Friday, 21 October 2016

Aberfan: man-made disaster

Fifty years ago today I was thirteen years old. I wasn’t highly alert to what might be happening outside the world of school and friends and family. 

Hey, I was thirteen.

Even so, I looked with incomprehension mixed with revulsion at the pictures on TV from a small Welsh village I’d never heard of, where a slag heap had slid down a hill and engulfed a school. 116 children, younger than I, had died as well as 28 adults. I might never have heard the name of Aberfan but after that, I’d never forget it.

Aberfan child coffins: the aftermath of a catastrophe made by man
A slag heap. The waste product of a coal mine. Surely an industry as old and established as mining knew how to handle slag? But it turned out that they didn’t. They’d simply planted it on the slope of a hill that was soaked with rainwater and natural springs. Underneath all that slag, the ground had become saturated and slippery and the whole thing had, eventually, come tumbling down.

A few hours later, and the school would have been empty. But as it was all but a handful of the village’s children were wiped out.

Perhaps even sadder was the other irony, that many had warned of the disaster to come. A year earlier, the head of the school, Ann Jennings had presented a petition about the tip from mothers of pupils, to the local council. No action was taken. And Ann Jennings would be one of the victims of the slip.

One of the most shameful repercussions of that terrible day in 1966 was the behaviour of Lord Robens, then Chairman of the National Coal Board. He denied that the slip could have been prevented, a statement that was found to be false by the enquiry into the disaster. He denied that the Coal Board had any responsibility towards Aberfan other than to stabilise the remains of the tip. When he finally agreed to get rid of it insisted, he had the gall to insist that £150,000 of the money raised for the village by the disaster relief fund (nearly 10% of the total) should be diverted to help pay for that work.

Robens had been a Labour MP – Labour, for Pete’s sake – and even a member of one of the great Labour governments, Attlee’s. The National Coal Board had been set up as a result of the nationalisation of the coal mines.

One of the central aims of socialism is to ensure that the sources of economic wealth, the means of production, should be held by the whole of society on behalf of the whole of society. This strikes me, as it would anyone who feels inspired by socialist views, as a highly laudable objective. I have to admit, though, that it’s hard to see a satisfactory way of achieving it. The shortcut adopted by many socialists or social democrats, from many countries, in the middle of the last century, was to nationalise industries. That means bringing them under state control.

It seems to make sense. At first view, the state represents everyone and belongs to everyone. So if it owns the means of production, then everyone owns them.

The problem comes at second view. Because do we all really own the state? Isn’t it, in reality, controlled by an elite as isolated and opaque as occupants of the board rooms of private industry? If they control the state, how can we say that we own what the state owns?

The lesson of Aberfan seems powerful to me. State ownership is not popular ownership. In that  little Welsh village, a state-owned industry did terrible damage to the people. It was ungenerous in its assistance and then it tried to leech on the support others gave.

Stateism isn’t socialism. The State is capable of being just as oppressive towards people as any private industry. State ownership isn’t in itself a route to liberation, it’s merely an economic tool to be used where it’s useful and avoided where it isn’t: some industries are better state-owned than privately-owned, some are better state-owned today but not tomorrow, others it’s best to keep well away from the state.

Socialism, if it’s to be worth anything, is about doing far more than demanding nationalisation. It’s about helping people like the inhabitants of Aberfan. Doing what we can to make sure that avoidable suffering is never inflicted on them again and, where it’s unavoidable – as in natural rather than man-made disasters – to come to their aid. The rest is just a means to those ends.

For today, though, on the fiftieth anniversary of that catastrophe, we should put all that aside and just focus on the victims. And remember the incomprehension so many of us felt back then. Even callous thirteen-year olds.

Wednesday, 19 October 2016

Kindness to children: too much to ask?

“It were better for him that a millstone were hanged about his neck, and he cast into the sea, than that he should offend one of these little ones.” So the King James Bible tells us (Luke 17:2).

It seems that, in spite of the behaviour of certain of its priests at certain times, Christianity as a belief system feels children should be protected from harm. I suspect most of us, of any faith or none, would agree.

