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  • Friday lunchtime with ten medical students – a wonderful opportunity for reflecting on the state of our world. The student – modal age 22 years, gender split equal have come to Manchester and to Medicine from many places: Bolton, Stoke (or near Stoke), London (where there?), Brunei, Germany, Malaysia, Mauritius and more. Manchester? ‘The only place which would have me’ (a sort of modesty – in fact it was his first choice).’ It is good for Medicine’.

    Medicine? Interesting, challenging – but underlying all – and scarcely admitted without a nudge – A wish to use talent and time to help others.

    The Guardian newspaper has continued its articles about the NHS – and also found top news stories which feature healthcare: ‘Cuts blamed as mental health death toll soars’ was the front page headline on Tuesday.

    These are not deaths amongst old people but the clients of inpatient and community services for patients with serious mental health problems of working age. Numbers in contact with such services have increased, beds provided have fallen: 751 patients killed themselves 2014-15 compared with 595 2012-13. Deaths from all causes have risen from 1,413 to 1,713.

    So we thought a bit about why people with severe mental illnesses die young. Some deaths are violent and may be at their own hand. Others are of natural causes – linked to illnesses of poor diet, poor habits and being poor. And we rage for a while on the lack of employment amongst the people who are known to psychiatric impatient and community services. We remember that the mental hospitals appreciated the therapeutic value of work. It was all they had before ECT and neuroleptics. Neuroleptics, antidepressants and mood stabilisers fail to help people achieve their potential if they have no work.

    The final column of page 11 provides insights into the working week of an Old Age Psychiatrist. Citing only one patient a day Monday to Friday the diary covers a range of scenarios and vignettes. It is puzzling that four of the five patients are men. That hardly reflects the world we know. Alcohol dominates the lives of two, depression the lives of a further two and dementia finds a place only on Wednesday and in a dementia specialist care unit. It gave us a structure to cover the experiences of mental health amongst older people. The theme of the session was: ‘Getting to know you’- and we sang a few lines of the song, as one might in a Cognitive Stimulation Therapy session. The point is that it is useful to know about conditions – but to be really helpful we must find the person and make a connections and work with them in their world of past, present and future. There is so much which can be achieved with the application of long understood therapeutic practices. 

    Page one today tells us that Addenbrook’s Hospital is £60m overspent and St George’s Tooting approaches £46m debt. Jackie Crowther rants on Facebook that hospitals must change to be better relevant to ‘Elderly Folk’ and I rail: ‘get rid of ‘The Elderly’’ after Bernard Isaacs. We do want hospitals to be kind to older people and to people with dementia. But they, like people with other mental disorders, are people.

    We can get it right for people of all ages, gender, origins – at home, at work as well as in hospitals by making best use of what we know and what we have.

    That is the message for these young people setting out on careers which will equip them to help others

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    The Health and Social Care Information Centre turns out streams of useful and important statistics. Unhappily much of this passes most of us by because we are busy doing things and need a nudge to look when something relevant has come to light. A recent entry tells a well-balanced tale of endeavour and success in dementia care: www.hscic.gov.uk/catalogue/PUB19812

    This is exposed to the glare of publicity by the media in less sober and more scandalous terms:

    ‘Dementia diagnoses rise by one fifth after GPs offered £55 ‘bribes’:

    http://www.telegraph.co.uk/news/health/news/12108080/Dementia-diagnoses-rise-by-one-fifth-after-GPs-offered-55-bribes.html

    For those most determined to see our diagnosis rate improved, the outcome may have justified the means. For others, like me, this seemed to be a demeaning way to treat a dignified profession – rewarding an activity simply by providing a monetary reward for a desired action. We were rebuffed by the observation that the same had been done to improve care for other illness conditions: The profession has been revealed to be corruptible or at least willing to be directed by carrots rather than its own mature and informed thinking.

    I wonder what follows once the carrot has been consumed. What people need is the mature, informed guidance and care of their personal physician.

    Prescriptions of cholinesterase inhibitors have increased six fold in a decade – perhaps a desirable phenomenon, and not as expensive as it would have been because the medicines are no longer under patent. But what people with dementia and their family need much more than these medicines is the mature informed guidance and care of a team of health and social care professionals to clarify what is happening to them and to support them through the journey.

    I am really not sure what is happening with the follow through. My personal experience as I come near to ending my own clinical contributions is not reassuring.

    In two services I have been associated with CCGs have withdrawn funding from models designed to provide support within primary care on the basis that ‘they are not working’. Published studies have demonstrated that such approaches have worked in other places – at other times. Perhaps there have been errors of implementation. Perhaps there are questions of commitment. Maybe it becomes impossible to be effective when social care funding is stripped away beyond a certain level.

    In another setting, the model of referral to a memory service from 50 practices labours under the increased referral rate. Provision of confident and sufficient follow through is lacking both in the specialist service and primary care. It is wonderful to meet people and to help them in the first steps of understanding, but I am saddened and concerned for their futures.

    I wonder what other people’s experiences are.

