Introduction
This paper argues that a shift in both the clinical and organisational approach to older bodies in medicine is evident which is so fundamental as to constitute the introduction of a new political anatomy of the older body. This shift follows Armstrong's Foucauldian observation that ‘medical knowledge both describes and constructs the body as an invariate biological reality’ (1983: xi). Just as our socialisation, according to Merleau-Ponty (Reference Merleau-Ponty1945/1962) and others, ensures we learn to discern certain things in our perceptual gaze and not others and in line with the Kantian and Weberian recognition that we impose order on the world that is not essentially there, so the medical gaze is socialised by the anatomical atlas which ‘directs attention to certain structures, certain similarities, certain systems and not others’ so that ‘In effect, what the student sees is not the atlas as a representation of the body but the body as a representation of the atlas’ (Armstrong Reference Armstrong1983: 2). Armstrong continues:
the analysis of the way the body is seen, described and constructed, Foucault suggests, might be called ‘political anatomy.’ It is political because the changes in the way the body is described are not the consequences of some random effects or progressive enlightenment but are based on certain mechanisms of power which, since the eighteenth century, have pervaded the body and continue to hold it in their grasp. From that time the body has been the point on which and from which power has been exercised. (1983: 2)
The concept of biopower makes clear how the history of medicine is not a smooth trajectory towards the discovery of ever-greater truth but a series of discourses and practices which constitute bodies and the problems associated with bodies according to these paradigms (Fox Reference Fox1993). This discursive construction is what Foucault understands by epistemology. It means that changed medical discourses do not stand alone but are part of a wider set of social discourses that in this case define a changed role for older people in society and construct old age in a new image. Within the context of biopower bodies are ranked and compared with one another, monitored and, if necessary, normalised. Thus, to understand changing medical paradigms around older bodies is to understand the changing place of old age in society.
Specifically, these changes relate to the ending of a ‘unitary “ages of life” culture’ (Gilleard and Higgs Reference Gilleard and Higgs2000: 2) and the substitution of a creative and reflexive construction of one's own life plan according to one's chosen script. Ageing, along with other phases of life in late modern consumerist society, becomes a ‘choice’ not a fate to which one has perforce to succumb. The clinical gaze which no longer differentiates between old and young bodies is part of the same cultural discourse: personal choice and personal responsibility includes ‘choosing health’ through a series of appropriate practices. These practices include maintaining one's body in line with particular physiological measurements, which constitutes the late modern definition of ‘health’ itself, with or without the intervention of doctors. However, although proceeding from one's ‘free will’ they, no less than any act of external coercion, are aspects of biopower, where, in Foucault's words, ‘discipline’ (including self-discipline) ‘produces subjected and practiced bodies, “docile” bodies’ (Foucault Reference Foucault1979: 138).
But to understand the meaning of the changes fully one must understand what preceded them and in this the gaze of geriatric medicine as it moved from the hospital and out into the community is key. Geriatric medicine, as it was establishing itself as a professional discipline in the United Kingdom (UK), adopted a particular epistemology of the older body and alongside it, and resulting from it, a very distinctive approach to its clinical management (Pickard Reference Pickard2010, Reference Pickard2011). Despite calls from leading geriatricians that geriatric medicine as a profession should base itself not just in the hospital but in the community, this was not generally taken up by the profession as a whole. Routine surveillance of older bodies, and thence most disease management in older people, passed to general practitioners (GPs), with the explicit encouragement of geriatricians themselves (Isaacs Reference Isaacs1982). However, there was not at this time any significant change to the medical epistemology through which the older body was approached. The GP Tudor Hart (Reference Tudor Hart and Isaacs1982) wrote of the need for GPs to ‘accept responsibility … for the elderly who are most difficult to transfer to secondary care’ (1982: 76) but in this venture spoke of GPs as ‘chief fieldworkers' to the geriatricians’ role as ‘leaders’ (1982: 77). The expansion of primary care in terms of prevention in old age was, moreover, consistent with the basic principles of geriatric medicine, key among these being recognition of a significant qualitative difference between old and young bodies.
This slowly began to change from the 1990s, with the introduction of evidence-based medicine (EBM) into routine medical practice, both at hospital and community level. In primary care its development begins with clinical guidelines, developed by the National Institute of Clinical Excellence (NICE), including several concerned with diseases commonly experienced in older age followed by evidence-based service models in National Service Frameworks (NSFs), with a service model specifically directed at older people (Harrison and McDonald Reference Harrison and McDonald2008). This trend culminated in the Quality and Outcomes Framework (QOF) introduced into England in 2004, comprising a combination of clinical guidelines and NSFs, which institutionalised the principles of EBM by tying them to financial remuneration. Concerned, at one level, with increasing professional accountability by rendering its practices more transparent, these guidelines have been described, in principle and practice, as biomedical and reductionist, valorising the achieving of standard physiological targets within an ever-narrowly defined range, and associated with increased prescribing of medication (Checkland et al. Reference Checkland, Harrison, McDonald, Grant, Campbell and Guthrie2008). Organisationally, they are delivered through bureaucratic procedures consisting of single-disease protocols administered by specialist nurse leads overseen by GPs, leading to fragmentation and lack of continuity in terms of individual patient–clinician interaction. A broader continuity is provided by the patients themselves actively engaged in self-care. As such, this practice departs radically from earlier practices associated with geriatric medicine and approaches the older body in a markedly different way.
In this paper I review both these changes and their consequences. To do this, I examine the disease protocols, comparing them with previous discourses around diseases in older bodies. I also draw on interviews, conducted mainly with GPs and supplemented by interviews with practice nurses, which demonstrate the concrete particularities of these practices, together with clinicians' perceptions of the nature of changes.