Some of the unhappier kids on the planet, or certainly Europe, have been living in dire conditions in improvised shelters in a makeshift camp called ‘The Jungle’, outside Calais in France. They have been waiting for the opportunity to cross the Channel, legally or illegally, to find refuge in Britain. Altogether, there are some 10,000 migrants in the camp, of whom about 1200 are children. They come predominantly to be from the horn of Africa, the war-torn areas of Syria or Iraq, Afghanistan and Pakistan. So they are escaping war or desperate poverty.

The Calais Jungle: not the most salubrious of places
The French authorities are about to close down the camp, and have asked Britain to take some of the refugees, particularly the most vulnerable. That means, above all, the unaccompanied children. It seems that under the terms Britain has negotiated for accepting some of these children some 400 would eventually come in.

Net migration to the UK – the difference between immigration and emigration – is currently over 330,000 a year. It’s hard to see how 400 would make a huge difference. Even 500, if it came to that. But even so some are cavilling at the idea of letting them in.

This reminds me of the phenomenon of the Kindertransporte in the last nine months leading up to the outbreak of the Second World War in Europe. They brought 10,000 unaccompanied Jewish children to Britain. ‘Unaccompanied’ because they often left the rest of their families behind. That meant that in most cases, they became the only members of their families to survive the war.

I’m not being churlish. It was an admirable, wonderful initiative. The churlish ones were those who spoke out even then against our taking these kids – and successfully spoke out against taking their parents. We know the results: 10,000 were saved but 6 million died. It seems shamefully ungenerous, a callous indifference to the fate of others, that condemned millions to die rather than suffer some discomfort ourselves.

Now we’re seeing the same arguments again, but for even more trivial numbers. We’re talking about a few hundred children, but there are people in Britain who feel they shouldn’t be taken. And those people maintain that if, grudgingly, the children are taken, then we must above all ensure that the ones who come are truly children.

In general, nothing special happens to us during the night before our eighteenth birthday. For the vast majority of people, the most significant aspect of that moment is the drink consumed. In our first day aged 18, we’re not particularly more resistant to suffering than we were on our last day aged 17. So if a few people aged 18, or even 19, make it, why should we care? I’d rather a few people who are technically adults sneaked in, than to leave a few real children behind.

That’s not the way it’s seen. There’s been a fuss about the refugees who look clearly over 18. Of course, the people making their case rather weakened it by pointing to one such person in particular, who was indeed well over 18, but turned out not to be a refugee but an interpreter. Ah, well. Who cares about accuracy when you’ve got a case to make against immigration?

The most remarkable claim of all, though, was made by a Tory MP. David Davies says we should carry out dental checks on all the refugees to establish their age. I’m glad to say the suggestion has been greeted with something of an uproar, not least from dentists who point out that the process is likely to be incorrect in 50% of cases. Davies replied on Twitter that he begs to differ with them, and who would you believe when it comes to examining teeth, a fully-fledged Tory MP or a mere dentist?

But what I liked most about Davies is that he is described – which I suspect means he describes himself – on Wikipedia as a Christian.

I’m inclined to say, “It were better for him that a millstone were hanged about his neck, and he cast into the sea, than that he be allowed to look into the mouths of these little ones. Even if they’re not quite as little as they claim.”

Saturday, 15 October 2016

The first victim of Brexit was the Truth. Swiftly followed by Good Judgement

It’s become a commonplace to say that the campaign which led to Britain choosing to leave the European Union was riddled with lies.

It’s a cliché, but clichés aren't necessarily untrue. Both sides spouted a lot of rubish, making it one of the least edifying campaigns I’ve ever seen. Sadly, the flow of misleading claims hasn’t stopped and, indeed, looks likely to sweep us all the way to the Brexit door.

For a time, the new Prime Minister, Theresa May, wouldn’t say what kind of Brexit she favoured. The broad options are:

  • soft Brexit: Britain remains in the European Single Market. That would minimise the negative impact of departure on the economy, but it would mean continuing to contribute to the EU budget and accepting EU regulation, including freedom of movement of EU citizens into this country, without having any further say in the matter
  • hard Brexit: where Britain leaves the Single Market and accepts the cost, but takes back control over its legislation and its borders

Recently, May has begun to lean towards the hard Brexit option. She told the recent Conservative Party conference, “let’s state one thing loud and clear: we are not leaving the European Union only to give up control of immigration all over again.”

