Tuesday, 15 July 2014

Community Spirit

After months of not having anything new to say, I was struck by something I read this week in the local parish paper.

Ever since I moved down here, I have seen walking around the village, through the lanes, and, on occasions, along the busy highways, a tall, elderly gentleman, who wore the unmistakable look of the dementia sufferer. But I have not seen him for a few weeks.

The update in the parish news told us that he had recently been admitted to hospital, and subsequently discharged to a care home. However, the message from his wife, was one of gratitude to the locals. She was thankful for the care, consideration and kindness they had shown to him when he went on his walks. He would spend many hours every day strolling outside. It seemed to be the one thing that kept him connected to the past, that was, for him, slipping out of memory. Locals would acknowledge him, talk to him, and when he wandered somewhere dangerous, they would bring him home, or alert her to where he had gone.

His wife was grateful for the support that her neighbours had shown him and her,  and for their indulgence. She could trust that wherever he went, he would be safe, and that people were looking out for him. She was thankful that with community support, they were able to stay together for as long as they did. Importantly, he was treated as a member of the community, and not just an elderly man with dementia.

I was touched by her ability to see the positives in his life as the fog of dementia descended. And I was touched by the realisation that she was talking about my community, about the people I see every day. I am relieved to discover that a common decency is alive and well in the place we live. It makes it feel like a good place to be.

There is something in this story for all of us, and to me, it talked openly about something I have been feeling for some time.

As I grapple with the challenges of caring for an ageing, and ever frailer community of patients, I increasingly feel that health and social care services can ever only be part of the solution. On their own, healthcare professionals can make a huge difference, but they cannot change the game. That is up to all of us.

Do we value the elderly? Do we empathise with them? Do we ever imagine what it might be like to when we age, and wane? I seem to recall my Dad once telling me, with the fervour of the first generation immigrant, that our health service, is the pinnacle of civilisation. I may have made this up, but it seems like the kind of thing he might say. I imagine the system was a little more limited where he grew up in Nairobi. For years, I agreed with him (a rare enough occurrence), but now I am beginning to wonder.

The NHS is a marker of a strong society when compared to what came before; but now it has been in place for over 60 years, perhaps we have started to rest on our laurels. What is the next marker of progress? If the NHS was a sign of a country keen to take care of its most vulnerable, then perhaps the time has come to take the next step.

Sometimes I wonder if we are up to it, but then I read stories in the parish paper that give me some hope. Can there be anything more rewarding than for a society to make the choice to protect better its most needy members?

Of course, the challenge is to decide what the response looks like. Perhaps, the key is not define the answer, but to define the challenge. Perhaps we could set the goal that no elderly person should go an entire day without social contact.

Of course, there is no imperative in all of this. That is perhaps what makes it such a compelling choice. We could, of course, allow our elders to continue to live lonely, marginalised lives. Or we could make the choice to make them part of the routine of our community living.

I'll let you know when I've had some ideas about how to make this a reality, but in the meantime, I would welcome any help I can get.

Sunday, 15 December 2013

It's more than 7 day working we need to change

7 day working is back on the agenda. It's been cropping up now at regular intervals - it keeps cropping up because it is something we haven't yet solved.

It sounds like a good idea to have consultant presence on the wards 7 days a week, and it reflects a reality of modern day health care: consultants are the means through which investigation and treatment plans are currently achieved. Another solution might be to have teams that function effectively even in the absence of the consultant, but this does not seem to be a solution on the wider agenda. Consultants are the de facto clinical leaders, and they should be the experts. More junior doctors may be expert as well, and in many cases they offer leadership - but there is too much variation. The difference in expertise between a first year registrar and a final year registrar can be huge. The best way for the system to guarantee the best expertise is to focus on the provision of those people who have successfully navigated the training, and demonstrated the ability deliver the level of care required to be a consultant.

How well our training system does this is the topic of another conversation. But I can see why the currency of expertise in the current health service is measured in terms of consultant numbers.