Although the narrative is set in the UK, it has wider resonance for geriatric medicine, and indeed for older patients, in other national contexts. Clinical guidelines based on EBM are prevalent in North America and the comparatively small and declining number of qualified geriatricians in the United States of America (USA) means that older people will often be treated by specialists outside the paradigms established by traditional geriatric medicine (Hogan Reference Hogan, Fillit, Rockwood and Woodhouse2010). The findings are also relevant in continental Europe (Crome Reference Crome, Fillit, Rockwood and Woodhouse2010) where the provision of geriatric services is in some cases very well developed and in other cases care of older people falls to other physicians, and in which EBM is also becoming increasingly important. Meanwhile the population continues to age and the older population to age itself, in terms of an increasing proportion of people aged 80 and over (Heath Reference Heath2008), meaning that these changes impact on greater numbers of patients.
To begin this review, it is necessary first to examine a little more closely the principles and practices of geriatric medicine as it established itself in the UK in the mid-20th century.
Hospital geriatric medicine and the older body
Hospital geriatric medicine has its roots in the late 19th-century work of Charcot in Paris who identified an essential pathology and deterioration of tissues in old age, even amongst the outwardly fit and healthy (Haber Reference Haber, van Tassel and Stearns1986). Importantly, he asserted that old age and pathology were conceptually distinct and corresponded to two separate cellular processes: tissue involution (the ‘normal’ changes of old age) and pathology. However, in practice these two states proved exceptionally hard to differentiate. The pioneering British geriatricians consciously continued this legacy, including grappling with this key problematic – the distinction between the normal and the pathological – and one way that they approached this was by attempting to identify normal physiological measurements in old age. They found that the latter contrasted with normal physiological measurements in younger age groups (Howell Reference Howell1944) without necessarily harmful results. Indeed, geriatricians identified a whole range of key tenets whereby older bodies were distinguished from younger bodies: as well as differing physiological standards these included an indistinct border between health and illness; a greater likelihood that several systems or organs in the body would be affected at the same time, and that an interweaving of social and medical factors would underpin ill health, all requiring a holistic gaze; and finally that it was necessary to apply a clinical gaze with a temporal dimension where a snapshot view of the older body would not sufficiently capture the instability of this phase of the lifespan, nor the insidious onset of illness (Pickard Reference Pickard2010: 11). It was these characteristics which geriatricians stressed when positing the need for a distinct disciplinary specialty within medicine. Specifically, at this time geriatric medicine introduced a new medical ontology (Armstrong Reference Armstrong1981) which involved a conception of normality as defined not just as the absence of pathology but as what was appropriate or normal to stages of the lifecourse (which was a parallel project to the work of paediatricians documenting ‘normality’ for childhood; see Prout Reference Prout, Williams, Gabe and Calnan2000).
However, the all but intractable challenge of distinguishing between normal and pathological ageing resulted in geriatricians stressing a more pragmatic ‘functional’ rather than ‘structural’ normality, a distinction which also underpinned the rehabilitation techniques which centred upon restoration of functional normality. This was made possible through survey evidence of older people in their domestic environment, and led to geriatricians further stressing the ‘social’ as well as ‘medical’ aspects of the patient's condition. They also set up screening clinics in the community, assessing patients referred by GPs in an attempt to remedy illness at an early age, although, as noted they quickly passed on routine surveillance of older patients to GPs (Pickard Reference Pickard2010). We turn to this next.
Geriatric medicine as practised by general practitioners
Continuity with hospital geriatric medicine
Although historically the roles and practices of hospital geriatric medicine and general practice with respect to older people contrasted, with the former concentrating on clearing beds and rehabilitation, and the latter on prevention and early intervention, epistemologically general practice inherited hospital geriatric medicine's views on the older body. There were certain compatibilities of approach which facilitated this, moreover. For example, like geriatric medicine, general practice stressed a unique disciplinary and professional approach rooted in holism. Medical holism comprised a cluster of concepts that variously: (a) privileged the general state of the organism rather than individual organs; (b) included psychological elements; (c) highlighted physical and/or social context/environment and (d) privileged the quality of interpersonal relations between doctor and patient against tendencies towards bureaucracy and depersonalisation (Lawrence and Weisz Reference Lawrence, Weisz, Lawrence and Weisz1998). This claim to holism was a legitimating discourse for geriatricians which differentiated them from (a) organ-based specialisms and (b) hospital general physicians who lacked this kind of knowledge of older people's bodies. In UK general practice, likewise, holism had a specific discursive role in terms of occupational closure and the professionalisation of general practice following the establishment of the British National Health Service (NHS) where the remit and province of general practice was a historical contingency without obvious epistemological foundation. In this context, claims to holism provided a necessary validation (Lawrence and Weisz Reference Lawrence, Weisz, Lawrence and Weisz1998).
Distinguishing element: unmet need
One way in which general practice built on the surveillance techniques that originated in geriatric medicine was through its particular emphasis, from the 1960s, of the concept of ‘unmet need’, with the first published statement on this concept (Last Reference Last1963), followed quickly by a paper indicating its particular applicability to older bodies (Williamson et al. Reference Williamson, Stokoe, Gray, Fisher, Smith, McGhee and Stephenson1964). In fact, the identification and addressing of unmet need became one of general practice's defining discourses. McWhinney (Reference McWhinney1997) defines unmet need in terms of two dimensions: firstly, needs of which the patient is unaware (which may include conditions that older people do not realise are treatable, considering them ‘normal’ for old age, together with preventive measures of which patients are unaware); secondly, needs the patient may feel have not been adequately addressed by the health-care system. Indeed, whilst Marx stressed ‘material needs’ rather than ‘ideas’ as the driving force of history, this is an example of the ideological facility of modernity to (re)construct basic material needs – specifically the apparently natural ‘needs of the body’ – in a way that fits its social priorities, involving in this case, a general problematisation of old age. Basing its judgement on an enumeration of morbidities, the concept of unmet need ignores the possibility that one reason older people may not bring problems to the attention of GPs is because they do not consider them to be so, preferring to explain them in terms of accepting poor health and limiting conditions as inevitable accompaniments of old age. Of course, expectancy of illness in old age, itself rooted in negative social imagery associated with this lifestage, can indeed mean that illness is ‘normalised’ by older people. This can result in the failure to report conditions which can often be ameliorated or even eradicated: for example, with aids as simple as glasses and hearing aids. There are also, of course, many asymptomatic conditions which, if left untreated, may have serious consequences. In other circumstances, however, older people's perception of health in terms of functional ability rather than physiology means that if they can continue to do the things they value (which will probably be rather different from the things that younger people value) then they will also continue to see themselves as healthy. Clearly, this whole area resists black and white judgements and confounds generalisations. However, dismissing such subtleties whilst classifying them all as unmet needs contributes to what Armstrong (Reference Armstrong1995) calls a ‘problematization of the normal’: a professional-led categorisation which further transforms the relationship of patient and doctor and which is a process without an obvious end (especially when physicians are required to identify those very needs that are unmet).