That was a rare moment of honesty in the Brexit debate. It confirmed the glaring fact that a lot of those who voted for Brexit were actually interested in only one thing: how do we get Johnny Foreigner out of our green and pleasant land?

Apart from that glimpse of truth, the continuing debate seems mostly drowned in falsehood or ignorance.

The most glaring deficiency of the vote was that it answered only one question: should we stay in the EU or leave? It’s one thing to vote to leave, but there was no way of specifying what kind of Brexit you wanted. Hard or soft? No one said because there was nowhere to say it.

To call for a second referendum once we know the actual terms proposed is, however, to be considered a traitor to the democratic will of the electorate. It can lead to accusations on Twitter of refusing to accept the verdict of the “massive majority” in favour of Brexit. That was one explicit charge made against me, as part of an indictment of my allegedly anti-democratic views. 

A 52%–48% split? A massive majority?

Even to call for a parliamentary vote on the matter leads to virulent denunciation. And that’s quite curious, because it usually comes from people who clearly view themselves as patriots. And yet denying Parliament a vote strikes me as a fundamentally anti-British stance.

Our constitution doesn’t place sovereignty in the hands of the people. Unlike the US, we don’t have a founding document that opens with the words “we, the people.” In fact, we don’t have a document at all. We have an unwritten constitution which evolves, sometimes dramatically – votes for women, for instance – but mostly in a slow, barely noticeable way.

Sovereignty in Britain doesn’t reside with the people but with the Sovereign in Parliament. That’s why an essentially silly ritual continues to matter so much.

At the beginning of each parliamentary session, a man in tights – he holds the title ‘Black Rod’ – approaches the doors to the House of Commons, which are ritually slammed in his face. That underlines the principle that the Commons is under no obligation to admit the monarch or her representative. He then hammers on the door. My wife and I visited the place just a few days ago and were shown by our able guide and local Member of Parliament, the place where the wood has been worn away by the hammering.

Black rod hammers on the doors of the Commons
The members of the House of Commons then emerge and troop along the corridor to the House of Lords. There the Queen delivers a speech – wittily entitled “the Queen’s Speech” – in which she outlines her legislative plans for the coming session.

Thus it has been for centuries.

However, though the forms endure, the substance alters. The monarch now performs an essentially ceremonial role. Her speech is written for her by Ministers, in particular by the Prime Minister. She appoints the Prime Minister, but no one can hold that office who does not command a majority in the House of Commons. Indeed, Lord Salisbury who left office in 1902, was the last Prime Minister to have led a government from the House of Lords. These days, though some ministers may sit in the Lords, the great offices are held by members of the Commons.

That means that sovereignty, while apparently unchanged, is in face exercised by the elected representatives of the people. There are still some matters of royal prerogative, but even there the sovereign’s supreme authority is actually exercised by her ministers acting in her name. In any case, their scope is being constantly reduced. For instance, after the debacle in Iraq, Parliament took to itself the authority to decide whether the nation should go to war, previously exercised by Ministers in the name of the Queen.

The evolution doesn’t stop. It feels to me that there is a big step coming, perhaps in a still relatively remote future: the replacement of the House of Lords by an elected chamber. It’s been in the air for so long that I think it will inevitably occur. 

Eventually. As is the British way.

You may like or dislike this way of doing things, but it is the British way. Power flows from the Sovereign in Parliament, but the powers of the Sovereign are now exercised by Ministers, who are themselves Parliamentarians. So political authority belongs to Parliament in creative tension with those of its members who also happen to be members of the government.

There is no provision in this arrangement for a referendum. If one is held, it takes place by Act of Parliament. Its result has no binding force on Parliament. The only obligation on MPs to follow it is the moral consideration that to ignore it would probably be career-limiting. But they and they alone have the authority to decide how they react to it.

