To live and let die

I don’t have an appetite for listening to clerics, nor am I much
of a royalist, nor is death a favourite subject of mine. So it was
with something of a heavy heart that I filed into St James’s Palace
recently to hear the Prince of Wales introduce the King’s Fund’s
annual president’s lecture from the Bishop of London on the subject
of “Healthy Living, Healthy Dying”. Was this a good way to spend a
sunny Friday in June?

Well yes, it was. What we heard was a broad, imaginative sweep
across the cycle of human experience, with a vision of what it
might be like to have a health system that gave equal respect to
every stage. We were invited to share the idea that, for all we
knew, death was as much an opening as a closure. One kind of
passage, like birth. Not a lesser experience, but one of equal
worth at least. A key point I took away was that healthy living and
healthy dying were not two sides of a coin, with one the reverse of
the other, but that both were on the same side. You don’t need a
religious faith to see things that way.

In the discussion that followed someone suggested there should be a
service equivalent to midwifery for death. Hospice care, and
Macmillan and Marie Curie nurses already attempt to do something of
this sort. But the sad truth is that most people die in hospital,
when they really want to be at home. And the fact that most of us
see death as an embarrassment – something we want to deny or forget
– makes it especially hard to build momentum for change.

Perhaps that extraordinary Channel 4 series, Six Feet Under, will
help to lift the taboo. For those who have been unfortunate enough
to have missed it so far (Sundays at 10pm), the series revolves
around a family of funeral directors, for whom death – of course –
is ever present and closely woven into the texture of daily life.
Death is never played for cheap laughter or for tears, or
gratuitous ghoulishness, although there are plenty of comic, tragic
and horrific moments. The dead and their friends and families are
treated with workaday kindness and consideration, much as one might
treat people arriving at a dentist’s, or even a children’s nursery.
Death is integral to life, the series suggests. Yet there is
nothing else so real and inevitable that most of us seek to avoid
so assiduously.

This issue of Community Care considers what can be gained
from integrated appraisal of older people. Here is one important
attempt to take a rounded view of experience, rather than treat
individuals as a collection of separate problems.

It may sometimes be harder to take an integrated approach, because
one needs to assemble knowledge and orchestrate expertise from
different sources and that is bound to take additional time and
effort. Yet it must surely be better in the longer run because
health depends on so many different factors, as well as the
interplay between them. This applies not just to old age, but
across the lifespan.

Which brings us back to the bishop’s vision. We’d all like to have
a “good death”, but equally we’d all like to enjoy as many years as
possible free of illness and dependency. Not only would it be good
for individuals and society, it would also make sound economic
sense. The extent to which our later years are healthy and
satisfying depends to a very large extent on what happens to us
from early childhood or even, many now argue, on our parents’
experience before conception.

Diet, exercise, education, employment, environment, family and
social relations, levels of anxiety and stress – all these things
help to determine our experience in old age and, consequently, how
much we call upon public services.

Health and social services are beginning to take a more integrated
approach to older people, but they still focus strongly on dealing
with problems that arise in later years, rather than on measures to
prevent their development.

Instead of its endless preoccupation with “modernising” services,
the government should set about building a whole health system,
geared towards promoting health and well being from cradle to

Anna Coote is director of the public health programme at
the King’s Fund.

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