However, to return to the narrative, from the 1960s onwards, geriatric screening took place in general practice: as ‘anticipatory care’ it was defined as ‘care with an eye to the future’ (Royal College of General Practitioners 1981). Insofar as it included primary, secondary and tertiary prevention (Williams Reference Williams1986), routine interaction and surveillance were all but indistinguishable. Freer (Reference Freer1985) makes this point in comparing screening younger bodies with older bodies, pointing out that ‘screening is designed to detect individuals who may have a disease such as hypertension or the early stages of cervical cancer. Many of the problems experienced by individuals over 65 or 75 years of age are unlikely to be so easily defined or identified’ (1985: 288). Surveillance in older age, Williams suggests, should thus concentrate on function and look at aspects key to older people's continued health including mobility/falls; vision, hearing, skeletal/feet; principal carers (Williams Reference Williams1986).
Let us turn next to the introduction of a new paradigm for viewing the older body in primary care: that of chronic disease management (CDM).
Chronic disease management: new principles and practices towards the older body
CDM as a formal process was ushered in through the QOF, itself introduced as part of the 2004 General Medical Services contract. It comprised (in its original form) 146 evidence-based targets relating to quality of care in ten chronic disease areas, revised in 2006 to 80 targets covering 19 long-term conditions (Ashworth and Kordowicz Reference Ashworth and Kordowicz2010). Most of the patients treated within this model are 60 and over, with the proportion of patients treated for more than one chronic disease rising exponentially with age (Alder et al. Reference Alder, Mayhew, Moody, Morris and Shah2005). As noted, the scheme has, subsequent to its introduction, been regularly revised and updated incorporating ever-more narrowly defined targets and additional diseases. Compliance is rewarded by powerful financial incentives which can make up one-third of a practice's income (Checkland et al. Reference Checkland, Harrison, McDonald, Grant, Campbell and Guthrie2008) and makes it highly unlikely that practices will resist. Despite the fact that CDM is directed overwhelmingly at older patients, neither its structure, processes nor clinical approaches specifically take this into account and are directed at all bodies generically. The scheme hugely increases the tendencies towards bureaucratic accountability and specialisation as well as biomedical reductionism over individual clinical judgement. The protocol-based disease areas are associated with increased use of medication and are potentially thus associated with overtreatment; however, they also contain the risk of undertreatment insofar as they do not recognise illness that cannot be explained in terms of disease (Reeve Reference Reeve2010) or measured in terms of ‘hard’ evidence. In addition, time and resource constraints mean that diseases that are not incentivised by the QOF are unlikely to receive more than minimal attention (McDonald, Checkland and Harrison Reference McDonald, Checkland and Harrison2009).
At the same time, GPs have introduced a range of increasingly bureaucratic organisational practices such as electronic record keeping, automated patient call and recall systems, and standardised templates for use during consultations. These are texts positioned within precisely delineated frames that exclude subjective patient experience and social details and admit very modest, if any, opportunity for the doctor to record impressions on any aspect of patient care that lie outside these texts. An examination of a chronic kidney disease (CKD) template illustrates this process. A series of prompts against codes follow on one after the other, requiring doctors to select mostly from a list of multiple choices. All prompts are related to physiology, e.g. serum albumen value, urine blood test, cholesterol value, height, weight, BMI. Smoking status features prominently with seven consecutive entries: ‘cessation readiness’; whether or not advice has been given and so on. Alcohol intake measurements follow. The only questions that recognise that the patient is also a person with a biographical and social context beyond the template relate to ethnicity and language skills. No free space is provided at all for doctors to record impressions, whether social or medical details, that may have arisen outside the format of the protocol.
Berg (Reference Berg1998) observes that such records structure doctors' ‘thought processes’. So ‘forms list the questions to ask, and differentiate between relevant and irrelevant information’ (Berg Reference Berg1998: 297) such as omitting certain items or not allowing free space for introduction of alternative tropes. This would suggest that doctors' impressions where they lay outside the protocol may at first be suppressed and then may cease to appear at all. In this sense, the protocol constitutes a violent rupture with previous texts, in the Derridean sense. This is not, however, an argument for the iniquity of this particular type of protocol: rather, all clinical forms, and particularly the more structured among them, will, by framing thought processes in particular ways, close off other ways of seeing bodies.
CDM also involves the reconstruction of patients as ‘expert patients’. An aspect of the ‘engaged and active citizen’ governmentality rhetoric and closely related to the ‘active ageing’ discourse, this rhetoric enjoins patients to be engaged, responsible and self-directed towards maintaining their own health (e.g. Department of Health 2006). Services then are partly reconstructed to help people to help themselves (Department of Health 2004). Self-care practices feature prominently in disease-led reviews by nurses (Sanders, Harrison and Checkland Reference Sanders, Harrison and Checkland2010) but less so in GP–patient interaction and nor do they feature in any clinical guidelines, which focus exclusively on targets for professional intervention.
