The healthy whole

Case notes

Practitioner: Elaine Pugh, social worker and Janet Raine, district nurse assessor.

Field: Community older people’s team (Copt).

Location: Knowsley, Merseyside.

Client: Maurice Needham, 73, a retired print worker and former local club singer, lives alone in a rented cottage. His only relatives are his daughter who lives in southern England and his older sister who lives nearby. He has always been very independent.

Case history: Maurice was first known to social services in 2002 following a fall down the stairs. An accident prevention officer, based in Copt, visited to offer advice and help make his home more secure. On discharge from hospital after some minor surgery, Maurice returned home to receive one month’s notice to quit from his landlord. He called eight or nine organisations but was told that he didn’t meet their criteria. As he had nowhere else to go he contacted the accident prevention officer, who passed him onto Copt’s well-being project. Given his state of distress Pugh went out to see him. Although his main concern appeared to be housing he looked “dreadfully ill”.

Dilemma: Maurice’s health was deteriorating and although he wanted to hang onto his independence he was refusing any care package.

Risk factor: Maurice’s wish to stay in the community without care support could leave him prone to further accidents.

Outcome: Maurice is living in sheltered accommodation and is taking an active part in his local community.

There’s little doubt that mental and physical health are interdependent. It’s not unusual to see formerly independent people who, once they are unable to look after themselves physically, give up the ghost mentally, detaching themselves from the will to improve or, often, live.

The community older people’s team (Copt) in Knowsley know this all too well. Its active, preventive ethos has seen it merge health care, social care and home safety. The case of Maurice Needham typifies the approach of tending to each aspect to improve the whole person.

Having been threatened with eviction and unable to find any support, Maurice chanced a call to the accident prevention officer based with Copt who had been helpful to him about six months previously and had left a card and contact details.

The case was referred to social worker Elaine Pugh from Copt’s well-being project, which focuses on health and well-being and gives service users and carers alternatives to meet their lifestyle needs. Part of Pugh’s role is to advocate for older people. “There were lots of issues for this fiercely independent, proud and private man, but the main concern was his housing; so I arranged for a housing officer to visit him at home and negotiated with his landlord to prevent him evicting Maurice before we had found alternative accommodation – because Maurice did want to move anyway,” she says.

However, there was a plan B if Maurice was evicted, adds Pugh: “He had agreed to move into very short-term residential care – so he wasn’t thinking ‘I haven’t got anywhere to live’ – which could affect his health mentally and physically.”

District nurse assessor Janet Raine also carried out an assessment: “I asked Maurice what his health concerns were. First he was worried that although the GP had said he needed to have some blood tests, Maurice felt too ill to get to a hospital. He was also experiencing frequent diarrhoea and although a light man he had lost two and a half stone in weight. The doctor had given him some build-up drinks but he didn’t like them – only drinking the few chocolate ones he had,” she says.

Maurice, who had a stoma (an artificial opening from the intestine on the abdominal wall), also explained his worry that the last time he was in hospital the doctor had stopped his blood pressure medication of more than 11 years.

The team believed that if these medical worries could all be dealt with it would relieve the drag on Maurice’s mental health and reignite the fight to regain his independence. Says Raine: “I arranged for the community nurse to visit the next day to take blood samples. Looking at his notes and talking to his GP, I was able to explain the reason for the diarrhoea which was related to the surgery he had been having and then discussed the way he should be using his medication.”

Raine explained that the drink supplements he disliked could be used to make milky drinks or added to food, which he hadn’t been made aware of. “He had a referral to a dietician because of his weight loss and I chased up that referral. I checked his blood pressure and while it was within normal limits, I rang the GP about the withdrawal of the medication. I knew the GP from working as a district nurse team leader – and she agreed to visit, after which she restarted his medication,” she says.

The visit may well have been the turning point. With all the health concerns settled the team could then look to concentrate on Maurice’s well-being, particularly as he refused any care package. “He understood that his situation had been quite critical and knew that he needed to live somewhere with support close-by but which still gave him his independence. We had meetings with housing and I took Maurice around to see a couple of sheltered accommodation complexes,” says Pugh.

Two months after his eviction notice, which had proved the catalyst in this chain of events, Maurice had a bungalow in a complex that includes family houses. “So it’s not as if it’s just houses for older people and that’s it. He really is back in the community,” adds Pugh.

Maurice now regularly attends the local community centre and has taken up painting again – a previous passion. He has also got himself involved with the Frank Sinatra fan club – swing music being another great love. “He’s like a different man. He’s out and about again and he goes out socially. It’s been a complete turnaround for him,” says Pugh proudly. 

Arguments for risk

• The community older people’s team combined its resources to take the time to sort out Maurice’s health concerns, advocate on his behalf, find suitable accommodation and, importantly, invest in his social well-being.
• Stabilising his health was only half the battle; the team, through its well-being project, could then target his quality of life which, in turn, would further maintain and improve his health.
• Sometimes people can be placed in residential or nursing care prematurely, and if they become resigned to that type of care they can give up the will to live and a dramatic decline follows. The environment may be safe and people’s physical needs taken care of but if they are more emotionally vulnerable there’s a need to balance those risks. Central to this balance has got to be what people want themselves. And Maurice wanted to live independently.

Arguments against risk

• Maurice’s health was clearly very poor and although bravely refusing to accept any care package of support it is perhaps also indicative of somebody whose reason and understanding may have been deteriorating, which could seriously put him in danger.
• It’s often forgotten or rarely considered that residential or nursing care is a community option. Care homes can be at the hub of a community and not places of no return. It may have been that a planned medium-length stay may have provided the care needed to help Maurice get back on his feet again. Care homes can provide rehabilitative and re-abling programmes. The added benefit would be that he would have 24-hour supervision through this traumatic period in his life.
• Maurice’s earlier experience of not being able to find anyone to turn to was traumatic. By keeping him in the community there was a chance that it would increase not decrease his need for statutory services.

Independent comment

How refreshingly practical to find a team focused on the well-being of older people which also contains an accident prevention officer! And this specialist was sufficiently flexible to respond to a call based not on the expertise he personally offered but on faith built up from a previous encounter, writes Jef Smith.

Far from fending off a referral that looked at first sight outside their terms of reference, the team immediately responded to Maurice’s obvious distress and recognised his call for help as having much wider implications.

What followed might have been an intrusive package of services aimed at helping Maurice but much more than “this fiercely independent man” would have welcomed. Instead, there was swift help to avert eviction, accompanied by a fall-back plan which was reassuring to Maurice. With accommodation stabilised, it became possible to focus on some serious health concerns, action for which the nurse co-ordinator’s personal contacts and practical advice counted for as much as any specific treatment. Support was gradually put together to help Maurice enjoy life again.

Maurice’s confidence is growing, from being alone and hostile to knowing that a number of people he can trust are on hand to help. Small steps led to the move to a new bungalow, where Maurice has been able to resume his role as an active member of a mixed community. The result – one satisfied Sinatra fan, who with a little help went on doing it his way.

Jef Smith is a writer, trainer and consultant in care for older people.