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  • 07th February 2016 | By David Jolley

    Oh – This has been a week of challenges!

    The week began with the Guardian giving headlines on its front page to the proposition that: ‘Loneliness will cripple the NHS’. 

    http://www.theguardian.com/society/2016/feb/01/loneliness-forces-older-people-into-hospitals-and-strains-services-say-senior-doctors

    And deeper in the same issue came a review of ‘Bed Blocking’ by ‘The Elderly’. 

    Well I was not comfortable with ‘loneliness’, nor with ‘cripple’; I thought we had outlawed reference to ‘bed-blocking’ some years ago and it is decades since Bernard Isaacs urged us the get rid of 'The Elderly'. (I gather he actually wrote "Let’s abolish ‘the elderly’").

    ‘The Elderly’ defines a group who are ‘not us’ – set apart for special treatment or with expectations that are at odds with the mainstream. They block beds, which should be (irrespective of age, gender, race, religion …. whatever) used for the proper purpose of the NHS, cure of younger people. Hence the perception that one way or another they are crippling this worthy animal (the NHS).

    Really the National Health Service is here to provide an appropriate response to the health needs – often complicated by social needs – of anyone and everyone.

    There is a misfit between what we are providing and what is needed. This goes across the health/social care spectrum. The problem is not with the needs – though maybe we can do something to reduce these; the problem has to be with the pattern and capacity of provision – and this we can certainly do something about. 

    I railed at ‘loneliness’ because it is so often equated with an older person living alone. Solution is that everyone moves back to multi-generation households or communal living. There may be advantages to such arrangements for some – but you can feel quite ill at ease cum lonely in your daughter-in-law’s kitchen, and life for children and grandchildren might be strained by the presence of a loved one of another generation and of different experience and expectations. Living with or near other older people can have its advantages, but there can be downsides.

    ‘Loneliness’ is not an objective state of isolation but a subjective feeling of being bereft, that the social environment is hostile and not supportive. It is very common among young people and is usually best seen as a symptom of depression or other illness rather than a social matter per se. When older people feel lonely, their reversible unmet needs are likely to be health related. They require awareness of this possibility, accurate diagnosis and tailored treatment rather than dismissal – as ‘not for us’ in this world of triage. 

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3874845/

    Sally Davies wrote critically of the concept of ‘well-being’.

    https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/413196/CMO_web_doc.pdf

    Focussing attention on loneliness without acknowledging its complicated aetiologies may be as misplaced and potentially dangerous as easy reference to well-being. Beneath the fluff there are hard realities which we can address to useful effect.

    A Care Worker’s Diary puts our feet on the ground and hope on our hearts.

    ‘Dementia in this case can be beautiful ….’

    http://www.theguardian.com/society/2016/feb/02/secret-care-worker-diary-dementia-this-is-the-nhs

    Read more ›

    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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