In focusing in succession the complex issues raised from the undebated and undemocratic expansion of the private nursing family sector and contraction within public provision.

In focusing in succession the complex issues raised from the undebated and undemocratic expansion of the private nursing family sector and contraction within public provision, Clive Bowman and colleagues have struck at the heart of a malaise within geriatric medicine. Like the Pied Piper of Hamelin they create a hopeful pathway, on the other hand are there any geriatricians left to chase their call and is it the right path?

The shift in responsibility for care of of advanced age and physically frail people from NH hospital extended stay to private nursing household care was more than an ideological swap of bricks and mortar. Intentionally or otherwise it helped in the formation of a modern consultant group, the "physician with an interest." Unfortunately for older the bulk of mankind the interest is rarely in chronic illness, rehabilitation, or prevention of disability. The specialty has embraced the medical standard with great zeal, extolling its virtues (for example, equal access to acute services in consequence of an appropriate setting) but remaining silent in succession the drawbacks (faster discharge with poor planning[1]; increased readmission rates; deskilling of specialist registrars; and the abrogation of responsibility to unprepared and unwilling general practitioners.) This impious mess threatens the survival of the specialty.

Using existing structures

I don't disagree with the riddle I differ in the pathway to a solution. The structur partnership between geriatricians and general practitioners might look attractive, but we already have a order that can be made to work for the benefit of somewhat old people. NHS geriatric units have teams that carry without assessment and evaluation before making decisions about residential and nursing family circle placement, practice rehabilitation in its broadest sensation and have expertise concerning the basics of chronic disease management (prevention of hurry ulcers, continence care, etc). Multidisciplinary teams have bring to maturityed flexible ways of working using day hospitals, outpatient clinics, outreach, specialist (such as thump or wound care) programmes, and domiciliary services. Geriatric medicine is now being rediscovered in residential and nursing hearthstones but the bureaucratic minefield that separates the public and private sectors effectively deprives residents of appropriate expertise.

Primary care assign places tos could help clear that minefield. They are structur to draw family and community health practitioners and social services together in pair important ways: firstly, through funding the cloyed range of services for somewhat advanced in life people and, secondly, by cooperating in delivering those services. Primary care clusters bear the same responsibility for quality and partnership as other parts of the health and social care system[2] and will have a national service framework to help them bring out with other providers in one as well as the other public and private sectors, those service agreements. to what end create a separate system when the instant one has not been allowed to answer effectively? Consortiums were developed in the United States because they lacked an established geriatric subspecialty and comprehensive primary care base.

The savings that Bowman et al intimate for their model may not be as great in reality, and short space of time costs (redundancy and redeployment richnesss plus the need to finish sufficient beds and lose staff) might put off any benefit. In addition, preciousnesss in general practice may increase if proactive management translates into standardised assessments, training protocols, appraisal, and cost-benefit review. Will the private sector willingly contribute to these increased costs? And will the different refinements accountabilities, and histories of the solution players reform in the adjoining matter of a consortium within any reasonable period? We should turn the thoughts at similar efforts to create funding and delivery consortiums for mental health services[3 4] for guidance forward these and related issues.

Changing the culture

the same question remains which neither Bowman and colleagues nor I have addressed. Do geriatricians still want to work with chronically frail somewhat old people? They divested this clinical responsibility surprisingly easily, and we now have a cohort of consultants with apparently little incentive to risk losing the mantle of medical respectability and become involved in chronic care. What of general practitioners? Financial inducement has in no degree produced sustained changes in management and care programmes when applied to simply one of the care providers. Clinical and political will is wanted to redirect the focus of attention within geriatric services away from acute patterns of care. The framework of partnership propos on Bowman et al would perhaps best be directed at removing the barriers to making geriatric expertise available to folks in residential and nursing dwellings It seems sensible to move that entry criteria based forward standardised assessments should routinely involve departments of geriatric medicine. Nursing abiding-places could be formally linked to the NH allowing innovations similar as staff exchanges and rotations, cros benchmarking, dual audit, and joint risk management plots We could then let clinical governance do its work at jobs in a care sector created outside the NH nevertheless connected to it. To many this issue is the past; in reality it is the hereafter Competing interests: None declared.