We are publishing a number of important articles about the health care of older people this week. The National Clinical Director for Older People has thrown down the gauntlet to GPs, exhorting them to rise to the challenge of contributing to the care of the growing population of older citizens. Other papers look at frailty, dementia, visual impairment, and hospital admissions from care homes, as well as the role of pharmacists in monitoring potential prescribing problems in patients requiring polypharmacy and, of particular importance for older people, the recurring questions about the value and availability of continuity of care in general practice.
These are all weighty matters, but in a way we are only scratching the surface here. Steadily rising life expectancy creates new medical problems, including the care and costs of chronic conditions and of supporting very old people in their last years of life. It also seriously compromises the surprisingly complacent plans that have been made in both the public and private sectors for the provision of retirement pensions, and the ways in which the state and individuals will be expected to fund the care of dependent older people in the future. The Dilnot report has set out a series of reasonable proposals for thresholds that determine how much older people should contribute to the costs of community and residential care, and there is now pressure on the Government to be clear about the ways in which elderly care will be funded in the years ahead. The prospect of working into the late 60s in order to qualify for a full pension is at the best unappetising, and at worst infeasible, for many people. It will be quite a challenge to ensure cost effective and clinically appropriate deployment of the workforce if consultants and GPs are faced with the possibility of working well beyond the current retirement age.
In the wake of last month’s talking heads feature on the NHS reforms, three commentators look at the future of the NHS. Martin Marshall makes a plea for reflection, understanding, and better use of evidence in guiding further changes in the system. Mark Rickenbach offers to guide us down the yellow brick road to integrated care, seen by many as the best way to contain costs and improve quality, with the help of a ‘review, feedback, change, and review’ cycle, further assisted by resources such as the King’s Fund Whole Systems Leadership approach and the RCGP’s network of Clinical Commissioning leads. Nigel Mathers and Mark Thomas take a cool look at integrated care and, as well as asking just what it is, identify a number of potential barriers to achieving it.
These are interesting times for the health service, and also for science publishing. The report by Dame Janet Finch on open access publishing looks likely to have an immediate impact on policy, with the science minister forecasting implementation of her proposals within 2 years. At present, medical, science, and most other academic publishing operates under a bizarre business model, in which authors write and submit their papers free of charge to journals, which then make substantial profits by restricting access to these papers behind subscriptions and pay-per-view firewalls. Increasingly, funders and researchers are pressing for the results of research, much of which is publicly funded, to be made available to all, at no charge, immediately after acceptance based on peer review — open access publishing. The Wellcome Trust has mandated that all the research it funds is published under open access arrangements. Under this business model the researchers pay an ‘article publishing/processing charge’ (APC) to the publishers for each paper accepted. These APCs are at present in the £1000–2000 range and are found from earmarked funds within research grants. This arrangement will mean that the funders of research bear the cost of the publication of its results, and that universities are gradually able to cut the very considerable costs of subscriptions to academic journals. In the ‘gold’ open access proposals, the financial security of the publishers is protected by transitional funding from the science budget. In an alternative ‘green’ open access approach, researchers are able to make their papers freely available online as soon as they have been accepted by journals, with severe financial consequences for journal publishers, including learned societies and some Colleges. There is presently some controversy surrounding the Government’s preferred ‘gold’ model.
The BJGP discussed this major change in publishing a couple of years ago and decided that primary care research was not ready for it. We now have to think hard about how we will navigate this potentially stormy area; we know that over half of the papers we publish are funded by research grants from sources that would include the costs of the APCs but we still publish valuable research undertaken without major grant support. We will be very interested to hear from authors and readers on this topic as we begin to draw up proposals for the future of the Journal.
- © British Journal of General Practice 2012