The National Service Framework for Older People: England's approach to ending age discrimination in services and therapeutics.

In 1997, the new Labour Government in the UK embarked on an ambitious programme of reform. One of the key changes has been the publication of a series of National Service Frameworks. The National Service Framework for Older People (NSFOP) sets out a 10-year programme that has as its principal standard rooting out age discrimination. Together with its companion documents, a series of robust milestones and standards are set out that have to be met. Although generally welcomed by the profession, the NSFOP has been criticised by some because it mandates the initiation of new 'intermediate care' services that may be seen as denying older people the opportunity for admission to mainstream hospital care. Monitoring tools covering both procedures and prescribing have been developed. The government-produced frameworks mirror guidelines produced by the profession and include a number of prescribing recommendations, e.g. the use of antihypertensives and aspirin (acetylsalicylic acid) in the prevention of stroke, and the use of calcium, vitamin D and bisphosphonates in the treatment of osteoporosis. In tackling age discrimination, both direct and indirect barriers to effective prescribing need to be considered. The evidence base on the effectiveness of medication in older people is more limited due to the previous systematic exclusion of older people from clinical trials. The consequent lack of evidence of efficacy, coupled with perhaps a natural reluctance to prescribe potentially toxic medication, may lead to underprescribing. Other indirect causes of age discrimination may include difficulties for older people attending hospitals for drug monitoring, and the difficulties of translating the results of trials into meaningful endpoints that older patients can understand and thus make valid decisions about whether they wish to take the particular drug or not. At the same time as the NSFOP argues against age discrimination, other government policies may operate in a contradictory manner. Examples include the trend to make drugs available over the counter in pharmacies and for which the patient has to pay rather than receive them free, the restriction of some prescription-only drugs from the health service, and the need for referral to specialist services for some drugs, e.g. sildefanil, which older people may be reluctant to access. Successfully combating age discrimination is likely to require a regulatory framework, continued monitoring, tackling indirect forms of discrimination, as well as embedding antidiscrimination policies in all facets of health education.