Old and frail, young and amazing: the ingredients for innovation?

October 13, 2011 by
Filed under: Public policy, The RSA 


Lots of explanations are being offered for the scandalous treatment of frail, mainly elderly, patients, which has been exposed by the Care Quality Commission. But whatever the deeper issues of ageism, organisational culture or bureaucratic neglect, the proximate cause is easier to identify: absence of voice; most of these patients were neither able to demand decent treatment themselves nor did they have friends or relatives to make this demand on their behalf.

Arguably, therefore, the underlying cause is social isolation; too many people without anyone to fight for them. And, while changing cultures or reengineering bureaucracies may take a long time and ultimately be unsuccessful, surely there are relatively simple community-based ways of addressing the isolation of vulnerable patients.

My policy proposal would be that any patient in hospital for more than 48 hours who does not have at least one regularly visitor should as a matter of right be allocated a volunteer friend. Of course, it is not easy to recruit volunteers and there is no evidence of its getting any easier. So I suggest forming links between hospitals and school sixth forms and FE Colleges.

The hospital would provide the young people with a short course – it need not take more than a few hours – covering basic hospital procedures, the standards the hospital is committed to meet, and how best to know whether someone who may be unable to use conventional communication is comfortable or in distress. The pupils would then volunteer to be patient friends.

On a rota system they would be called up by the hospital to visit a patient –they might go on the way home from school. There are more sixth formers than elderly patients in hospitals so if most students signed up they would probably only be called on every few weeks, but they would be encouraged, once attached to a patient, to try to stick with visiting them until the end of their stay.

A simple password restricted on-line space would be created for the students to log any concerns they had which had not been met by staff on hand (the students could text from the bedside).

All the students who participated would get some kind of award showing they had done the course and delivered the service. Universities would commit to taking these awards into considering student applications for places.

I wonder if there is anyone out there interested in scoping such a scheme? If you are an RSA Fellow or can get a Fellow involved you could apply for a Catalyst grant.

If the idea is any good (and it may be pants for reasons that just haven’t yet occurred to me), then the indirect credit goes to Acland Burghley School.

I went there on Monday as part of a new Speakers for Schools initiative and was incredibly impressed by the sixth form group I spoke to (memo to Speakers for Schools: ‘the best part of your scheme may not be what the kids learn from the speakers, but what the speakers learn from the kids). These young people seemed to me to have the values, energy and the ambition to change the world. It just needs to be channelled.  

Indeed, it wasn’t just the sixth form that impressed me. Acland Burghley is a great school. Its intake is diverse in every social sense but it manages to combine a really strong sense of community with very good and improving exam results. And for all of us trying to promote greater public sector collaboration how about this? The head teacher told me the school has successfully run combined post-16 provision with four other – quite different – schools for 30 years!

It’s only a pity that the school is in an increasingly decrepit building (it was as victim of the scrapping of BSF) and, as one of the those most unfashionable of institutions – a genuine and proud comprehensive community school – it won’t be expecting public plaudits from Government ministers any time soon.

Share

Comments

  • http://www.knowingyoumatter.com Andy Bradley

    Mathew
    thanks for this blog – simple genius. My work is described as ‘catalytic’ as i seek to close the gap to which you refer – combating isolation through the cultivation and application of compassion and mindfulness which results in the giving of ‘undivided attention’ by people with assets who are invited to show deep care to people who are (evidently) vulnerable. Our ‘Everyone matters’ programes in NHS trusts, private companies and social enterprises are seeing major impacts in the realm of care giving. In addition to the young people with listening ears and open hearts that you have been inspired by I would add another group of ready listeners – elders who are fit and well and who have time to listen and take action. These elders training the young people will add another layer of connectivity. I believe you know Des Kelly from the national care Forum – a solid ally and supporter of our mission – to create and sustain consistently compassionate caring environments. We are already talking to a school about an ‘Everyone Matters’ project which would connect people up in the way you imagine. If you felt that we were the right people we would be delighted to ‘scoop up a catalyst grant!’. Can i discuss with you or a colleague? My mobile number is 07960473347
    Warmest regards and appreciation
    Andy Bradley
    Founder of Frameworks 4 Change

  • http://www.unitedforallages.com Stephen Burke

    Huge problems in the NHS and hospitals in particular – rampant institutional ageism (see my blog: http://unitedforallages.com/blog/). We need to ensure every older person in hospital can access independent advocacy so they have someone who can speak up for them and help get the care they need and support them when they leave hospital. For many older people hospital is probably the worst place to be and we need proper support at home and in the community providing more appropriate care.

