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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