Below I examine in more detail the management of two diseases/conditions in older people. The first condition is hypertension, contestably a ‘disease’ that affects older bodies in particular, and for which I construct a genealogy of shifting attitudes over time. To start the genealogy, I revisit the arguments of pioneering mid-20th-century hospital geriatricians on this matter, and then review its changing management in general practice as this appears within three editions of a popular general practice textbook. I then examine CDM guidelines. Finally, I return to contemporary textbooks used by hospital geriatricians to gauge how much they also reflect shifting discourses because, even though the vast majority of hypertension management takes place in general practice, it would be misleading not to include in this review the degree to which contemporary hospital geriatric medicine shares the new assumptions and approaches. Following this, I look similarly at CKD which is a ‘new’ disease arguably introduced by the QOF itself (Oliver Reference Oliver2008).
Epistemologies of the older body, past and present
Changing attitudes towards hypertension
As noted, the pioneering hospital geriatrician Howell (Reference Howell1944) found that it was ‘normal’ for older people to have much higher blood pressure than younger people and that, far from being pathological, in some cases this was equated with particularly good health. Moreover, whether or not hypertension is a disease was, for many years, contestable. Formally, it was a risk indicator, but Tudor Hart put it thus: ‘If by disease we mean that those who have it can be shown to differ qualitatively from those who do not, then the disease hypertension does, just occasionally, exist in the elderly’ (Tudor Hart Reference Tudor Hart and Isaacs1982: 71).
This understanding persisted in general practice's approach towards older bodies. In McWhinney's classic textbook of family medicine (1989) he echoes these observations. Declaring: ‘The benefits of antihypertensive drugs in the elderly are still uncertain’, he advises against treatment in ordinary circumstances:
it may be … that high blood pressure in the very old has a different significance from high blood pressure in the young. A ‘normal’ blood pressure in the aged might be a blood pressure that has fallen as a result of cardiovascular disease. A high blood pressure in the aged might actually have survival value. (1989: 291)
This approach, moreover, is consistent with a section earlier in the book that discusses ‘the meaning of normal’. In this section, McWhinney stresses two types of variability, including that within an individual – physiological values vary widely with different times, contexts, environments – and that between individuals. Failure to understand this has led the history of medicine to be cluttered with examples of individuals erroneously classified as abnormal. One of the implications of this, McWhinney suggests, is as follows:
Because of his or her long-term relationship with patients, the family physician is in a good position for obtaining baseline values from patients. This enables the physician to compare subsequent readings on the same patient with this baseline value – a potentially much more useful comparison than that with a ‘normal’ range. (1989: 169)
However, an increase in standardisation and biomedicalisation is apparent in the changes to advice on this issue through two later editions in 1997 and 2009 (McWhinney Reference McWhinney1997; McWhinney and Freeman Reference McWhinney and Freeman2009), both of which bear the imprint of the NSFs and the QOF, respectively. These later editions depart from the first one in distinct ways. Firstly, the section discussing hypertension in older people becomes appreciably shorter; gone is any discussion of the advantages and disadvantages of treating hypertension in this group with drugs, including the discussion in the first edition of the potentially negative effects of pharmacological intervention. This is replaced with the view that treatment should be the rule not the exception. There are no longer any indications that normality is qualitatively different in older people; indeed the second and third editions provide standard guidelines for treating patients when their blood pressure is above a specific level which adhere closely to the QOF guidance, and give little importance to issues specifically relating to older bodies. The second and third editions acknowledge that the trials, which provide the evidence for intervention, ‘excluded … the very frail and those who suffer from co-morbidity … [so] the trial results do not apply to all hypertensive patients in this age group’ (McWhinney and Freeman Reference McWhinney and Freeman2009: 329). But they omit to add that, in practice, this excludes a very high proportion of older people (latest figures suggest that half of all adults over 65 have three or more co-morbidities; Fortin et al. Reference Fortin, Hudon, Haggerty, Akker and Almirall2010). This advice, however, is consistent with QOF guidelines. The latter (for 2010–11) uses a measurement of 150/90, in line with the British Hypertension Society's recommendations for audit; drug treatment is recommended. Specific conditions are highlighted in relation to blood pressure, with added incentives for GPs to reduce this to 140/90 for diabetes and even lower for CKD; age is not highlighted as an issue at all.
Clearly, one explanation might be that this change is consistent with advances in medical knowledge and indeed evidence-based trials are cited throughout. However, several recent publications challenge this construction (Hadler Reference Hadler2008; Mangin, Sweeney and Heath Reference Mangin, Sweeney and Heath2007; see also the stream of letters submitted to the British Medical Journal in response to this latter article) and attest to the meagre benefits, the attendant risks and ultimately the substituting of one form of death with another. As older people themselves are rarely aware of this trade-off it has been described as ‘morally questionable’ (Mangin, Sweeney and Heath Reference Mangin, Sweeney and Heath2007).
Meanwhile, how is hypertension discussed in current hospital geriatric medicine textbooks? To answer this question I will examine the seventh and latest edition of Brocklehurst's Textbook of Geriatric Medicine and Gerontology (Fillit, Rockwood and Woodhouse Reference Fillit, Rockwood and Woodhouse2010). In his chapter on hypertension, Potter (Reference Potter, Fillit, Rockwood and Woodhouse2010) acknowledges the greater and more straightforwardly positive outcomes attached to treating younger people with high blood pressure. But his discussion indicates the entry of a new trope into hospital geriatric medicine, and both this chapter and his (almost identical) contribution in the sixth edition of the same volume (Potter Reference Potter, Tallis and Fillit2003) reveals the privileged position now occupied by EBM in discourse. Thus, the discussion distances itself from the former ‘general reluctance to treat hypertension in older people’ (Potter Reference Potter, Fillit, Rockwood and Woodhouse2010: 300) and draws on EBM to back assertions about the almost unequivocal benefits of intervention. However, at the same time it continues to assert the older (and agonistic) idea that (a) high blood pressure is normal in older age and (b) this means that most people between 65 and 94 years are therefore hypertensive. The chapter ends with the somewhat equivocal conclusion, in which the ghost of Tudor Hart's discussion can be felt: ‘we have come a long way in a short time in terms of evidence based management of the older hypertensive patient but too many elderly patients remain undiagnosed or inadequately treated (Potter Reference Potter, Fillit, Rockwood and Woodhouse2010: 311). A chapter on ‘laboratory medicine’ by Lapin (Reference Lapin, Fillit, Rockwood and Woodhouse2010) addresses this tension directly. First referring favourably to EBM he then goes on to explain that geriatric laboratory medicine is confounded by the ‘individuality and variability of the senescent process from both a clinical and a biological point of view’ (2010: 218). The most useful method of risk stratification for older people, he suggests, is where ‘interindividual differences’ are used to monitor change over time in the same individual. This, of course, is an emphasis that goes back to geriatric medicine's origins; nevertheless the emphasis in the QOF is of course in the opposite direction and this suggests that clinical ‘advances’ cannot be solely responsible for this epistemic break.
