a service although they lacked adequate resources and staffs, had poor ward accommodation and inadequate investigative/treatment facilities, and were not always based on the main hospital site. They had to fight antagonism and resistance from their fellow consultants and some hospital management committees. One chairman of such a committee refused a consultant geriatrician the use of empty beds in general medical wards: ‘Over my dead body’, he said. When he died, the geriatrician got the beds. Another consultant had to fight for proper washing facilities in the wards and for curtains to be placed around the beds of elderly patients. Yet others had to struggle to get heating installed in the wards and repairs made to the leaking ward roofs.
Important studies of the elderly living at home or in residential homes appeared shortly after the war. Dr Joseph Sheldon, a general physician, published The Social Medicine of Old Age in 1948, which was the result of his research into the health of the elderly living in the community in Wolverhampton. In 1955, Professor William Hobson and Dr John Pemberton published The Health of the Elderly at Home, which was a study of older people living at home in Sheffield. In 1962, Professor Peter Townsend published The Last Refuge, a seminal study of old people living in residential homes.
The British Ministry of Health, which was created in 1919, and its medical officers supported the newly emerging style of medical care of the sick elderly patient with official circulars, memoranda, meetings, and documents. These highlighted its firm belief in modern management of elderly patients and the drive to establish a geriatric unit in every health district. The Ministry organised surveys of hospitals in England and Wales, which were to be the basis of the forthcoming NHS. The reports, published in 1945, were generally very critical of services and accommodation for the chronic sick. ‘The worst and oldest buildings were set aside for the chronic sick’.5 ‘The buildings are old, dark, devoid of modern sanitary conveniences, death traps in the case of “fire”, and unfit for the nursing of the chronic sick’.6 ‘The first essential is that every patient should be thoroughly examined and treated with a view to restoring a maximum degree of activity’.7 Later, Lord Amulree and Dr Edwin Sturdee, both medical officers of the Ministry, presented a paper on the care of the chronic sick to the Parliamentary Medical Committee in 1946.8 In it, they stated, ‘Not only is the problem of the treatment of the chronic sick not being met, but also most people do not realize there is a problem’. In 1957, Dr Christopher Boucher, a Principal Medical Officer at the Ministry, published the result of an important survey of services available to the chronic sick and elderly.9 However, the Ministry realised that it could not force change but could only use persuasion to improve proper medical services for older people.10 Perhaps this was why even in 1978, 42 health districts in England still lacked geriatric beds in general hospitals.
The British Medical Association played its part in planning the medical care of older people with a series of very specific reports. A coordinated geriatric service was recommended to the newly created Regional Health Authorities, supported by a wide range of domiciliary services, which would be needed by the infirm elderly to enable them to stay at home for as long as possible.11–13
However, commentators looked back to the old Poor Law and the new NHS with mixed feelings.14–17 They pointed out that whereas the old Poor Law system had given a coordinated personal service to its clients, the tripartite structure of the NHS service led to lack of cooperation and coordination between the arms of the service. Chronic and mental services received a smaller share of capital and revenue, and clear guidelines for the treatment of old people were lacking. The political will to produce a nationwide effective geriatric service was lacking. On the other hand, the new service did provide the less well off with forms of care to which previously they had only limited entrée, and the elderly now had access to consultant services.
The early pioneers in geriatric medicine
In 1935, Dr Marjorie Winsome Warren, CBE, MB (1897–1960), was placed in charge of 874 patients from the adjacent Public Assistance Institution. These included 16 maternity patients and about 144 ‘mental observation’ patients, who were subsequently transferred to their appropriate departments. She assessed and examined the remainder. She described the situation as follows: ‘Having lost all hope of recovery, with the knowledge that independence has gone, and with a feeling of helplessness and frustration, the patient rapidly loses morale and self‐respect and develops an apathetic … temperament, which leads to laziness and faulty habits, with or without incontinence. Lack of interest in the surroundings, confinement to bed … soon produces pressure sores … inevitable loss of muscle tone make for a completely bedridden state … [leading to] disuse atrophy of the lower limbs, with postural deformities, stiffness of joints, and contractures … in this miserable state, dull, apathetic, helpless, and hopeless, life lingers on, sometimes for years’ (Warren, 1946).18
She criticised the medical profession: ‘It is surprising that [it] has been so long awakening to its responsibilities towards the chronic sick and aged, and that the country at large should have been content to do so little for this section of the community’.18
She recognised the importance of the environment in helping patients recover. She improved ward lighting, arranged repainting of the wards from the previous drab colour to cream, replaced old‐fashioned beds, provided modern bedside lockers, bed tables, and headphones, and also bright red top blankets, light‐coloured bedspreads, and patterned screen curtains. Wards were equipped with handrails attached to the walls, and suitable armchairs provided. Floors were no longer highly polished, and steps were avoided. Special chairs and walking sticks and frames were provided for arthritic and heart patients. Some equipment that she designed herself is still used today. She was the first British geriatrician to publish admission, death, and discharge data. By 1948, Warren reported that the general medical staff acknowledged that their ‘chronic’ elderly patients actually did better in the geriatric unit than in their own wards.
Mr Lionel Zelick Cosin, FRCS (1910–1993), came from a surgical background to the care of the elderly chronic sick.19 At the outbreak of war, he was drafted to Orsett Lodge Hospital in Essex, which had been upgraded to an Emergency Medical Service Hospital in 1939. He became responsible for 300 chronic sick patients in addition to his surgical commitments. He found that they were fed and kept clean, but no other treatment was given. When ordinary admissions restarted in 1944, he admitted elderly women with fractured femurs, successfully operated on them, gave them rehabilitation, and discharged them home.
In 1950, he was invited to establish a geriatric unit at Cowley Road Hospital in Oxford, where he became its first clinical director and established the first day hospital in the UK. He classified, diagnosed, and treated his elderly patients. He reorganised inpatient accommodation, creating an acute geriatric ward for investigation, treatment, and physiotherapy, and also a long‐stay annex ward for the permanently bedfast, long‐stay wards for the frail ambulant, and ‘residential home’ type of accommodation for the more robust patients. These methods resulted in the average length of stay falling from 286 to 51 days. The proportion remaining in the hospital longer than 180 days declined from 20 to 7%. Admissions increased from 200 to 1200 per year through the same number of beds. The average age of the patients increased from 68 to 75 years. Approximately 10% of his patients became permanently bedfast.20
Dr Eric Barrington Brooke, FRCP (1896–1957), became the first medical superintendent of the newly built, 800‐bed, St Helier Hospital in Carshalton. The building was hit several times by enemy bombs, his superintendent’s house was destroyed by a flying bomb in 1944, and he was severely wounded and lost an eye, but he returned to duty in due course. In 1953, he was appointed consultant physician to the Southampton group of hospitals.
His approach to his long waiting list for admissions was different from others because he had few hospital beds. He devised a scheme of managing patients at home with a domiciliary ‘inpatient service’ supplemented by increased use of the outpatient