So when Brexiters proclaim their enthusiasm for returning control to our own institutions from Brussels, what they’re calling for is the return of power to Parliament. How, in simple consistency, can they then deny Parliament a say over that process?

The alternative is simply to leave it up to the government itself, free of parliamentary scrutiny – the kind of arrangement, now abandoned, that led to the Iraq invasion. Not terribly British, is it, to go back on the process of extending the power of elected representatives and return it to an Executive answerable to no one? I suspect a lot of Brexiters would reject the very idea as the kind of misguided thinking generally associated with that pitiable figure, Johnny Foreigner.

Trouble is, if truth was the first casualty of Brexit, good judgement was close behind.

Tuesday, 11 October 2016

Theatres can be surprising. As I discovered on a hospital project

Avoiding the avoidable is an excellent goal. But sometimes healthcare, including acute healthcare, is simply unavoidable. Not all the people walking into Emergency Departments are ‘walking wounded’ or ‘worried well’ who can be sent home with instructions to see their General Practitioner in the morning. Some really need hospital care and have to be admitted.

However, avoiding the avoidable doesn’t stop at the hospital bedside. Work still needs to be done to make sure that even within a hospital stay, the care delivered is precisely what the patient needs, and no more. In that context, initiatives that I’ve mentioned before that focus on discharge planning are important: from the moment of admission if not before, work needs to be put in place to discharge the patient as quickly as possible:
  • The patient should not have to stay longer in hospital than they need to just because test results are not available
  • If necessary, doctors have to review the organisation of their work to ensure that all the necessary paperwork, including prescriptions, are signed and ready in time for a prompt discharge
  • Where hospitals have to ensure that a patient is discharged to an environment with adequate care, all the arrangements should be in place beforehand
That’s the surest way of avoiding unnecessary hospital care: get the patient out of hospital and no longer incurring the elevated costs of nursing, medical care, tests or hospital drugs, to say nothing of surgery.

Even while in hospital, we can take action to avoid resource wastage. That’s where good information services come into their own again. Sometimes, they don’t even need to do anything exceptionally clever: they simply have to report in a clear and undeniable way on what’s going on in the hospital.

Often, that kind of reporting does just one of two things, both useful:
  • It may confirm what everyone knew, or at least suspected, but couldn’t prove
  • It may surprise people who hadn’t anticipated that the problem would exist
Occasionally, the same piece of information may confirm one person’s suspicion and surprise another. That happened to me when I was working, many years ago, on a reporting system for theatres (as we quaintly refer to operating rooms in the UK) in a major acute hospital. Theatres are hugely costly, both in the amount of capital they require – not just for building space but also for equipment – and in their running costs, requiring large numbers of highly-qualified staff in relation to the numbers of patients. It’s no surprise that many cost-containment initiatives in hospitals make a specific point of working on cutting unnecessary theatre costs.

One of the costliest areas in a hospital
so no bad place to look for economies
The project was fun because we set up a live link between our reporting system and the theatre management system. That meant we could see what stage of an operation any one case had reached: arrival in theatre, start of anaesthesia, first cut, last stitch, out to recovery, return to ward.

I appreciate that’s only fun for a geek who’s got too used to working on retrospective reporting systems, as I was: to me, it was exciting to be able to follow individual cases in near real time, as the theatre nurses entered information on their own system.

The real surprise came, though, with one particular report. We hadn’t been second-guessing the users at all, but building reports only as they told us they wanted them, using information they’d asked to collect. One of the reports, however, struck me as singularly dull. It simply showed the number of cases when the patient had been due to have a general, regional or local anaesthetic, plotted against which type of anaesthetic was in fact administered. The report looked something like the fictitious example illustrated (from memory – please forgive any implausibility it contains).

Anaesthetic report: I couldn’t see what was so exciting about it
The Medical Director of the hospital was also the head of anaesthetics. He looked at the report and immediately crowed with delight.

“That’s what I thought!” he proclaimed triumphantly.

I looked again at the report. I couldn’t see anything inspiring in it.

