• Rage, Rage 24 October 2016 | View comments

  • 16th October 2016 | By David Jolley

    When I was a medical student and attached to one of the first specialist services for older people at Severalls Hospital, Colchester, I was excited to see the openness of that hospital to new ideas. This included better accommodation, and wards and areas of the grounds where men and women could mix and live together as they received their treatments.

    It also included the practice of going to see people at home as soon as they were referred for help. This was initiated through the vision of Dr Russell Barton, interpret in practice by Dr Tony Whitehead.

    A little while later I read and heard Tom Arie, doctor at the time but professor before long, describing his experiences when applying the same principles: Go to people when and where they are in difficulty. Show them that you care about them and have understanding of them, their circumstances, strengths and their problems and will work with them to find solutions. Follow things up over and again as needs change, supports fail and additional considerations appear.

    These approaches transformed prospects for people with dementia and other mental disorders of late life, from avoidance, rejection and dumping – to a waiting list or long-stay ward. The service would work with people and families and with other agencies using their own home as the base. Together we would see things through to death.

    Tom Arie in Goodmayes had responsibility for a catchment area which included 40,000 older people. He worked alone until the appointment of Elizabeth Taws. When I began the service in South Manchester in 1975, my catchment population included 30,000 over 65 years. I carried it gladly until we found money and had trained sufficient doctors to take on similar patches in the North West and beyond. Five years and we dared to appoint a second consultant to this teaching and researching service. Every new patient was seen at home within a matter of days of referral. Communication was direct to me via a secretary. We shared office space and we linked effectively with a community team which began with one social worker and two CPNs. Letters were typed on typewriters. Letters were sent to GPs after every contact and most contacts were to people in their own homes.

    Tony Whitehead and Tom Arie showed they could see more people by this approach and reduce the reliance upon beds. In South Manchester we had very few beds – The task was to survive without too many disasters. We did, thanks to domiciliary practice. 

    I understand the specialty of Old Age Psychiatry has lost its love for this, its cardinal characteristic. Consultants are too hard pressed to take time to see patients at home. Strange that we are so hard pressed when the number of consultants has risen and risen and catchment populations of 40,000 or 30,000 would be laughed out of court.

    Time to be spent on recording activities in a way that can be handled by computer systems. Yes – all well and good – but information is collected for the benefit of patients and families if it is to be justified at all.

    Time to be spent reading brain scans? Maybe – but this is not where clinicians achieve the greatest effect in caring for people.

    Time spent in clinics rather than in homes and on the road. We did find working with a Primary care Clinic at Gnosall was rewarding and effective – because it was close to home and shared with the regular medical and nursing staff who know individuals and families. The DNA rate was almost zero, as it is for domiciliary contacts.

    Clinics at hospitals are heartless, wasteful of the time of patients and families. They may soak up ambulance time or other commissioned transport and almost always attract a higher DNA rate.

    Inheriting such an arrangement when I returned recently to South Manchester I was told by one patient and her family:

    ‘It is so good that you have come to see us at home. We were missing appointments at the hospital, frankly because it took up a lot of time and was not a comfortable use of the day. We did not feel the people took interest in what was important to us: checklists and measurements are meaningless to us when we want to talk about real difficulties and some of the good times. Coming here you can see how we are living. You show appreciation of what we are doing and that means a lot even if you cannot make big changes for us. We know this is a shared journey.’

    The development of Psychogeriatric Services, like Geriatric Services before them, shone light and hope into places which had been dark and hopeless. Working with people in their own homes was, and still is, the essential technique which opened the windows and doors.

    Please let us not lose all this out of regard for the needs of computers, and the service based, fragmented pseudo-logic which insists on dealing with a living system as if it were a machine. For if we do, we will be no longer the vital presence which changed the world for people with dementia and their families. 

    Do not go gentle into that good night

    Rage, rage against the dying of the light

    (Dylan Thomas of course)

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