Rory Fisher, MB, FRCP(Ed)(C), Director, Regional Geriatric Program of Toronto and Interdepartmental Division of Geriatrics, Faculty of Medicine, University of Toronto, Toronto, ON.
In Canada, the sustainability of the health care system is a major issue. Two commissions have been established to address the future of health care.1,2 Improvements in technology and changes in the delivery of health care have led to major restructuring of the system. Acute hospital beds and the length of hospital stays have decreased with the concomitant expansion of ambulatory services. The aging population, which is increasing dramatically in Canada, particularly with regard to the oldest old, is a major priority policy issue in these discussions.3 However, the current management of the elderly in acute hospitals is of concern. In the United Kingdom, an enquiry into the care of older people in acute wards in general hospitals entitled "Not because they are old" found that problems existed with older patient and relatives' dissatisfaction with the care, numerous deficiencies in physical environments, clear evidence of staff shortages and concerns about nutrition.4 Problems were also identified with preserving dignity, interactions with staff, insufficient training, discharge planning and the accessibility of services in the community. In addition, a recent study by Health Canada on unmet needs for health care reported, an estimated 7% of Canadians, or about 1.