“Look at all those times they asked for a regional or general anaesthetic and ended up using a local! What a waste of an anaesthetist’s time, standing by to administer the anaesthetic, without being required.”

Suddenly the report made sense, as did his reaction. And I made a mental note: don’t imagine you know everything a reporting system should do. Talk to the users, learn what they want, and you may come up with something that will surprise you and delight them. 

Particularly if it highlights an area of waste that can be avoided.

Sunday, 9 October 2016

Racism and xenophobia: we need to recapture the spirit of Cable Street

It was as shaming as it was sad to learn that Muslim female colleagues of my wife’s are afraid to visit France.

It was photos from Nice that had been the final straw. They showed four armed policemen converging on a woman in Muslim clothes on a Nice beach, to tell her to wear less. My first thought was of my youth, when the cry was for women to wear more on beaches. Ironic that society always feels it can tell women what to wear or not to wear.
French police move in on an existential threat to our civilisation:
a woman wearing too many clothes on a beach in Nice
My second thought was bleaker. Whether we like the police or not, we all ultimately rely on them. They’re supposed to make us feel safer, indeed to keep us safer. At their best, they should only be a threat over things we’ve done; but these police were a threat for what that woman was. Nothing suggested she’d done anything to harm anyone else, but because she was Muslim and felt the need to follow what she believed were the strictures of her religion concerning dress, she became a target for the police.

Where does a woman like that turn for protection if the police start off predisposed against her? No wonder my wife’s colleagues are so afraid of France. They feel unwelcome in a country that prides itself on being the homeland of human rights.

Sadly, we’ve been here before. At the end of the nineteenth century and for the first few decades of the twentieth, in many countries it wasn’t safe to be a Jew. Dress differently to mark your Judaism and, particularly in central or eastern Europe, you gave up your right to expect the police to look after you.

In some nations, the movement went to terrible extremes. In Germany, it turned into Kristallnacht where Jewish shops and business were vandalised and many Jews were beaten or killed in the streets, a harbinger of the full-scale Holocaust to come. In others, it was an insidious, subterranean hostility, which might be as mild as a refusal to allow a Jew into a club: you may remember the story of Groucho Marx, who was told he could join a club on condition he didn’t use the pool; he asked whether his daughter might be allowed to wade in up to her knees, since she was only half Jewish.

In Britain, the British Union of Fascists had been organised by a former Labour (and previously Conservative then independent) MP, Oswald Mosley. It wanted to bring anti-Semitism out into the open and even aped the militaristic uniforms of the German and Italian Fascists. In October 1936, the BUF decided to march through heavily Jewish areas in the East End of London. Anti-Fascists felt otherwise and mobilised to prevent them.

The result was the battle of Cable Street of 4 October 1936, whose eightieth anniversary fell last week. The battle didn’t pit anti-Fascists against Fascists, but anti-Fascists against the police. But the result was that Mosley got well away from there and the BUF rallied in Hyde Park, in the West End, instead of the East End.

Battle of Cable Street: the Fascists did not pass
The BBC spoke to a couple of survivors
Views differ as to whether Cable Street was as significant in halting the progress of fascism in England as many have believed. But it seems to me that whatever it may have achieved concretely, it was hugely important symbolically: 20,000 turned out against the Fascists, only 2000-3000 on the other side. The voice saying ‘no’ to an abomination was by far the louder. The battle is much more significant for what it revealed of an attitude than for what it may or may not have accomplished.

At a time when there’s once more a terrible lurch towards the far right across the great democracies, with increasingly overt xenophobia or downright racism, we need to recapture that attitude. Whether we’re confronting Trump in the US, UKIP in England, Viktor Orbán in Hungary, it’s the spirit of Cable Street that has to drive us.

And – who knows – why not start by finding it in France?

Wednesday, 5 October 2016

Misty's diary: an injury? Not something to get me down

It’s so tedious. Interloper cats really get on my nerves. I mean, sure, yes, I sometimes stray outside my own territory. But when I meet another cat, I just greet them politely, make my excuses, and get the hell out.

