The column this week is a game of two halves, starting with a reflection on the implication of the general election for training bodies in medicine, and finishing with good news on falling rates of dementia and disability among older people.
Politics rarely feature in my column, but the outcome of the recent election prompts a comment. One of the key drivers of dysfunction in the health services is the toxic combination of political interference and multi-seat constituencies, as exemplified by the inability to effectively implement successive reports on hospital reform, from the Fitzgerald report in 1968 to that of Hanley in 2003.
Put simply, there are too many small hospitals with insufficient critical mass for each to provide the type of 24/7 services at the level that would be expected by international standards.
Rather than politicians providing leadership in developing a multi-partisan approach to rationalise acute services to 12 major hospitals with elective and rehabilitation services in the remaining hospitals and effective ambulance cover, any such attempt is stymied by the threat of vicious one-upmanship within multi-seat constituencies.The right thing Portlaoise hospital is a classic example (iti.ms/1Qrzd7i), where clinicians and managers recommended ceasing 24/7 emergency cover but preserving Dáil seats determined the outcome, with a range of Cabinet Ministers and the Taoiseach over-ruling those who knew what they were talking about. However, it is also clear that any noble attempt to do the right thing currently would serve as an immediate catalyst for Opposition candidates to make hay with a complicit and often under-informed electorate.
The huge rise in the number of Independents and small parties is likely to paralyse further any attempt at building a hospital system of which we can be proud, and which does not divert badly needed resources and manpower by diluting them through too many small hospitals.
Given this decision stasis, the professional and training bodies in medicine need to step up to the plate in a more forceful way and provide leadership on informing public debate on the reality of developing high-quality acute hospital services. The Royal College of Physicians in London has undertaken just such an initiative in its report The Future Hospital.
In addition, the training bodies need to resist enormous pressure on them to recognise training posts in units without sufficient critical mass in terms of patient throughput, facilities and formal training.
Dementia
On a happier note, 2016 has brought good news from the world of research on older people, particularly about a significant drop in the likelihood of developing dementia and disability as we age.
A number of recent reports had already suggested that this was likely to be the case, and important confirmatory research papers were published in the New England Journal of Medicine and the Lancet last month.
The first tracked inhabitants of Framingham, an affluent town near Boston, and found that the prevalence of dementia not only fell by almost a half over 30 years since 1977, but that the age of onset was also delayed, rising from an average of 80 years to 85 years.
This welcome news was matched in the second study, a major survey of older people in the UK, which showed an increase in life expectancy over a 20-year period with equivalent gains in the time spent without dementia, better self-rated health, and less severe disability but more “minor” disability.
The findings are welcome from so many points of view, but in particular they will help defuse notions of demographic “time-bombs”, a concept which seems to freeze constructive thinking on providing services for those with age-related disability. We need to move from worrying unproductively about tomorrow to galvanise provision of such services today.
Education
The reasons for these improvements are complex, and are similar to those which have led to major reductions in heart disease and stroke: better living conditions and nutrition, less smoking, less salt, more attention to blood pressure and diabetes. The most surprising one is better education, which was a key component for reduced risk of dementia in the Framingham study.
This ties in with animal studies of preventing dementia through stimulation from an early age.
When Donogh O’Malley introduced free secondary education in 1966, little did he imagine he might also have helped to reduce, and delay the onset, of the challenge of dementia for future generations.
Des O’Neill is a geriatrician and co- chairman of the Medical and Health Humanities Initiative.