    There are lots of examples of intergenerational projects that link schools/colleges with older people’s housing schemes and care homes (some to be celebrated in the forthcoming Awards for All Ages). We need to open up hospitals in the same way as you suggest. Organisations like CSV already place volunteers in hospitals and could also take on the roles you suggest. Hospitals will need to open up as institutions to make this happen which goes back to changing culture.

    We need to create ‘hospitals for all ages’ just as we need ‘schools for all ages’ where older people are common place adding to all aspects of school life and their local community. And thereby changing perceptions so that young people are seen as amazing and older people are not seen as just being frail.

    Happy to discuss

  • http://www.hilaryburrage.wordpess.com Hilary Burrage

    Looks like many of us are thinking along the same lines: http://hilaryburrage.wordpress.com/2011/08/01/unmasking-age-the-significance-of-age-for-social-research-bill-bytheway/ .. and the give-and-take is two-way of course, with elders helping younger people as well as the reverse.

    I would however caution (as I know the other writers here are also would) that all this takes proper training – of the employed practitioners, in how to use the input from members of the wider community, as well as of the volunteers. I can recall an experience of student volunteering which nearly put me off for life… sure many others can too!

    PS Even if we’re not actually participating in any formal programme, we can all be doing a lot to ensure inter-generational respect and understanding. That would help to keep expectations (and therefore service delivery) up at a standard we must all demand. And maybe that would also help in making the training and conditions of non-clinical practitioners good enough that they know we value their work in looking after our older family members and friends.

  • http://uk.linkedin.com/pub/edward-harkins/15/40/635 Edward Harkins FRSA

    Heartening stuff Matthew and I think I can offer something similar in quality and context. Inter-generational knowledge-sharing and mentoring is a core value of the The Galgael project in Govan on the banks of the river Clyde, Glasgow, Scotland. I have had the great privilege to have been involved on the fringes of Galgael’s activities some time ago.

    The project is located in the heartland of the old shipbuilding and manufacturing inner-city community of Govan. With the familiar collapse of these industries, much of the Govan neighbourhood and the people in were treated – well as though they were redundant no longer needed, in fact no longer wanted.

    Some inspirational people brought Galgael into being many years ago. They utilised the still-powerful cultural legacies of boat construction in the West of Scotland, and ‘making things’ and the Scottish Gaelic heritage. This was, however, no couthy, nostalgic kailyard project. It was (and is) about inclusive outreach across the generations and blending older wisdom with youthful enthusiasms and needs, and about helping many people with deeply challenging life circumstances.

    The key ingredient would seem to be a combination of belief in people, empathy and the importance of individual people being able to ‘make things’ as much by hand as by brain. Marvelous stuff as you can see from the link below. A word of warning though; never ever make the dire mistake of describing their reconstructed Highland Galleons as ‘Viking Ships’!

    http://www.galgael.org/index.aspx?AspxAutoDetectCookieSupport=1

  • Stuart

    Hi Matthew

    The charity that I used to work had an office in Northern Ireland that would always have access to more volunteers than the UK national office. A lot of this seemed to be down to the Millenium Volunteers programme – http://youngcitizens.volunteernow.co.uk/millenium-volunteers

    To me it seemed widely accepted that young people would volunteer especially in and around Belfast. I believe the support the Department of Education offered to the scheme was one of the key reasons althoigh I’m sure a lot of hard work also went into communication.

  • http://www.mypoliticsdegree.co.uk Tom Brookes

    This is of course a shocking story on the face of it, but does it really smack of institutional ageism or uncaring across the NHS? Or something a bit more human.