Consultants are useful tools around which a health service can be shaped. But they are also the most expensive tools. We have to ensure that consultant time is used to the greatest possible utility.

If we look at how we might offer greater presence of consultants on the wards at weekends, there are a number of solutions that we might choose.

  1. Employ more consultants - costs more money, and requires more consultants to be trained. 
  2. Pay current consultants more money to work more hours - costs more money, risks burn out, risks deterring young doctors from entering specialties that require 7 day working
  3. Focus 7 day provision on acute services, and cut elective services to create the capacity for more acute work - this will lengthen waiting times, and perhaps create a perverse incentive for more people to use acute services for chronic problems: we might arrive at a situation where the best way for patients to receive timely, expert care is through the acute services. 
Something has to give, and it is not simply an issue of giving the problem money: even with unlimited resources, we would not currently be able to staff 7 days services across the country, for the want of appropriately trained consultants to take up the work. Within geriatrics at the moment, within current service provision models, many trusts across the country are struggling to recruit suitably trained doctors. 

Therefore, we need to decide how important this is, compared to the work that consultants already do. 

And this, I suspect is where the possibility for change lies. Implicit in the attention being focused on 7 day working is the knowledge that the acute pathways are struggling with demand, and the evidence that emergency outcomes, and surgical outcomes are worse at the weekends. 

Now this really is a complicated issue, but I've had a simple thought about it: the acute services experience high levels of demand, not just because we have high levels of sick people, but because they are the only services that mirror the preferred usage patterns, and expectations of the patients. They are the only services that respond to patient's needs when they have them; they are the only services which provide patients with answers in the time-scales that they feel they need, or they expect.

And let's remember, many of the people who use A&E are not really patients: 40% of them are sent home with only advice. This is telling us something. 

I know there has been a whole heap of work done around how people use health services, and how we can provide better out of hours care for non-urgent problems. But perhaps it tells us something else as well, and perhaps one of the areas that needs real scrutiny is how we provide routine, elective and non-urgent care.

If we accept that acute services respond to individual's needs in the time-frame that patients expect them to be, then what does that say about the way we deliver out-patient and elective care. 

If you take the kinds of out-patient services I have worked in, then it is evident that the nature of care provided to patients is significantly organised around the capacity and structure of the service. The ability of a clinic to review new patients is often a function of clinic capacity, not of patient need; and the frequency and time between follow-up appointments is not always dependent on clinical need, but on the nature of the service. 

Too much out-patient care is based on an old-fashioned and historical structure which bears little resemblance to the health care habits of the modern day. The time of need is not weeks or months after the referral was made, but on the day that they went to their GP with the problem in the first place, or the day that the ailment started. 

Too much out-patient care is delivered too late, too infrequently, and is influenced too much by the limitations of the service. 

This is the area of care that we need to deliver differently. This is the area of our system that we could revolutionise to provide more rapid diagnostics, assessments and treatment plans, and the area of our system that could share more of the burden currently borne by the acute services.

So let's figure out how we can use consultant time more effectively for the benefit of our patients, but while we have the chance, let's also figure out, at the same time, how we can adapt the way we work, to help consultants help patients better. 

Monday, 25 November 2013

0800 4 70 80 90

When I first started at prep school, the only way I could communicate with my parents was by letter - something we were made to do every Sunday after Church. These letters were screened by the teachers, to make sure we were gave them appropriate care. Aged 8, I barely wondered whether it was acceptable to have my missives home checked by someone who worked at the school that I might well have cause to complain about.

I never felt like I needed a more immediate, less monitored means of reaching my parents - I was too busy having fun, larking around in the woods with my mates, planning raids on enemy bases, to be too concerned by such matters. I was too busy being happy.

But boarding school is a relentless place to be sad, or lonely or scared. And someone realised this.

