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.