Author Archives: Paul Goulden

Ticking boxes is on the way out in the NHS… but there is a need to think wider and deeper to change it.

The idea of giving the million most frail older people a named GP to look after them was trailed last week by the Health Secretary and on the face of it seems like a good idea – the aim is to get away from a box ticking mentality and to focus more on the needs of the older person.

My worry here is with some practical problems – not least that older people themselves can be quite stubborn when it comes to their GP and might not take kindly to this idea if it involves the local practice changing their contact. GPs also report that older people come to see them over trivial matters when all they really want is some company – having a named GP might actually make this significantly worse, if older people believe they now have a real right to see the named person.

I’m also wondering what will happen within GP surgeries? Will the named GP actually become a dumping ground for all the patients no-one else wants? And what is the betting that this will be the newly qualified doctor rather than the managing partner? And let’s not forget that most GP surgeries operate on a tight timetable of appointments – I’m not sure this idea will help that time-scale and will probably put more pressure on it.

However, I’m quibbling here and the emphasis on needs rather than box-ticking is a very positive move.

But is it enough?

Er, no.

There are some real basic cultural problems with the NHS that mean the turning of this particular supertanker may take longer than any of us may have left to live. The main one is the medical focus of the NHS…

Medical focus of the NHS? Isn’t that what it’s there for? Well yes, but the problem here is that NHS care is far too blinkered when it comes to other treatments and interventions that may help a patient.

And I can see where this comes from – doctors and nurses train hard for many years and experience things every day that most of us would lose our lunch over, so they are right to be protective of their expertise and dedication. And they are also pushed for time – GPs have 5 minutes to see a patient and five minutes to write up the notes? Does this seriously give them a chance to really engage with a patient?

Given the time available, they have to see a condition and then prescribe a pill or some tests, without maybe looking at the whole person and what else is going on in the patient’s life. What about the patient’s finances? Or the falling out they’ve had with their only living relative? Or the fact that they are 87 and also a full-time carer? I think this is what Jeremy Hunt is getting at with the line about returning to the “old fashioned family doctor”, but it actually needs to start with the doctors themselves.

Doctors need to have it ingrained into their daily practice that social care solutions can dramatically improve patient health, and that the combination of health and social care solutions can bring benefits to patients greater than the sum of the individual parts. Here in Bexley, tentative steps are being made in this direction, with the Council and CCG working together on an integrated care pathway for hospital discharge. It is early days, but the fact that it is happening and that both health and social care professionals are committed to it means that patients here will benefit.

We don’t want doctors to become social workers, but how do we get them to appreciate the social care side of improving a patient’s life?

My solution? Every GP and nurse should have a social care module as part of their training, that they have to pass in the same way that they would with medication and anatomy.

If anyone wants help writing this course, give me a call.

Ideas are cheap – volunteers aren’t . . .

I’ve previously praised the care minister, Norman Lamb, for saying that we need to look at the care in the home provided by care agencies – but today’s report, that he thinks Neighbourhood Watch should be involved in helping with the care of older people, nearly had me causing a motorway pile-up.

Now I’ll start by saying that Neighbourhood Watch are a great organisation and good at doing what they do. They are strong here in Bexley and are an excellent example of community minded people giving up their time to keep neighbourhoods safe.

So why did others drivers see me shouting at my radio? The simple reason is that this is another example of the thinking that volunteers are a cheap resource and a magic wand for providing services that the government can no longer pay for.

So here are some reasons why this is a poor idea . . .

Mission drift – however this starts out I can guarantee Neighbourhood Watch will start getting calls from hard-pressed social workers and care providers along the lines of, ‘Would you mind popping round to see Mrs Smith?’, and of course Mrs Smith will need a lot more than just a chat. She will need shopping done, meals cooking, forms filling in, bills sorting out, maybe even dressings changed. Which leads on to . . .

Boring but important – insurance, procedures and responsibility. Where does the responsibility lie if a volunteer visits a client and finds them with no electricity, in their night clothes in the middle of the day and clearly disorientated? And if the volunteer leaves them like that and they are discovered dead a few days later or wandering the streets? Anyone dealing with the more vulnerable in society needs to know what they are doing and where the responsibility lies, or else the older person is still in danger and the volunteer is putting themselves and the organisation at risk. Which leads on to . . . .

Looking after your volunteers – piling more responsibility onto volunteers is a sure way to lose them. Managing their expectations, thanking them and giving them the proper support is vital if you want to keep them. And to be effective, this support needs to be done by paid staff.

It’s already happening – this is the main reason why the Big Society has sunk without a trace is because it tried to brand something that has been going on anyway regardless of what governments do (or more likely, in spite of what governments do).

