Years of life, or life to years?
The plight of elderly patients continues to make headline news. Those who have been in hospital, are now ready to leave but cannot be discharged - because they are waiting for NHS services such as community physiotherapy, or social care services such as home visits - are particularly relevant for an NHS straining under pressures of numbers and budgets. In jargon, these patients are DToCs - "delayed transfer of care". Every needless day that patients remain in hospital costs approximately £650 - as we used to say - "the most expensive B&B in the UK". In June, Age UK reported that between June 2010 and March 2015, 2.43 million bed days were wasted, as people waited for social care so they could leave hospital. This is no small-scale problem.
However, it is a struggle to find the few available and affordable places in care homes, or the private agencies that can provide carers to visit patients at home at the right time and for the right price in rural areas. The shortage of places means the private care companies, on whom councils now rely, can set whatever price they wish. The average national cost of a place in a care home is now £29,389 per year. Of course, most don't want to go into residential care at all. The aim of social services, for financial and humane reasons, is to keep them in their own homes for as long as possible - but care packages (with frequent visits to frail people) also don't come cheap.
To paraphrase Edmund Blackadder: "We haven't got enough money, Baldrick." We can keep re-organising the deck chairs, but the ship is still sinking.
For those who find themselves in a nursing home, new ways of thinking could improve the quality of their final years. I recently read Being Mortal by Atul Gawande. He recounts the tale of how a nursing home in New York was transformed when a young doctor started working there. Initially the nursing home depressed him. At first, he tried to fix it the way that, as a doctor, he knew best. Seeing the residents so lethargic, he suspected that some unrecognised condition or improper combination of medicines might be afflicting them. So he set about doing physical examinations of the residents and ordering scans and tests and changing their medications. But, after several weeks of investigations and alterations, he had accomplished little except driving the medical bills up and making the nursing staff crazy. He was sure something better must be possible for them. So, acting on little more than instinct, he decided to try to put some life into the nursing home (the way that he had done in his own home), by literally putting life into it. If he could introduce plants, animals and children into the lives of the residents, what would happen?
They moved in one hundred parakeets, four dogs, two cats, plus a colony of rabbits and a flock of laying hens. They threw out all their artificial plants and put live plants in every room. Staff members brought their children to hang out after school; friends and family put in a vegetable garden at the back of the home and a playground for the kids. It was shock therapy and the effect on residents soon became impossible to ignore: the residents began to wake up and come to life. People who staff believed weren't able to speak started speaking and those who had been completely withdrawn and immobile started coming to the nurses' station and saying, "I'll take the dog for a walk."
Researchers studied the nursing home over two years, comparing a variety of measures for these residents with those of residents at another nursing home nearby. Their study found that the number of prescriptions required per resident fell to half that of the control nursing home - psychotropic drugs decreased in particular. The total drug costs fell to only 38% of the nearby home. Deaths fell by 15%. The researchers couldn't say why, but the medic thought he could. "I believe that the difference in death rates can be traced to the fundamental human need for a reason to live."
Given the gap between what we would like to provide and where we are now is largely determined by a resource we don't have (money), how can we bridge the gap?