    Look at the examples in the BBC report – underwear exposed, 25 minutes rattling before being seen, not offered pre-meal hand washing, staff conversing while assisting patients with eating (?!) & a half-hour to be given help eating…

    Ok, it isn’t brilliant, but it’s not exactly abuse, is it? Hospitals are not hotels, or crèches, they are buildings packed with sick and dying people with far too few doctors and nurses – who do a wonderful job, but they have to prioritise the patients in greatest need. Exposed underwear is not ageist, just moderately inattentive, & in a hospital you cannot expect to be totally dignified all the time, or for nurses to catch everything. A patient capable of rattling his bed & calling for help for 25 minutes is clearly less urgent than one slipping into cardiac arrest or being monitored for life saving surgery. Staff conversing seems peurile – we cannot penalise hospital staff for making their job more pleasant by socialising… I could go on with these examples, but won’t.

    I had to spend the night in hospital last week & was on a ward with 4 elderly patients, 2 of whom didn’t have visitors for the 36 hours I was there. As far as I could tell there were 2/3 nurses & one doctor overseeing at least 3 wards for the entire night – that’s 18 patients, & the nurses do the lion’s share of the work. In fact I was mightily impressed by how impossibly kind, caring and reassuring the nurses were, particularly with the elderly patients, who were evidently confused & frightened – one fellow kept trying to escape! Yes, sometimes patients have to wait a bit, but we can’t blame hospital staff for prioritising the sickest when they’re overworked, & the nurses probably still underpaid for what is a rather unpleasant job. We should remember everything they do brilliantly, before suggesting reforms for things which are relatively trivial compared with a hospital’s primary mandate – making sick people better! This seems like an issue of bureaucracy & staffing more than ageism & uncaring.

    I think we should be more careful in our analysis of the facts before we jump to conclusions about the NHS. Indeed, if this is a government backed report are we that surprised it pours scorn on the NHS – to grant some vague mandate for its NHS reform/privatisation agenda?

  • http://www.unitedforallages.com Stephen Burke

    For more on why this is institutional ageism ie systemic failure, read these letters to The Guardian: http://www.guardian.co.uk/society/2011/oct/13/institutional-ageism-in-our-hospitals

  • http://www.ndti.org.uk Helen Bowers

    I completely disagree with the view that the poor, inadequate care experienced is “not abuse, it it?” Yes, it is. And its not new. This is one of the dangers: those working in and around the system have normalised unacceptable standards of care, treatment and behaviour. I think sitting in your own urine and having your cries for help ignored is pretty abusive. This happens on well staffed wards as well as those where resources are tight. Resource allocation is an issue but so too is a fundamental lack of concern for responding to people’s basic humanity and needs. Institutions can be dehumanising places for all involved – as the Winterbourne View scandal showed. Unpleasant job? Highly skilled, challenging, essential and life changing. Under paid? Some are, some aren’t. As for trying to escape – I wonder why that was?? Sounds like a pretty reasonable course of action to me!
    This isn’t just about nurses; its about highly paid consultants and matrons and managers as well. Hosptials are an ecosystem of professional hierarchies; this is partly the problem! And Matthew is right – amongst all of that, older people’s (and other patients) voices go completely unheard.
    I agree – lack of voice is a key factor in all of this. Volunteer programmes have been running in /to/by/around the NHS for decades. Maybe this one or something like could be the one to create the fundamental change that is required but it does need careful design and implementation and is not the only answer. I would also be wary of saying that its only about younger people. Older people who are not well or who have high support needs can also have (and should have) a voice, we need to build and increase that (it is possible). Well and fit elders I agree have a key role here. And staff too (e.g. from other fields and “settings”) whose voices are also often unheard or squashed.
    I think this illustrates why many of us (myself included) have commented that this is a form of insitutionalised ageism. These problems are deep rooted, deep seated, complex, societal as well as professional and its cultural, structural and systemic. It needs a multi faceted programme of rehabilitation and recovery – for failing hospitals and healh care systems, those that commission them, those that deliver them, those that work in them and those who are served by them.
    We’re in the process of discussing our ideas about what this recovery programme should or might look like with others. If you’re interested in being part of this let me know.