‘New’ problems of the ageing body: chronic kidney disease
I now turn to CKD, by contrast with hypertension a newly constructed disease, introduced by NICE and then institutionalised through its inclusion in the QOF. Based on work by the US National Kidney Foundation published in 2002, the disease is constructed as follows: stage 1 of CKD is ‘normal or increased eGFR,Footnote 1 with evidence of kidney damage (which might include persistent proteineuria)’ even though proteineuria is commonly found in older adults. Even stage 3, ‘moderately reduced kidney function’ has few or no symptoms and is again fairly common especially in older people (see Renal Association website at www.renal.org/CKD). This process then problematises older people's kidneys where in previous clinical regimes renal function of this type would almost certainly have been identified as involutionary and hence ‘normal’ for old age.
The new approach is encapsulated strikingly in an example found within a resource page produced by the Renal Unit of the Royal Infirmary of Edinburgh (source: www.edrep.org/pages/textbook/ckd-1-3.php [Accessed 2 August 2011]). ‘The widespread use of the MDRD equation to report eGFR has led to many older people, especially women, being labelled CKD3. Are they abnormal? Probably most of them are … Imagine X-raying the hip of an 85-year old. It is quite likely to show some osteoarthritis. Is this normal, just because the hip is 85? No, it is abnormal, but if the patient is 85 it maybe isn't so surprising’. What this assessment overlooks absolutely is both the notion of involutionary processes as well as the patient's own situated perception, or the distinction between structural and functional normality. Osteoarthritis may be detectable by X-ray but not registered or experienced by an older person themselves (this is certainly not uncommon) or, if so, then only mildly. Why, then, should this be classed as abnormal? Or even as unmet need? But alternatively: why not? Hadler circles around the conundrum carefully. He writes: ‘Some diseases would be unusual at any age; but some would be abnormal in youth but are so common after sixty that to be spared them is abnormal’ (2011: 9). He goes on: ‘By sixty, some diseases are so normal that we dare not call them disease … or do we? Illnesses are never normal, even if they are common.’
Both textbooks and the QOF acknowledge the greater likelihood of older people in the population having CKD but there are few suggestions that this might give pause regarding intervention. Yet the fact that renal capacity diminishes with age has been associated with a different discourse in previous texts: there is no record of this process as a condition, or problem by any other name, in any of the editions of Brocklehurst's textbooks before the sixth edition in 2003, nor in McWhinney's general practice textbooks until the third edition in 2008 (when there is a brief mention of it in the context of hypertension). The sixth edition of Brocklehurst's textbook (Tallis and Fillit Reference Tallis and Fillit2003) neither names CKD nor discusses it elliptically but rather describes changes to the kidney in ways that recognise the difficulties in separating normal from pathological changes in older age. It explains:
In a normal young adult, renal capacity far exceeds the ordinary demands for solute and water conservation and excretion. In old age, renal function, although substantially diminished, still provides adequate regulation of the volume and composition of extracellular fluid under ordinary circumstances. (Tallis and Fillit Reference Tallis and Fillit2003: 1081)
A minimal degree of intervention is proposed. It is only in the seventh edition of this textbook that one finds a significantly different approach. Pointing out that 37 per cent of those aged 70 and over in the USA have CKD stage 3 and above it states that the ‘primary renal diagnosis remains unconfirmed’ (Fillit, Rockwood and Woodhouse Reference Fillit, Rockwood and Woodhouse2010: 695) in the majority of cases. In other words, the cause is not attributed to age, or ‘involution’ as the older discourse would have it but is ‘unknown’, as if there must be some as yet unrecognised pathology present. The conclusion states: ‘age per se should not be a contraindication to good treatment’ (Fillit, Rockwood and Woodhouse Reference Fillit, Rockwood and Woodhouse2010: 696). Turning finally to the QOF indicators, the ‘frequently asked questions’ (British Medical Association (BMA) 2011) draw attention to the ‘progressive loss of eGFR with age’ but then states: ‘this in itself should not preclude these patients from receiving care as outlined by NICE’ (BMA 2011: 9). Moreover, the clinical recommendations talk of bodies generically, omitting age as a consideration altogether.
Principles and practices concerning the older body in general practice: empirical data
In the rest of the paper I explore the views of clinicians, focusing mainly on GPs, but also of practice nurses, regarding the technologies through which older bodies are being approached in primary care, within the terms of evidence-based CDM together with the meaning clinicians attach to this. Participating GPs were based at four practices in the North West of England, selected to represent contrasting characteristics: rural, inner city and suburban. All practices scored maximum, or near maximum, QOF scores. Following ethical approval, interviews took place with as many doctors as possible in each practice between 2008 and 2009, with all senior partners interviewed and up to three others (Practice A=4; B=2; C=3; D=3). Up to four practice nurses involved in CDM were also interviewed in each practice (all names are anonymised).
