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‘Cardiac rehabilitation works, so why isn't it done?’ asks Bethell and colleagues on page 677. Despite clear evidence of cost effectiveness, comparable to many pharmacological interventions, and NICE's recommendations, only about 30%of those eligible enrol into programmes. The authors offer some reasons, but here is an intervention that has, perhaps, fallen victim to the primary/secondary care separation in the UK. Rehabilitation is also being promoted for long-term respiratory disease, and such programmes have similar take-up rates to those for cardiac rehabilitation. The qualitative study on page 703 explores some of the reasons, especially a fear of worsening breathlessness. But the programmes may help sufferers to regain some control of their condition. For primary care there is one crumb of comfort, with the study on page 699 reporting that where exercise referral schemes are concerned, practices working in deprived areas are more likely to refer patients than those in more affluent areas. One small piece that doesn't fit into the inverse care jigsaw.
There's a much more serious challenge to the conventional wisdom about the inverse care law on page 720. The authors argue that we have been collectively preoccupied with disadvantaged populations, and the mismatch between need and provision. This has blinded everyone to the increased need for care among older groups of patients. Age and its associated pathology is so strong a determinant of morbidity and mortality that areas with higher numbers of older patients should receive higher funding allocations. However in the commentary on page 726, Graham Watt takes a different line. Asking ‘What is the NHS for?’, he questions whether Asthana and Gibson have confused activity and need. For the GPs, whose main concern is answering the immediate demand, activity does tend to dominate thinking, but for the policy makers the desire to try to compensate for the imbalances of deprivation should command a higher priority.
The multiple morbidities of ageing populations is illustrated on page 688, where an association is reported between musculoskeletal pain and mental ill health. In passing, the study also casts some doubt on the value of the short two-item screening approach (now enshrined in one of the QOF indicators). It's consistent with all the other evidence that poor physical health is associated with poor mental health, and that this includes painful conditions shouldn't surprise readers. Older people get more physical problems so would be expected to have higher rates of mental ill health. This is backed up by one line in Table 1 of the paper on page 680, where the older patients with depression are shown as having an average of two chronic illnesses each. This trial tested out an educational intervention to improve GPs' handling of older patients with depression, but the control doctors weren't as bad at the task as the authors expected (echoing some of the recent research into younger patients with depression), and there was little overall difference between intervention and control groups. As in younger age groups there seemed to be improvement over time in both groups, presumably happening through the patients' own efforts. Just as patients with mild to moderate depression favoured self-help over any help from professionals (page 694). The editorial on page 675 reminds readers of the potential consequences of untreated depression in older patients, and wonders if the problem is to do with their reticence. This may be one area where personal continuity plays a vital part in helping patients feel comfortable to discuss their problems.
These articles are a reminder, once again, that we should treat the problems and not put them down to the natural process of ageing. There is a tendency to think of such ‘ageism’ as a modern phenomenon, but 200 years ago Samuel Johnson was quoted in Boswell's Life of Samuel Johnson:
‘There is a wicked inclination in most people to suppose an old man decayed in his intellects. If a young or middle-aged man, when leaving a company, does not recollect where he laid his hat, it is nothing; but if the same inattention is discovered in an old man, people will shrug up their shoulders, and say, ‘His memory is going.’’