In the December issue Iliffe1 assured us that our article ‘anticipatory care of older patients represented the triumph of hope over experience’.2 We find this a bewildering claim in view of the extensive research evidence to the contrary. No less than six controlled trials between 1979 and 1993 showed that a programme of care, tailored to the special needs of those in advanced old age, reduced the time spent in institutional care (hospitals and nursing homes). They are referenced in our book.3 In addition Beswick in 2008, a much more recent meta-analysis than that cited by Iliffe,4 has made a thorough appraisal of nearly all the research work done in this field. From 89 studies he showed that interventions reduced the risk of not living at home, of nursing-home and hospital admissions and falls. However death rates were not reduced.
Iliffe completely ignores these objectives in pursuit of his opposing views which may not be comparing like with like and he appears to be suggesting that our claims were exaggerated. In fact our claims are exceedingly modest but very important to vulnerable old people. The object of our proposed anticipatory care models is to target vulnerable and frail subjects. They are then offered more time, care and support from the primary care team and trained volunteers. The aim is to enable them to enjoy the best life possible in each case and to remain active and independent for longer. We think the best measure of improved outcomes is the reduced time spent in institutional care and hospital as bed days. Iliffe admits that there is research evidence in support here, together with improved patient morale and (in some papers) reduced mortality. However his negative view of preventive care of vulnerable older patients defies the main body of research findings. They are also overturned by the findings of a recent Care Quality Commission Survey. On 21 November they reported5 that, in the past year, no less than 530 000 people aged ≥65 years required an emergency admission to hospital for conditions which were preventable. Had the GPs involved run an anticipatory care programme the saving to the Exchequer would have been great. Without appropriate action by government, the RCGP and other medical, social and voluntary organisations, there remains a major cause for concern for the welfare of frail older people within the UK.
- © British Journal of General Practice 2014