It’s already happening No. 2 – caring and the voluntary sector go hand in hand. There are so many existing organisations who are keeping a look out for vulnerable members of the community already, so does the Minister think we aren’t going the extra mile to alert other organisations when we find someone in need?

It’s already happening No. 3 – voluntary sector organisations are already using volunteers for supporting vulnerable people and we’ve got a lot of experience at it. If the Minister wants to talk about better ways to reach older people and have better impacts on their well-being, then why not talk to the people who are doing it already – local Age UKs and any of the many other excellent local charities who already do this work.

Reading this blog back, it does sound a bit whiny and negative. I don’t have any problem with Neighbourhood Watch exploring this with government and if they want to move into social care and they are using this as a foot in the door then I wish them all the best.

But the tone of this story is still about cutting care budgets – basically using volunteers to replace proper properly funded support for older people. Volunteers are a fantastic way of helping older people but whilst they cost less per person than paid staff, they aren’t free – or even cheap. To get good results from volunteers they need looking after so, Mr Lamb, why don’t you challenge us? Don’t try and get savings by assuming volunteers are free – pay voluntary organisations to support volunteers properly and we’ll reduce care bills by keeping older people away from statutory services for as long as possible.

Life imitates art . . .

. . . as ‘The Big Bang Theory’s’ Sheldon helps dementia clients in Scotland . . .

The BBC are reporting a pilot scheme in Scotland, where driveable robots are being used to help older people with dementia – the story can be found here.

The thing is, I saw the photo and thought, “I’ve seen this somewhere before . . .”

For those of you who haven’t seen it, ‘The Big Bang Theory’ is an American sit-com about four science geeks and how they deal with the world. Doesn’t sound promising, does it? But it is a hit on both sides of the Atlantic and is up there with ‘Friends’ and ‘Seinfeld’ in terms of success.

The episode ‘The Cruciferous Vegetable Amplification’ sees Sheldon Cooper attempt to deal with the world by retiring to his room and interacting with everyone outside using a robot with a webcam – and his head displayed on the screen. The Scottish trial is using the same principle but with relatives able to drive the robot and talk to the person with dementia, reminding them about taking pills and also being able to see what is going on.

The article suggests that previous trials in Australia have shown that the clients are not afraid of the robot, and that the Remodem project has high hopes that it will help improve the quality of life for dementia clients.

This is going to be fascinating to see how it develops – I’ve always been sceptical about IT and the internet being a ‘magic bullet’ for solving problems around social isolation, but this combines the human element and could be a real lifeline for both clients and carers. For more information, go to www.remodem.eu and let’s hope it makes a real difference.

PS – The big question is, can their robots knock three times and ask for Penny?

Andrews Salts or a better diet? – if the government wants home care with dignity then it will have to find better ways of paying for it.

Care Minister Norman Lamb has announced that there is an urgent need to transform care in the home – highlighting the fact that, according to CQC, 25% of care is failing to meet basic standards. He’s right that this is an accident waiting to happen, but the solution is tricky.

The economics of the problem are quite simple. Carers get the minimum wage or just above, and the margins for care agencies are very slim. Local authorities are under pressure from central government to cut costs and so will look to cheaper providers and also make requests such as half hour or even quarter hour slots. Providers are in the position where if they don’t accept the local authority work on offer, then they have a serious hole in their income so they have to oblige. It also means their training and management costs are under pressure and there is no spare cash to invest in developing staff.

The upshot is that despite the local authorities and care agencies wanting to provide quality home care, they are forced to concentrate on the money rather than the people – and against their natural inclinations, clients can become “units” and care staff can become “resources”.

In terms of looking at the long term treatment of clients, it is also a false economy: by spending more time with clients and providing consistent care, the person receiving the care feels better, is happier and therefore more able to cope with life in general. This in turn means that any decline in health and well-being is slowed – which means that the costs to the local authorities for residential and nursing care are reduced. The current system is just storing up trouble for the future.

We need care providers to have the income to be able to employ and invest in staff, giving them the quality time with clients but also meaning that the care agencies are viable. In turn, local authorities would need to have clear contracts for the services they are funding and a high standard of inspection – none of this is difficult to achieve, and is largely what agencies and local authorities want to do anyway. The issue lies in where the money comes from . . .

However, it is no good just going to the Treasury and asking for more money – that is not going to happen. So the challenge here is how does Mr Lamb deal with the financial constraints on the one hand and the political and social care pressures on the other.

It is the difference between treating the symptoms or dealing with the cause. Tinkering around the edges and asking the care providers to work in different ways will only deal with the surface issues – the Andrews Salts to provide a burp of relief in the system. But this will only put the crisis off – what we need, and what I hope the Minister is going to look at, is a transformed way of paying for home care, because only a better financial diet will mean that we finally get dignity and proper care to those who really need it.