Interviews were semi-structured, took approximately 90 minutes, and covered a broad range of topics with the main focus on the structures and processes of QOF and perceptions regarding the advantages and disadvantages of their application to older patients. This was contextualised through questions that explored historical practices and the ways in which the QOF impacted on these, specifically in the fields of hypertension, diabetes (type II), CKD and raised cholesterol, diseases or risks chosen because they form major sections of the QOF, they are particularly likely to afflict older bodies (Alder et al. Reference Alder, Mayhew, Moody, Morris and Shah2005) and they represent a mixture of established and new problems of the older body. Where appropriate vignettes were employed in order to tease out GPs' approach to older patients, past and present, with a wide range of clinical and social characteristics. All interviews were carried out and analysed by myself, employing themes originally derived from my reading of the literature on QOF, which identified the major changes as those of (a) procedures and delivery of care; and (b) epistemologies underpinning care. The third theme sprang from the data and concerned the degree to which these changes impacted on broader perceptions of health and illness in old age. Empirical data were iteratively compared and contrasted with discourses in the textbooks already noted above.
The next section presents the data within the context of these three themes.
Delivering chronic disease management
Several sub-themes emerged here from the interviews: the automated call and recall letters sent out from the practices that turned older people into ‘patients’ in the absence of ill health but the presence of ‘risk factors’ like raised cholesterol and blood pressure; the tendency to overlook illnesses not prioritised by the QOF; emergence of a new type of interaction between clinician and patient underpinned by a distinct, though implicit, epistemology of older bodies.
As a result of the automated call and recall procedures, the standardised systems and processes associated with CDM mean that older people often find themselves no longer patients as a result of their own decision to seek help but because they are summoned by regular letters for review. Although Heath (Reference Heath1995) identified this self-nominating aspect of patienthood as a key part of the ethos of primary care, this current practice is, of course, an extension of surveillance medicine; but unlike surveillance medicine it is the construction of a person with no obvious symptoms, into an actual patient. Thus, older people who have had mild asthma for years, for example, or have in the last couple of years developed mild and stable non-insulin-dependent diabetes, will be ‘managed’ as patients within the standard ‘protocols’ that exist for both those conditions. This means that both patient and doctor are locked into a formalised relationship that demands prescribed actions from both. Thus, as Dr H says: ‘If we know that mild hypertension in a fifty-five year old man … that it doesn't really matter whether you treat it or not … but … they're on the hypertension registers, so we're forced to treat them’.
However, the obverse of this is that people whose problems do not fit these categories may not receive the attention they might have had before these protocols were established. One experienced practice nurse (‘Nurse L’) from Practice B explained how this could skew relationships between patients and clinicians:
There are a lot of people out there who've got far more complex needs and health problems … but because it doesn't have a label attached to it, then it doesn't show up on the QOF and they don't become somebody who you would then allocate to a long-term nurse.
A new ideal-typical doctor–patient interaction is associated with the QOF involving particular patients with defined labels embedded within routines which are formal, rigid and highly constrained. When a patient presents for any regular consultation, their chronic conditions are listed on their notes in the form of a summary of active problems, a simple record that does not allow for the recording of their severity nor for whether they are stable or unstable; nor is there any section which records patients' subjective experience of their own health or the effects of these conditions on functions or activities of daily living. As we have noted, there is no space, either in the QOF, or in the template constructed by individual GP practices, to record social or personal details of relevance in individual cases. In each practice specialist nurses oversee one main disease area where they undertake routine reviews in that area with stable patients. Thereafter only if the patients developed specific problems would they be referred on to the lead GP in that disease area.
Certainly these processes do not encourage familiarity with older patients' lives and circumstances where, from this basis, the physician might hope to pick up change or deviation from the norm – the preferred modus operandi of geriatric medicine as we have noted – that may not be obvious in disease reviews. Within the confines of such a system, then, one might ask: how can a doctor access that subtle knowledge about a patient that enables her or him to determine the difference between disease and illness in an older body or understand whether or not the patient is normalising conditions about which something can be done or not reporting other features which may be salient to a professional but not to the older person themselves or alternatively, as Heath (Reference Heath1995) puts it, seeking medical relief for what is actually suffering of the soul? Rather, it is assumed that there is a logical reporting of conditions, classifiable through a simple yes or no answer, or in terms of a quantification, which then meets with a discrete intervention.
In between consultations it is assumed that the patient will self-care, applying an equally rational approach. Discourses around self-care practices are located within the context of the long-term reviews carried out by the nurses. Nurses describe a nurse–patient relationship which is, on their part, an educative one underpinned by surveillance designed to instil in the patient the disposition to self-manage individual conditions (with here, as elsewhere, each condition treated separately; see Pickard and Rogers Reference Pickard and Rogers2012) including changing lifestyles if necessary. Nurse H explains this as follows:
For instance, somebody who would have hypertension might have got into a routine over the years of coming to see the doctor to have their blood pressure checked and … authorise medication but they wouldn't have the opportunity in their little consultation to talk about the three teaspoons of salt they're putting on their food every day or whatever it is … you know, are they exercising? Are they eating healthily? (Practice A)
A keenly self-reflexive nurse, however, was able to discern the less flattering aspect of this: what she called a ‘downgrading’ of the care of older people, in the very structures through which it is formalised. Thus, they are formally delegated to what Nurse R calls the ‘least qualified members of the general practice team’.
The clinical gaze upon older bodies
Several key sub-themes emerged from interviews with GPs regarding the nature of the clinical gaze constructed by the QOF. These were: a focus on discrete clinical conditions rather than on the interconnections between them; a tendency towards homogenisation and standardisation both in terms of older bodies themselves, and between older bodies and younger bodies; an emphasis on pharmacological intervention.
