Sunday 1 April 2018

Dying for a Bed: Or the need to change our approach

One of the things that gave me great pleasure as Dean of School was welcoming the new students to the University on their first day. Our largest lecture theatre held 350 people, so my welcome speech had to be repeated three times. I took the opportunity to share with the new students five people whose work had helped shape my thinking and approach to professional life. They were: the nurse Virginia Henderson; the midwife, Ina May Gaskin; the psychologist Carl Rogers; the social worker Mary Ellen Richmond; and the philosopher Michel Foucault.

Each of these people wrote about approaches to life, therapy, care, beliefs and values that resonated with my own thinking and approaches. I was reminded last week of Mary Richmond’s work.  She developed a ‘casework’ approach to social work that was based upon social theory rather than adopting an approach based on psychological theory. Her approach was predicated on the belief that social problems for a family or the individual, should be looked at in the first instance by the individual or family, then other close social relationships, such as families, schools, churches and their place of employment.

What I liked about her work and thinking was her focus on the strengths of the person or family rather than their weaknesses. She held steadfast to the belief that the community is the greatest resource for those in need of care and support. This was revolutionary thinking way back in the early part of the early 20th century. Today we think about this as being an assets-based approach. It’s an approach critical to the development of a community that can come together to achieve positive change through the use of their own knowledge and skills and lived experiences. I am not sure we are succeeding very well with this ambition.

It was something brought home to me at last week’s Trust Board meeting. We had invited Lord Peter Smith to join us. Lord Smith is both the leader of Wigan Council and the lead for the Greater Manchester Combined Authorities Health and Social Care (GMCA). The GMCA works with all the NHS providers in Greater Manchester in developing more integrated and cost-effective approaches to health and care services. Whilst he is very aware of the issues challenging the wider NHS, we wanted to take the opportunity to share with him the Wigan context. Dr Sanjay Arya, a Consultant Cardiologist, and the Wrightington, Wigan and Leigh NHS Trust Medical Director set out our position and challenges.

His presentation was entitled ‘Compassion Heals’. It could have also been called ‘Dying for a Bed’. The focus of his presentation was on the care of the frail older person. We have an ageing population and more patients aged 75 and over come into hospital than ever before. Indeed, while overall attendances at A&E have been on the decline, attendances by those aged 75 and over have continued to rise. This increase has corresponded to a continued rise in admissions of such patients from A&E. Problems of overall bed capacity are being exacerbated by these admissions and the lack of proper community-based services, including ‘step down’ and ‘supported care’ beds. If beds are used to provide care for the frail older person, they cannot then be used for other patients, with cancelled or delayed elective surgery often being the victim of this lack of beds.

At present 7% of the population are aged over 75, a figure expected to rise to 12% by 2039. Over 75s currently account for 43% of all bed days (the number of days that we have someone in a bed) - a figure set to double by 2039. As early as 2019, the increase in demand would result in an extra 19 beds per day being required. And our hospital already has the third lowest number of beds per 1,000 of the population of all the hospitals across Greater Manchester. Providing care for older people who will often have many complex needs can result in what I describe as ‘heroic doctoring’ and the preservation of life whatever it takes.

Sanjay told a hushed Trust Board, how when he did his ward round, he sat at every older person’s bed and held their hands while he talked to them about what was happening. He routinely took them off the drugs his junior doctor colleagues, who perhaps with good intentions, appeared to habitually prescribe for these patients. Just these simple acts could bring about a wonderful change in the patients’ health and well-being. Whilst these patients may be close to their time to die, how and where this might happen is the challenge for us all. As long as such patients are brought into hospital at the end of their life, and as long as we continue to try and treat their every problem, change simply won’t happen. Sanjay’s strategy was a simple one, and much of it could be implemented tomorrow:
  • Advanced care planning in the community/care homes/and hospital by appropriate healthcare professionals in partnership with families and the individual patient’s wishes
  • Medication review in the community/care homes and hospital
  • ‘Step up beds’ in care homes for each locality so as to provide primary care doctors with specialist help where needed
  • Direct phone access to specialists (cardiologists, gastroenterologists, respiratory physicians and acute physicians) to help avoid admissions to hospital
  • Align integrated care services with A&E to prevent admission and facilitate discharge of the older person 
We need to find ways of better mananging patient and families' expectations of what is medically possible and/or desirable. 

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