Icing on the cake for older people
We have cake – now we need the icing
Emeritus Professor of Geriatrics, St. George’s, University of London.
There is much that is good in our current health and social care service, but there is a fatal flaw. We have cake, but it needs icing. The NHS was a social contract between the State and the people who fought the Second World War. Everyone was to benefit, whatever their age or medical need. Unlike other countries in the world, the chronic sick were included in the plan. Now, by sleight of hand, the NHS hospitals have changed. The dependent sick are no longer wanted on the voyage. Unless the prevailing attitudes change, their plight could be our future.
Older than whom?
At the 2005 Pensioners Parliament, a delegate’s passionate plea “Please stop talking about older people; we are old people” met with enthusiastic acclaim. “You are old Father William” the young man said, “Why do you keep standing on your head.” Wake up and see, by introducing the term “older people” government has skilfully moved the goal posts, away from the urgent need to redevelop an acute hospital based community supportive service to meet the genuine needs of sick and dependent old people.
Example to us all
The National Service Framework for Older People embraces everyone over sixty. “Why should we be treated differently from the young? Far from being a burden, we are the cement that holds society together. We do most of the voluntary work. Single parents and working couples rely on their parents to look after their children when they are sick; many pensioners spend their lives providing day care so that their children can get sufficient income to pay the mortgage. Travelling the world we keep the campsites, hotels and seaside resorts in business so these facilities can be ready for school holidays. “Do too many old people cost too much?” Far from it, without us the pack of cards collapses.
Creating the problem
During the Thatcher years the hospitals geriatric and psychiatric, community supportive services, developed by the NHS to meet the complex biological, psychological and social needs of frail and dependent old people sick, were run down. Thousands of hospitals beds have now been, and consultant physicians, trained in geriatric medicine, are doing acute medical care, with no responsibility for long-term care. Now, at the fag end of the Blair years, the rhetoric is of patient choice, but the reality is different. The logic is clear. We have a market. In a market, people with money make their own choices. So, give people without money, money, so they can make their own choices. Sounds good, but is it wise? Wouldn’t it be better to increase the pension and plan a free, knowledge-based service to meet the needs of sick and dependent people?
Developing the solution
Seven Principles for Planning Services
1. The political will
2. A coherent plan
3. Task definition
The choice to something is the choice not to do something else.. Here I conclude this short article with seven principles that I consider should be taken into account in planning our future care.
First the political will has to change. Hospitals are care in the community’s ultimate safety net. Rather than denying the genuine needs of sick frail and dependent old people; to meet their needs a new style hospital based community service has to be developed, based on medical responsibility, not interest. I became interested in the care of dependent patients because I was employed to develop and run hospital based geriatric medical services for the London Borough of Merton. In the early years of my consultant life I met regularly with the Director of Social Services and the Medical Officer of Health. I also had to write an annual report for the Borough and the Hospital Board. When District Health Authorities were introduced I was accountable only to God.
The hardest part of any job is getting the team to work. After a new rhythm of ward management is introduced it is difficult to change it again. Medical leadership is the key to quality geriatric medical services. If the object of the new policy is to control the need for residential and nursing long-term care, by reviewing the accuracy of diagnosis and treatment then a specialist physician must lead the team. Rehabilitation and rapid discharge are poor bedfellows. If patients are given no time to regain fitness, one simply fuels demand for long-term care. Hence responsibility, accountability leadership, rehabilitation and task definition are essential components of any plan.