Geriatric medicine traditionally emphasised the interconnectedness of: all organs and systems in the older body; disease and health; social and medical conditions. These principles are noted still in the seventh edition of Brocklehurst's textbook (Rosen, Kortez and Reuben Reference Rosen, Kortez, Reuben, Fillit, Rockwood and Woodhouse2010). However, not only are there no linkages or cross-references built into the individual clinical guidelines but none of the practices in the study had any formal or informal procedures for identifying patients with more than one long-term condition, despite the consequences this co-existence was likely to have on overall health as well as clinical management. Additionally, disease reviews are organised around single-disease conditions. The older body constructed within geriatric medicine's first phase is invisible here.
Secondly, the use of protocols encourages standardisation. Dr H has no problem with this: ‘They're all the same. They've all got the same illnesses and what you do, obviously before they come in, you look at their records and … you know … exactly the type who is going to walk in’ (Dr H, Practice C).
There is another kind of homogenisation apparent, however, concerned with dissolving the distinction between older bodies and other bodies and conceptualising all bodies according to the same physiological standards. Several GPs, in accordance with Standard One of the NSF for older people, declared the importance of treating older people in the same way that they treat their younger patients. When discussing this, however, GPs appear to conflate two separate aspects. Firstly, they stress the importance of treating older people when in previous decades treatment was denied them, either explicitly or implicitly on the grounds of age – kidney dialysis being the obvious example. Secondly, they do this not strictly on the basis of biomedical epistemology but for a cultural and social rationale, the suggestion, that is, that to behave otherwise may be ageist. Dr L comments: ‘So we're not in that situation any more, basically age is no longer a barrier so, you should … treat them the same’ (Dr L, Practice B, my emphasis). Treating them, and treating them ‘the same’ are here elided conceptually (whereby treating older bodies as equal but different does not appear to be a consideration).
Indeed, ‘treating them the same’ involves a ready tendency to prescribe medication. With reluctance the following doctor concedes defeat where some older people decline pharmacological intervention:
I've got a lovely couple, they're both in their mid-eighties and their blood pressure isn't well controlled. And I've tried various things and I've called it quits, because they are fit and well, their blood pressure is higher than I would like it to be … And at 85 they're still gardening for eight hours. (Dr L, Practice B)
Here, Dr L does not seem to register the irony inherent in the fact that these people are what he readily admits ‘fit and well’ yet he still wishes to ‘treat’ them. The uncomfortable co-existence of both perspectives, however, indicates that while he is able to shift his gaze to the context of their continuing to be able to garden, this perspective now lies outside the ‘frame’ of the consultation as structured by disease management protocols. In these circumstances ‘unmet need’ becomes a portmanteau term that by implication defines intervention as an undisputed good; that therefore carries the meaning of ‘need for pharmaceutical intervention which is not being met’ as, for example, with the older couple described above. There is also no acknowledgement in the discussion of any risks that this intervention (as opposed to its absence) may also contain. Thus, whilst no methods exist in the QOF for identifying the subjective experience of health in older people, this can be justified by the notion that older people may well ‘normalise’ what are in fact ‘problems’. As one GP states:
They accept their reduced abilities as being part of a process, so it's quite important when you do see these people, that you actually go beyond that and you actually have got to look for what they can do and what they can't do. (Dr B, Practice D)
This doctor credits the protocol with sensitivity to do this: ‘[But] now the MRC breathlessness scale, you now actually have to document so that another person can check and see whether they're actually going down the scale or not … That's … meaningful’ (Dr B, Practice D).
This is undoubtedly a good thing; however, GPs also justify the failure to include older people's known priorities or indeed certain recognisable health-care needs by the fact that the latter cannot be judged according to the statistical methods contained within such protocols. Thus, it is not the system of measurement that appears at fault, but the need itself for not being sufficiently quantifiable. When I raise the question of the desirability of having regular reviews for sensory impairments such as eyesight and hearing and problems with the feet – all well-recognised in traditional general practice textbooks as crucial in preventing falls in older people – Dr W demurs: ‘QOF is meant to be evidence based. Now, there's no evidence base around hearing loss, that I'm aware of, that would give you an outcome that would be appropriate to QOF’ (Dr W, Practice A). Bodily needs then cannot be ‘seen’ unless located within the cosmology opened up by the QOF. This is particularly true insofar as the ten-minute consultation is already pre-populated with criteria determined by the protocols. As one GP described it:
Right, well have I got their blood pressure up to date? Have I got their smoking status up to date? Have I got their latest HbA1c diabetes test? Have they had their, if they are COPD [chronic obstructive pulmonary disease], FEVFootnote 2 done recently? (Dr D, Practice C)
New health, new normality
The protocols associated with the NSFs and the QOF privilege achieving a standard physiological target over either functionality or deviation from one's personal norm. Views that were expressed during the interviews suggest that the targets come to be viewed by clinicians not as measuring something called ‘health’ or ‘normality’ but as ‘health’ or ‘normality’ itself. Consider the following statement from Dr K of Practice A:
I think before QOF … getting somebody's blood pressure to an absolute number, if you were not achieving it, it was easy to say, ‘Oh, well, you are stressed today or well try again for a little bit longer,’ or the patient was not keen and it … would drift along a little bit. Whereas QOF drives you to make a change and review somebody and actually put … what you should be doing actually into practice.