The generation game – and why the current debate over universal benefits for older people is irrelevant…

The coalition is currently split on the question of universal benefits for older people, such as the free bus pass and winter fuel allowance. This split is either healthy for democracy or a sign that the marriage is coming to an end – you decide. But the argument itself is largely academic, because reality is over-taking policy.

If my grandparents were alive they would be in their late nineties – they were the generation that fought in the Second World War, and came home to the promise that the state would look after them. The welfare state and the NHS were products of their time – but they were only a good idea for the situation that the country faced at the time, and certainly not future-proofed. The feeling of ‘I’ve paid into the system so it will look after me’ is very much of that era, as is the idea that this support would always be there.

My parent’s generation has some of the hangover from this view of the state, but they’ve also been influenced by living through the inadequacies of the state in the ’70s, the explosion of personal aspiration in the ’80s, and then the excesses of that coming home to roost in the ’90s. They are the ones slowly breaking down the old reliance and expectation of the state always being there.

My generation (anyone in their ’40s) probably has a more pragmatic view of universal benefits – given the economic climate and the pressures of population growth and demographics, I can’t see universal benefits being around in 20 years time. My guess is that, whatever happens, I’ll be personally paying for far more care and support than older people are at the moment, and because this expectation is already in the air it has become accepted.

My niece’s generation (anyone currently under ten years old) will be facing a different situation, because the pressures will have moved on – by the time she retires the NHS and welfare system will have been going for over a hundred years, and no-one can realistically expect a 1940’s solutions to a late 21st century problem.

Now you can argue that I’ve got my generations wrong because of course it is difficult to section society off in this way, but it does illustrate how far we’ve come and where we are heading.

So, universal benefits are going to go – either because future governments won’t be able to afford them, or because there won’t be a government because it will have been bankrupted by care and social security costs. The main question is what replaces it – private insurance? Means testing? An ‘opt-in’ benefits system? And this discussion had better start soon, because the rate at which these issues get tackled means that the future might be on us before we realise it.

Dear Deceased, It’s Not About You . . .

I’m not a great fan of funerals, mainly because I’ve had such mixed experiences of them – but, working with older people, they are an ever-present fact of life.

As events go, they tend to bring out the best and worst in people (although local election counts come a close second), and it may sound a little ghoulish but people-watching at a funeral is a fascinating experience. From grace and fortitude through to seething resentment and, of course, wondering who finally gets their hands on Aunty Joan’s tea set, you see it all.

I’ve often wondered what the deceased would think about the people who come and about the event itself – which is odd because the main focus of the day is probably in no position to either know or care about what happens at their funeral.

So funerals are less about the deceased and more about us and how we cope with loss. How do we work the death into our individual version of how the future is going to pan out and what our role in it is – and this is where we can lapse into easy and old habits of behaviour, or reflect and maybe think about moving on in how we deal with the world in general.

Which brings me to Margaret Thatcher’s death and funeral. I’ve been very uncomfortable by some of the reactions, from the fawning adulation to the bitter hatred, not because they offend me but because of what it says about those people. It is easy to react by clinging to what we thought, whether it is hatred because of the miner’s strike or glorification because of privatisation, because it is safe and safety means not having to deal with the unknown of the future.

So I hope we don’t see any of either extreme; violence or worship – because when we disrespect the dead, we are only disrespecting ourselves.

Reinventing the wheel?

Age UK London recently hosted a presentation from an organisation called care4care, and when I saw it I thought this is something I have to look at. Partly because of the need to tackle the problem of future care for older people, but I have to confess mainly because it is fronted by Professor Heinz Wolff – the archetypal professor from ‘The Great Egg Race’ in the late seventies. Along with Johnny Ball (how did he get voted off SCD?) and Johnny Morris, he inspired many of my generation to have an interest in science and the natural world. So what did he have to offer?

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Hair of the dog?

The Panorama programme on older people and alcoholism last night highlights a growing headache for society, but Panorama’s solution is more likely to make things worse.

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Wanted: Government advisors. Must be over 60!

Yes, the reshuffle is the big news today, but I was more intrigued by the fact that George Osborne has a group of young advisors, one of whom is in their twenties. In their twenties?

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Home is where the heart is . . .

The news last Wednesday featured a report by the Intergenerational Foundation on what they call “house hoarding” – highlighting the housing problems faced by young people. They suggest that older people who stay in their family home are creating a housing crisis and that they should be encouraged to downsize by being given tax breaks (for example on Stamp Duty). There have also been comments on the web about this being unfair on younger people, because these home owners had it easy when the bought their properties.

I’m not sure they have really thought this one through . . .

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