So here’s my question: why does that ghastly black and white cat from two doors down behave as though he owns our garden? My garden? More to the point, when he invades it and I courteously tell him he’s in my territory, why doesn’t he just get out like I would, instead going for me with tooth and claw?

He reckons he’s better than me because he’s from around here, and I’m an outsider who’s moved in. So what? Place doesn’t belong to him, does it? And I’ve been here four years. Practically half my life. I reckon that gives me the same rights as any local. Though sadly that’s not how he sees it.

The ghastly animal got me in the face the other day. Took me completely by surprise. When I was younger I’d have given him as good as I got but, these days, I’m not the aggressive scrapper I used to be. Put on a bit of weight, perhaps. Nothing excessive, of course, but you know how it is, I’m not quite as quick as I might have been once.

Still, I’m quick enough to leg it back into the house pretty fast. Had to nurse the injury. It certainly needed nursing: blew right up, nasty red and black coloured thing, that hurt like hell. The domestics were full of sympathy but, hey, what’s the use of sympathy? I needed help.

Luci tried, of course. But, you know – a toy poodle? About as skilful as a poodle toy.

I had to sort it myself. Got my claws into the nasty mess on my face, and that hurt badly too. But it did some good. Some vile liquid came out and the whole thing shrank to a sensible size which hurt a lot less.

Next day, once they’d had a decent night’s sleep themselves, the domestics actually got around to helping me.

“It looks less bad,” said number 1, “it’s like he’s managed to lance it himself.”

I’ll say. You weren’t going to do it, were you? Had to do it myself.

“Still, we’d better get him to the vet,” she went on.

There was a time when those words would have filled me with horror. But, you know, I reckon now that, though you get poked and pricked, at least you leave the vet’s feeling better than when you went in.

Not that I like going there. It means getting into that ghastly sort of brown cage thing they put you in. It’s made of cloth but believe me, it’s as much a cage as if it were all iron bars. Got Luci all upset too – she went bounding around and sniffing and saying useless things.

“Don’t stay in there, Misty, come out and play. Come on. It can’t be nice in there. Just come out.”

Lots of words. But no unzipping of the bit which would let me out. She’s as useful as a wet rag, like I said before.

How about not telling me to come out
and actually helping me out, you useless dog?
Anyway, I put up with it. We were off to the vet and I suspected it would do me good. So I did my best to be nice. I mean, when he jabbed me with a needle – and he did it twice – I didn’t give him a HOWL, more of a half-power protest. Quarter-power. Sort of Mrrrrr. Just to mark the fact that I knew they’d stuck me with steel and they shouldn’t start to think that just because I’d put up with it, I was going to go on putting up with it in the future. 

Even though I’d put up with it twice.

He’s good that vet. Did the trick. When I got home I was feeling a lot better. Comfortable, basically. 

OK, so can I get out now, please?
Domestic number 2 opened the door to the nasty cage thing – thank God he’s worked out how to use a zip – and I emerged. In a dignified way, though I did nuzzle his hand and let him stroke me. I mean, I didn’t want him to think I wasn’t appreciative.

And of course little Luci came dancing round.

“You’re out of that nasty carrier thing!”

“Cage,” I corrected her.

“Who cares? You’re out of it.”

She was dancing around so much she didn’t notice she’d left her blanket empty, so I curled up on it. I left her a little bit on the edge and she joined me. Which was fine. It was quite nice having her silly wet nose pushing against my back. Companionable.

I was feeling good about things again. There’s nothing like getting rid of pain. Why, I could even think of the nasty black and white cat from two doors down and, you know, I didn’t even feel bitter about him. Revenge? What good would it do even I managed to exact it?

Though if he gets too close to my claws with his back turned, I might just revise that opinion.

Tuesday, 4 October 2016

Ageing: a crisis for healthcare. Or an opportunity for integrated care?

It’s obvious, isn’t it? The wealthy nations face a crisis due to their ageing populations. The problem’s particularly acute for healthcare.

It’s so obvious that even I have said it in the past. But it isn’t entirely true. The error needs correcting, if only because ageing isn’t a curse but a measure of unprecedented success. At the beginning of the last century, life expectancy in the US was just over 48 years. Today, it is nearly 79. In Britain over the same period, it has grown from 45 to 81. How’s that a disaster?