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    Small World 20 January 2016 | Comments (0)

    My wife is an enthusiast for low tech approaches to getting things done without burning fossil fuels. We are both enthusiasts for being respectful to ordinary people and realising that we all have abilities which can be fostered or crushed.

    This month’s issue of Small World caught my eye, especially the quotation from Dr Fritz Schumacher:

    ‘The gift of material goods makes people dependent, but the gift of knowledge makes them free – provided it is the right kind of knowledge of course’

    He was thinking of developing countries where people lack basic resources including clean water and sanitation. But the ideas have relevance more widely.

    In Manchester and no doubt other towns and cities there is controversy over decisions and ‘consultations’ which are requiring cessation of some sorts of surgery in local hospitals and their relocation to other hospitals which are designated expert. From Ashton under Lyne you go to Oldham for eye problems and Stockport for genitourinary disorders. The most recent upset will see general abdominal surgery removed from Wythenshawe hospital (University Hospital of South Manchester) to concentrate resources at Stockport. Colleagues quote figures which say that outcomes in these specialist centres are better. I wonder quite how ‘outcomes’ are being defined. I do not like a system which sees me as a collection of organs rather than one person who may have a number of pathologies but wants to be treated as someone.

    How often are we to say: ‘The surgery was successful, but the patient’s life was ruined’?

    My post-Christmas reading is: The Shepherd’s Life’ by James Rebanks. He accounts for the resilience and success of his family farm by their return to old fashioned systems which do not rely on subsidies or supplements from outside agencies. Old fashioned is good to me.

    I am unhappy with the way that agencies in support of older people and people with dementia have lately gone to a central model providing handouts and commissioned services rather than a grass roots multiplex which feeds ideas and strength to a central liaison and information-exchange hub. I suspect that the experience of – Rose-Marie Droes from Holland which we heard about at Telford can help us. She began to encourage local people with dementia and their carers to come together and decide what they most needed. They found a meeting place and looked for resources which would work and that could be afforded. Thirteen centres in Holland, maybe more by now, are doing this. Other countries are picking up this the model: http://www.meetingdem.eu/. The extraordinary Dawn Brooker in Worcester is the UK lead.

    I wonder if we might join this movement through our ‘Conversations’.

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    I have been privileged to work with Dr Michael Tapley, Ann Regan and other colleagues at Willow Wood Hospice, Ashton under Lyne since summer 2010. We have developed a specialist service to help people with dementia as they approach the end of their lives using the model pioneered by Dr Victor Pace, Sharon Scott and others at St Christopher’s Hospice. In doing this we have come to work very closely with colleagues in other sectors who are caring for people with dementia and their families. This led us to establish an informal tea time network event which meets once every two months at the hospice.

    Tapley M, Regan A and Jolley D (2015) A UK hospice plays host to a local network of people involved in dementia care. European Journal of Palliative Care 22 (4) 165 – 168

    This week the session was led by Pam Kehoe who is an Admiral Nurse and has the Dementia Lead within Tameside’s General Hospital. This is a massive responsibility and one which draws upon all Pam’s experience and personal qualities. She was sharing the story of Dr John Gerrard who suffered greatly when admitted to his local general hospital. This so motivated his daughter Nicci that she has established John’s Campaign: www.johnscampaign.org.uk/

    This asks that when adults, including older people, disabled by dementia or similar conditions are admitted to hospital, their carers be allowed to stay with them and contribute to their care and treatment. The campaign asks that the families of older people are granted the same respect and privileges as the families of children in hospital. It is well established that children are more likely to make good recoveries and progress when properly supported – and the same is true for older people with disabling conditions.

    Not rocket science – but it took an individual tragedy and an able and motivated family to make the point and begin to get things done.

    Pam has support at Tameside’s Hospital for the campaign and its requirements to become active there. Over 200 hospitals around the country have signed up – Is your hospital one of them? – brilliant if they are – best tell the Chief Executive about it if they are not.

    Lots of other simple but effective ideas were exchanged. A lady from Public Health (Public Health is doing wonders for people with dementia in Tameside) gave me a Twiddle Muff – I am ashamed to say I did not know about Twiddle Muffs – I do now – and they are being used to good effect to calm the anxieties of ladies in Ashton under Lyne.

    www.best-alzheimers-products.com/twiddle-muff.html

    Now muffs might be used by men too – but there is the alternative (for either gender) of a Twiddle Box – or some such bit of kit which has knobs and hinges holes and corners, maybe a drawer or two. There are versions which can be purchased – but the charismatic Pam was moved and astonished when men from the Estates Department came along and proudly presented her with 20 boxes they have produced for use in the Hospital. She had not asked – but they had heard the story and seen the effectiveness of the muffs (which are being knitted by knitting clubs all around Ashton!). They could see an opportunity to use their skills – hey presto!

    www.nursingtimes.net/Journals/2014/08/07/p/t/t/130814-Low-cost-strategies-to-improve-dementia-care.pdf

    So the Hospice is a safe place within the spectrum of services for people with dementia.

    Meeting informally over tea and cake encourages friendships and generates and shares ideas. Nothing here costs a lot – but the outcomes are priceless.

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