When Child Line was introduced in the late 80s, the school was fitted out with a pay phone that took those old school phone cards, that you could renew with the judicious use of some Tippex. It was all just a game to me - one term, when I was off games with a broken arm, I once phoned up Child Line and asked them for help with my Latin homework. To their credit, they gave it a go. I guess it all seemed like a bit of fun to me.

But under other circumstances, it might not have been fun - it might have been my only window to the outside world. Not all kids had the fun I had at school, and not all kids at my boarding school had the fun I had. For some, the chance to phone home, to phone Child Line might have been a Big Deal indeed.

The launch of the Silver Line reminded me of all of this. I have written before about loneliness being a big illness in the elderly. I have watched it, seen it, touched it, but I have never found a way to do anything about it.

That embarrasses me. But my embarrassment means nothing - it is not important. It is, important, however, that someone has found the energy to do something about it.

I don't really know what it feels like to experience the kind of aching loneliness that many of our elderly must feel. I do know that I don't want the people in my life to experience it, and I do know that I don't want our elderly folk to experience it.

Silver Line may just be a phone line, but to some people, it may just be a very Big Deal too. And perhaps, more than that, it might serve as a reminder to all of us, that while we are out there exploring the world, for some people, that is no longer possible.

For them, the challenge is to bring the world to them. Perhaps Silver Line is the start of something, just as Child Line was the start of something.

I hope so. I hope that Silver Line has the kind of impact that Child Line had, and I hope that its reach is broader, and that from this simple, important intervention, something bigger in our society can spring up.


Thursday, 21 November 2013

The right intention, but the wrong idea?

Here at the British Geriatric Society Conference, much of the conversation so far has been based around the challenge of meeting the needs of residents in care homes.

At face value, it seems like a good idea: care homes are where the frail elderly often go to live. It makes sense, therefore, to organise care around these units, as they are good ways of selecting out the people most in need of comprehensive geriatric care.

But I have a number of concerns about this shift in organisation. Let me explain:

1) A great many frail and elderly patients live in care homes, but a great many do not. By organising care around care homes, the risk is that we create differential levels of care for those inside care homes compared to those outside them. Perversely, this may create a driver to admit patients to care homes, so that they receive the kind of long term care that they need. Our challenge, however, is to create a system that meets all need, not just those of an artificially selected care home population.

2) By organising services around care homes, we are doing very little to influence the use of care homes in the first place. As a strategy, it does not change the game enough: it is a response to a situation we find ourselves in, and not an attempt to modify that situation to something more acceptable, and more effective. By organising services around care homes, are we acknowledging that there is nothing we can do to support the frail elderly in their own homes? Could we not, with differently organised, and better managed services, respond to the needs of the frail elderly at home, and forestall or delay the need for them to enter care homes altogether.

3) A care home is simply where someone lives. It is perhaps a marker of their needs, but it also represents more: it could be a function of the choices that individual has made, the nature of their family and social support networks, and a whole range of other factors. A good system responds to the needs of individuals wherever they live, and adapts around that person. A system that organises around care homes is using the admission to the care home as its surrogate marker for frailty. This may well be fairly accurate, but it is not comprehensive, and it encapsulates a fatalistic view of our ability to influence the need for individuals to enter long term care.

The current use of care homes is currently unsustainable, and it is impersonal. Stories abound about patients admitted to hospital in a crisis, and then without ever having the chance to visit their own homes again, are admitted to long term care. Life sometimes falls off a cliff, but perhaps, with better and more intelligent organisation, we could slow down that falling trajectory.

My fear is that, as we enter a period of great change in how we look after our frail, elderly patients, we resort to type, and continue to organise care around physical units (acute hospitals, community hospitals, and care homes) and not around the individuals. The care we give, and how we give it should be influenced by the needs of the patients. The organisation of services should adapt to those needs. Historically, and currently, the care we offer our patients is significantly influenced not by their actual needs, but by the resources and set-ups available. We approximate the needs of the patients to the needs we can meet.

This is classic cart before the horse stuff, and I think we ought to put it right. Perhaps more importantly, I think we can put it right.