After all, it’s not as though the picture is the same everywhere. In Syria, life expectancy is 64.5 years. In Sierra Leone it's just 50 years, little better than the US over a century ago.

Where there have been gains, the extra years include an increasing proportion in good health. That’s according to a study by the British healthcare think tank, the King’s Fund. It suggests the trend is likely to continue, with our ageing population adding further years of healthy life.

More years of healthy life? Why’s that a problem?
Not so much a healthcare crisis as a cause for celebration, surely. 

That being said, the trend does raise new challenges for healthcare. They need to be addressed. That means a change in approach.

As the King’s Fund points out, what we are seeing is an increase in the specific kind of health problem characteristic of old age. There are more long-term conditions such as diabetes, some lasting for life, and more patients suffering from several disease conditions at the same time.

Why is that such a challenge to the health services? Because historically healthcare has been built around specialisation. Hospitals are organised into departments dealing with neurology or rheumatology or cardiology. But today they’re having to deal with patients who may have suffered a stroke exacerbated by a chronic heart problem, who are also struggling with the pain of rheumatoid arthritis.

How does a specialist of just one of these conditions approach such a patient?

These issues also raise the question I’ve been addressing throughout this series: in what setting should a patient be treated?

The King’s Fund tells us:

…we must strive wherever possible to ‘shift the curve’ from high-cost, reactive and bed-based care to care that is preventive, proactive and based closer to people’s homes, focusing as much on wellness as on responding to illness. When asked what they value in terms of wellbeing and quality of life, older people report that health and care services when they become ill or dependent are only part of the story. Many other things matter: the ability to remain at home in clean, warm, affordable accommodation; to remain socially engaged; to continue with activities that give their life meaning; to contribute to their family or community; to feel safe and to maintain independence, choice, control, personal appearance and dignity; to be free from discrimination; and to feel they are not a ‘burden’ to their own families and that they can continue their own role as caregivers.

Admission to hospital may be vital in certain circumstances but, as well as being the most expensive way to deliver care, it corresponds to only a tiny part of the aspirations older people expressed to the King’s Fund team. They propose reform based on nine points:
  1. helping people maintain their independence, to live at home in good health, for as long as possible;
  2. helping people to live as well as possible with simple or stable long-term conditions if they develop them
  3. helping people deal with complex or multiple health problems, including dementia and frailty
  4. in cases of real crisis, delivering rapid help close to home
  5. when it becomes necessary to provide hospital care, making sure it’s good and delivered humanely
  6. planning discharge from hospital on admission or before, ensuring patients leave with sufficient support and avoid the risk of readmission
  7. providing good rehabilitation and re-ablement services so patients quickly return to the best possible level of health and independence
  8. providing high-quality long-term nursing and residential care for those who need them
  9. ensuring that services supporting patient choice and control, with all the care and support required, are available towards the end of life
The tenth point is that all the others require integrated healthcare, bringing together medical, nursing and social care, in hospitals, family practices and community settings. An integrated approach sees a patient as a whole, not as the vehicle of a single medical condition, or even several. It accentuates quality of life and does everything to maximise choice and independence. Such care would certainly be the best imaginable.  What may seem paradoxical, but isn’t, is that is also likely to be the least expensive. That’s because it minimises healthcare demand and shifts as much as it can to less costly settings, in particular away from the acute hospital.

This approach will have benefits far beyond care for elderly patients. As the King’s Fund argues:

The balance of evidence is clear that integration can improve people’s experience and outcomes of care, and deliver greater efficiencies… It is important to recognise that achieving improvements for older people will also positively affect care for the rest of the population. More effective urgent care and post-acute rehabilitation and re-ablement services are important for people of all ages, while reducing inappropriate care and shortening acute lengths of stay for older people could release resources to meet other needs.

Avoiding the avoidable and coordinating care more effectively will deliver better care. Far from costing more, that may free up resources. So the ageing of the population may not be so much a crisis, as an opportunity.