentors, educators, and role models are being financially rewarded for leaving the bedside and taking on management roles. Once they have taken the corporate shilling, they are no longer an independent advocate for patient care. While there is no excuse for the total lack of care or professionalism described by the author,1 system reform could prevent a repetition of this tale. If the same performance pressures were applied to basic care and communication as for outpatient access times or financial balance then perhaps directors of nursing and trust boards would take more interest.


Competing interests: None declared.


1. Anonymous. So, you want to know what's wrong with the NHS? BMJ 2007;335:994 (10 November.)
2. Audit Commission, Healthcare Commission, Commission for Social Care Inspection. Living well in later life. 2006.
3. Department of Health. The national service framework for older people. 2001. [PubMed]
5. Healthcare Commission. Investigation into outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells Trust. 2007.

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