Thursday, 14 November 2013

Time and Health

When I sat down to watch the analysis of the Wales-South Africa match on Scrum V the other night, I did not expect to have a moving experience. But one interview changed all that.

Wales had lost - they had never looked like winning. Some things never change. Throughout the 1990s, they were ruthlessly put to the sword by successive Springbok sides. These days the results are the same, but the matches are close. In those days, there was barely a contest.

One man often stood out for the Springboks. Joost van der Westhuizen. You wanted to hate him, but, boy, he was good. There are some athletes who remind you why you watch sport - he was one of them. Tall, powerful, fast, quick-thinking, and utterly ruthless. He was a giant of rugby.

Today, aged 42, he has motor neurone disease. He is a shadow of the man he once was. But he is also a different kind of hero. He is a man laid low by devastating, progressive and incurable illness. His voice is stuttered by the weakness of his nerves. He has months to live.

But he has something important to say about life. He tells us that we all think we have time, and health. He has neither, and he has something to tell us.

Do one thing for me today - listen to him speak. That's it. That's all. Good night.


Saturday, 19 October 2013

Loneliness - a simple problem with complex answers.

Jeremy Hunt has been talking about the national shame of loneliness of the elderly in the UK (http://www.theguardian.com/politics/2013/oct/18/jeremy-hunt-uk-families-asia-elderly) . I feel like I have been harking on about this to anyone who will listen to me for ages. Perhaps even you, dear reader, is getting bored of my fixation with this issue.

But bear with me. Companionship is not just a nicety of civilised living. Loneliness is recognised risk factor for ill health, and it is a bell-weather for how society functions. The way we treat the elderly is a symptom of how fast, and how much, the functioning of modern society has changed. The pattern of our lives has altered so much that we have not yet adapted to deal with an issue that has not troubled previous generations in the way that it currently troubles us.

There are a number of truths that we need to consider: that individuals are living longer, that elderly individuals are often living not just longer lives, but significant periods of their lives in poor health; that families are now smaller and more dispersed. I would encourage you to absorb the impact of those three factors, to get away from the idea that somehow the elderly in our society are lonely because their families and communities have stopped caring about them. It is unhelpful to blame the attitude of families, and communities, in the way they care for the elderly, because it fails to acknowledge that the issue we have with the elderly is not just the result of a change in the way we care, but also of some profound changes in the way we live.

Perhaps your view on the issue is shaped by your direct experience. Perhaps you know of children who travel hundreds of miles each week to check in on their parents who live in a different town. Perhaps you have seen the worry, the stress and the anxiety caused by wanting to help, but not being able to, due to the insurmountable obstacles of the need to work, and the impossibility of moving cities.

Perhaps you know people who take no interest in their parents or grandparents. These people undoubtedly exist, but is theirs an attitude borne out of a habit of our age, or is it more complex than that?

Jeremy Hunt suggests that the start of an answer is simple: take a lesson from Asian families who tend to care for their elderly relatives at home. It might be that easy, but I doubt it.

The issue is underpinned by the impact of social mobility. Where I live, my neighbour was born in the house she still lives in. Her  brother lives across the road, and her son lives three doors away. In this context, it would be possible to take on a care burden. But she is relative rarity. For children growing up in Dorset today, the majority of them will have to move away to further their education, and to seek employment opportunities. In a world of heightened opportunities (recent recessions notwithstanding) the price we have had to pay for greater autonomy and choice in our life patterns has been the requirement to relocate. This won't change.

Add to this the rising reality of prolonged old age, and prolonged dependency in old age, on a scale never previously seen before, and one can really start to question to validity of any assertion that the main solution to loneliness in old age starts and ends at home with the family. That is not to say that it wouldn't be ideal - it is surely preferable to the elderly to be surround by their kin. The issue is that it is not practicable.

