It's official. A ruler can kill you!

My own primary care trust has long been careless with the term "Health Inequalities". They always include within their strategic plans the lofty aim of: "eliminating health inequalities within the trust's area". They also have another lofty aim of making sure that our resident's health is at least as good if not better than the London average. To me, the first aim misses the point and the second is at best contradictory and at is also illogical (if we get better then we have shifted to inequality somewhere else).

Whenever someone sees some else getting a better NHS deal elsewhere, they trot out the "postcode lottery" weapon and fire it off in all directions. Well, in terms of primary care, we like differences. We like to think we do things better than average. We like to think that when we refer a patient to hospital, we arrange for all the tests that the hospital are likely to need to have done so that the hospital diagnosis and treatment is not unnecessarily delayed. We know (from feedback) that we are reckoned by hospitals to be one of the better practices. That means others are not as good.

This is an "health inequality". The cure is to set sensible minimum performance standards and then ensure that all of us maintain them. It would be even nicer if they then recognised those that exceed them and held the underperformers to account but I'm not holding my breath.

Now the WHO has passed its ruler over "health inequities" and found out that these measurements can be lethal. Their report contains much sense although some of their conlcusions are less than revolutionary:

"The Commission found evidence that demonstrates in general the poor are worse off than those less deprived, but they also found that the less deprived are in turn worse than those with average incomes, and so on. This slope linking income and health is the social gradient, and is seen everywhere – not just in developing countries, but all countries, including the richest. The slope may be more or less steep in different countries, but the phenomenon is universal."

God alone knows how much it cost to reach that conclusion!

I just get an awful feeling that somehow using the jargon phrase makes easier reading for those who hold the public purse strings. "Health inequity" is a measurement. It doesn't kill anyone. The actions and inactions of policy makers and politicians lead to changes in mortality (for good and ill). Yet somehow "health inequity" doesn't have the same ring as unhealthy housing, hunger, ignorance and waste. It's softer.

With the best of intentions

I am one of only two people to whom an elderly distant relative can turn for any contact in her ever-shrinking world. Elsie is ninety years old and currently in a general hospital "somewhere in England". That "somewhere" is two hundred miles cross-country from both me and also the other relative. Her latest crisis started some months ago when the accumulated effects of her self-imposed social isolation finally caught up with her. Since then she has been resident in three places:

• The psycho-geriatric assessment and rehabilitation unit;
• A local care home;
• Back in the general hospital.

Elsie is not much better than she was in the spring and I am really fed up about it. I don't expect the NHS or her local authority social services team to turn the clock back but between them they have failed to deliver the care she needs. The "between them" bit is the problem. I find it difficult to find too much fault with any one particular body but somehow in this instance "the whole is less than the sum of its parts".

Caring for the elderly is done by people many of whom should receive some form of endurance medal. The elderly can suffer from any number of physical ailments the treatment of which is made more difficult by them being difficult, vague, uncooperative, confused and confusing.

In Elsie's case, each team has done everything that it "says on the tin". The hospital have cured her UTI. The psychogeriatric services took her, assessed her with social services funded a place for her in a care home. The care home tried to cope with her, but she seemed to be too ill for them so she ended up back in hospital. The hospital says they can't see what is wrong so can't treat her. The psychogeriatric unit say they have already done what they are supposed to do. The home won't have her back because they say she's too difficult for them. Everybody I speak to is really nice. They all seem to care and they all do their bit. The bits simply don't add up to a solution that sees Elsie being treated or cared for effectively.

Conversations with friends in similar situations reveal a common experience. They also reveal a common conclusion: unless there is someone whose job it is to act as advocate for the individual irrespective of which agency they are dealing, then Elsie and others like her fall into one or more of the many gaps that exist between these agencies.

I am certain that on paper there is a clear definition of boundaries and there are no gaps at them. However, once an agency thinks they have done their bit, they pass Elsie over to the next agency. This next lot don't think they should have been given Elsie so they tell the first lot that Elsie belongs somewhere else. And so it goes on. Fridays come and "they didn't get back to me." Meetings take place where "the person that usually deals with this case is on leave and I don't really know Elsie". I once travelled up to the hospital for a "case conference". Waited three hours ("doctor is on his rounds at the moment") to be told that the doctor had gone for lunch. Waited two hours and was told the doctor had been called away on an emergency. "Could I come back next week?" You get the picture, I'm sure.

So here we are. Elsie is "on everybody's radar". She's costing the NHS and social services loads of money. Over the past few months they have managed to lose all her clothes and the replacement personal supplies we bought for her. Her medication records have huge gaps in them ("they don't seem to have told us who stopped her diazepam" or why). Elsie is frightened and lonely. I feel guilty that I cannot do more, shout more or visit more.

Everybody has done their job but somehow Elsie has got lost in their efforts.