This correspondence of health with normality is presented as age-blind within these frameworks. To be more precise, youthful bodies are the standard because it is youthful bodies that are included in the trials from which evidence of normality is derived and then presented as universal benchmarks. This leads at best to greater diagnosis of illness in older people, at worst to the creation of whole new disease categories based on problematising what were formerly understood to be normal organ-based changes. As we have noted, chronic kidney disease is one such emergent disease category ‘created’ by this system. In my interviews, GPs accept this uncritically, for the most part: ‘Chronic kidney disease has suddenly appeared and we've got 420 [older] people with chronic, we've got a significant workload’ (Dr L, Practice B). Some GPs take the next logical step and make the positivist claim, not that this category has shaped the way they see illness or even constituted a new disease category but that this disease was always there waiting to be discovered:
Nearly every elderly person has got CKD…; maybe we didn't measure it as well in the past and now you've seriously got to look at, right, should we put them on that anti-hypertensive? (Dr H, Practice C)
This leads to the possibility, indeed likelihood, of further discoveries of pathology: thus, more generally
Now you've got to have a register, you've got to look at your prevalence and is your prevalence as is expected or not? If it's not, why not? Maybe because you're not diagnosing them. There are loads of people with COPD out there who have not been diagnosed, you know, so from that point of view it is becoming useful. (Dr H, Practice C)
Nevertheless, ambiguities and alternative readings of health are apparent to some GPs and indeed to some practice nurses too. So one GP muses rhetorically at what point the ‘ordinary’ occurrence of having a chronic condition or several chronic conditions equates to ‘ill health’. Dr B reflects:
You may have a number [of long-term conditions] and we all do, with advancing age, and we will do because that is just part of ageing, but at what point does it actually affect individuals' lives? … It may not be relevant but it could be. It may be that they have other social problems, psychological problems that also interact, and so the art of medicine is around making sure that you can translate that into an individual patient.
He is freely acknowledging that medicine is interpretive; that standardised medical approaches require fine tuning in the case of older people's bodies. The problem is that, other than through ‘exception reporting’Footnote 3 this is not enabled within the processes of CDM as they currently stand. Moreover, exception reporting cannot be a satisfactory response to the health-care needs of older people which require a positive approach of its own, characterised by unique and alternative standards of normality, and not one that defaults from the ‘regular’ approach and is by definition ‘exceptional’ and ‘pathological’. Exception reporting has the implication of tolerating ‘remnants’ or fragments from an old approach: until we can learn to think wholly within one paradigm we can except out the ‘anomalies’. Dr W acknowledges that older people may not be served well by this standardised approach: ‘I mean, we may except them on things like BP [blood pressure] targets because, you know, we make them fall, we make them have fractures and all the rest of it which can't be good medicine. And yet, that's not taken into account at all, is it?’ (Dr W, Practice A). Currently, all the evidence suggests that the two logics, an older and a newer one, jostle for prominence in doctors' heads:
Patient who is 85 who has an eGFR of 47, that's probably normal, that's probably not a disease, unless, see there's always a counter argument, there's a counter argument that actually you can find 85-year-old people who have an eGFR of 90, which is normal. You know, which is right? This same argument goes for cholesterol. (Dr S, Practice A)
Concluding thoughts: towards a new political anatomy of the older body?
The genealogical excavation undertaken in this paper of past and current practices towards health and illness in old age has required a long sweep of the contours of medicine to highlight the elements both of continuity and change. Continuity can be seen in an underpinning mentality that stresses the burden of ageing, its need for expert mediation, and the general likelihood of older people succumbing to illness without such expertise. But there are also important elements of change in the technologies as they appear today. The older theoretical distinction between involution and pathology has been lost; the pragmatic distinction between structural and functional normality features in but a minor way; and perhaps most significantly of all, the distinctiveness of older bodies has melted into irrelevance in the statistical regime of evidence-based medicine. However, I want to stress that what I am identifying here is not the replacement of a superior old paradigm, associated with the pioneering days of geriatric medicine, with an inferior new paradigm, the former being closer to the ‘truth’ of the ageing body than the latter. Rather, what is of most interest is that each paradigm is associated with different truth claims about the role of older people in society. The old clinical regime that emphasised the uniqueness of older bodies was embedded in a context whereby at the same time the structures of welfarism set older people ‘apart’ from the ‘adult’ members of society; today's conditions of possibility are different. Moreover, each construction of the ageing body is certainly ‘mixed’ in terms of meanings and consequences for older people. So, in the case of CKD assumptions that all bodies should be measurable by the same standard leads in many cases to the problematisation of the ageing kidney, which in turn results in the increasing medicalisation of old age and its impact on the subjectivities of older people. However, owing to the recognised dangers in assuming a harmony of biological and chronological age for individuals (BMA 2011), extending treatment allows the possibility of avoiding this conflation, in turn enabling healthier third agers to separate themselves from the less healthy fourth agers. The key argument of this paper is that the ‘conditions of possibility’ for any set of assumptions to emerge as self-evidently ‘correct’ owes less to clinical ‘truth’ than to the social and political conditions in which such truth is embedded. If, after Armstrong, the atlas – in this case a highly specific set of clinical indicators – directs the clinician to look for one thing rather than another then it is the fluidity of retirement, the transformatory powers of consumerism, the ethos of responsibilisation which makes the focus of this gaze possible. The underpinning cultural assumption is that the preservation of normality is not a collective fate but an individual choice dependent on both expert intervention and personal merit. But here what is seen as ‘merit’ is perhaps less choice than an example of ‘docility’ to dominant discourses, simultaneously valued and increasingly an expectation for the ‘normal’ meaning that ‘fate’ itself has simply become individualised.
Indeed, what has been identified in this discussion is the changing definition of normality in old age, seeing, after Derrida, EBM guides and protocols as frames which achieve a particular meaning. By this reckoning, what is excluded is every bit as important as what is retained (Fox Reference Fox1995). But once deconstructed, such a frame loses its power: one glimpses beyond the text, whether one is a clinician or patient, towards the contours of an alternative, postmodern even, political anatomy of the older body.
Acknowledgements
The empirical data on which part of this paper draws was made possible by funding from the National Institute of Health Research School of Primary Care. The funders took no part in designing, executing or analysing this study. All views expressed in it are those of the author alone. I wish to acknowledge Pete Bower, Bonnie Sibbald and David Reeves at the University of Manchester for their role in the research design and funding application for the empirical study. Warm thanks to Michael Mair at the University of Liverpool and also to the two referees for extremely helpful comments on a previous draft of this paper. Ethical approval for the study was granted by Wrightington, Wigan and Leigh Research Ethics Committee. Rec reference no. 08/H1014/90.