Where do we start in the search for practicable solutions? Any approached needs to be many pronged: it starts with consideration of how the frail elderly among us can be afforded the opportunity to interact with the people near us. This perhaps starts with some concept of surrogacy: if you are not supporting your own parents and grandparents, then perhaps there is something that you can do to support the parents or grandparents of someone else, who live near you. With small beginnings, the impact of paying this kind of volunteering forward could really begin to tell.

But the future for modern society needs to consider the impact it can have on stemming the tide of elderly disability: socially engage, mentally stimulated, and physically active elderly men and women accumulate illness and frailty less quickly than those who are not. Embedding not just a role, but a reciprocal obligation of society to accommodate the elderly, and the elderly to take part, heralds a future in which the elderly not just have a role, but a community network that enjoys their input, and then supportively wraps them up, as they become less able to take an active part.

What does that look like? It could be anything, but it to me, it looks like the elderly reading with primary school children, running workshops to teach children about the past, and the skills they developed over time. It involves cross-generational community projects, play schemes, sharing of hobbies, interests and sports through  local clubs. It looks like whatever you want it to look like, because it looks like whatever you make it.

Wednesday, 16 October 2013

A short thought about the way we think

How many people in the UK have mental health problems? What makes the burden of mental illness tangible? How can we make it seem relevant to our lives?

About 10% of the population will suffer from depression during their lives. About 4% have bipolar disorder, just under 1% have schizophrenia. Add in insomnia, addiction, eating disorders and the behavioural problems associated with dementia , and mental illness starts to become the norm - not the exception.

The statistics rarely capture the reality. Throughout our communities there are pockets of expertise, borne not out of education or learning, but out of experience. The sharpest understanding of what it means to suffer, live and cope with mental illness comes from suffering, living and coping with it. The profoundest empathy of the struggles of others suffering, living and coping with mental illness comes from supporting someone you love with their own troubles.

Mental illness in all its forms is so common that these pockets of lived expertise must be everywhere. And yet we live in a society where the perception is that mental illness is the poor relative of physical health problems. Anyone whose life has been touched by these problems knows how profound, disruptive and real mental illness can be; and they also perhaps know how joyful it can be to emerge, for however long, from the shadow cast by psychiatric relapse.

The truths of mental illness are self-evident to all those who live with it. The succour of clinical expertise, loving families and good social support are the cornerstones of happy outcomes. And yet, a great many of the worst sufferers exist in social isolation, without friends, money or families, in communities that pretend they don't exist.

Marcus Trescothick was an international cricketer, whose depression undermined his ability to continue. When he left the England Cricket team during their tour of India in 2006, the team management told the press that he had left on account of personal problems. This wasn't entirely accurate. He left because of depression. He found the obfuscation unhelpful. When he found the strength to be open with people, he discovered a whole world of support, and understanding, both from people he worked with, and people he had never met.

No one wants to have to be an example to others when they are at their lowest ebb, but sometimes, some people find the strength to drive progress. In his own little way, Marcus achieved that: he enabled the people around him to learn about his problems, and to let them demonstrate to him that they care.

And this is the Catch 22 of mental illness. I imagine the majority of people would want to help, to be supportive if someone that they knew was going through a mental health crisis. But we do not know how to broach it. And for the person with the problem, being open about the issue is hard to do, when they are at their most vulnerable, and when they might feel some shame about their problems. You probably wouldn't hesitate to tell me if you'd had pneumonia, but you probably would if you'd been off work with depression.

Society cannot take a lead on changing the nature of its mental health dialogue - it just doesn't work like that. And we cannot place the burden of openness on the people suffering the most.

But perhaps, we can all through our language, and our approach, make it clear that life is tough, and sometimes, the manifestation of illness is psychiatric, and that we get that. Perhaps we can be the people who by being mindful of mental health problems in other people, are mindful and open about our own problems. We may not suffer in the same way as others, but we may also suffer worse. Openness is easier to start when you are feeling strong. Don't wait for your moment of weakness to wish that we were better at talking about mental health.