  • http://www.mypoliticsdegree.co.uk Tom Brookes

    Stephen – That article doesn’t actually say why institutional ageism is systemic, it just makes that a statement of fact without any supporting evidence – which doesn’t make it a fact at all, just an assertation.
    Looking back again to the BBC article Matthew linked to 55 hospitals out of 100 randomly checked having slight issues like those referred to in my previous post – bit slow to respond, staff chatting, mild indignity etc are 55 instances from a limited range of hospitals. The guardian says 1/5 hospitals are not providing the required level of care in ‘eating and dignity’. Well, no, they aren’t. One in five of the hospitals inspected weren’t – not 1/5 hospitals nationwide. The distinction is important – there are over 1,000 hospitals in the UK.
    I wonder, how do we get from spurious statistical evidence to this idea of systemic ageism requiring massive overhaul? Perhaps we should trust that doctors and nurses, people who spend years learning to care for & cure people, & evidently don’t do it for fun, know what they’re doing. Sometimes it is necessary for hospital staff to condescend to patients if they’re being particularly intransigent. Once again I make the point that a hospital’s primary concern is making a person well enough to leave – not providing hotel service & overworked NHS staff have to prioritise patients. You can wait half an hour to be fed, you can’t wait half an hour for, say, intibation or resuscitation, pain medication or emergency surgery.
    I would postulate that it is far more systemically ageist to assume that just because someone is elderly they are automatically frail and helpless. I would also point to an issue a sociologist friend raised with me while discussing this – its a psychological phenomenon called ‘learned helplessness’, Wikipedia provides a good overview: http://en.wikipedia.org/wiki/Learned_helplessness

  • http://www.mypoliticsdegree.co.uk Tom Brookes

    Helen,

    It’s interesting how we can have wildly different interpretations of the same facts. I would draw your attention to the point in my second post about the limited nature of the CQC report – 20 cases of delayed food / attention considered sub-par care out of 100 hospitals surveyed. Hardly conclusive given the 1,000 + hospitals in the UK.

    I haven’t seen anything in the CQC reports about patients sat in their own urine either. Have you a link to that? It probably happens occasionally, but hospitals routinely catheterise patients with really significant mobility problems, so I doubt this is widespread – indeed it sounds like sensationalism.

    I agree with your point about institutional hierarchies – too much management and not enough frontline care. Though I disagree that working for a healthcare institution is dehumanising. Doctors and nurses sometimes have to be objective and distant to provide unprejudiced care, and so they don’t go mad. Regardless of the money, can you imagine dealing with the sick and dying every day? That takes dedication, and I think we’re far too quick to judge. If NHS care standards are so awful then why does patient satisfaction keep going up and up and up? A quick google shows that, as of 2007, 90% of patients rated their care as very good or good, & of those 42% said it was excellent, an increase on 2006.

    But I simply don’t see, or accept, the jump to institutional ageism. Also on the other example – rattling for help & being ignored for a half hour – yes that sounds bad, but a patient who’s capable of half an hour’s rattling simply isn’t in as much need as others, irrespective of age. These, unfortunately, are the realities of understaffed healthcare – staff have to prioritise the sickest. Even if school volunteer visitors were to text in perceived problems without the manpower what difference would it make? If anything hospitals would have to put more money and people into administering this system, rather than into frontline care. Granted the company would be pleasant for elderly patients, but I reiterate – they’re there to get better, not have a nice time – hospital is not a hotel, it’s an intrinsically horrible place to be because something horrible has happened to you! How would you have patients maintain their dignity and get helped to the toilet, get a prostate exam or wear an embarrassing surgical gown? I think we have to accept that being sick and cared for is a process which inherently involves a little indignity, but if we’re grown up about it really it isn’t that bad – it’s often necessary, & yes these things are routine for healthcare professionals but that doesn’t dehumanise them – it’s their job.

    As for the gent trying to escape – that isn’t as bad as it sounds, he didn’t like being hooked up to IV saline, blood, painkillers and a catheter – didn’t think it was natural. Oh and this was at 2am, the nurses were patient as saints, even when he fell over and pulled out all his tubes they fixed him up, got him back into bed & practically begged him to stay there for his own health!

    @TomBrookes_86

  • http://www.ndti.org.uk Helen Bowers

    Tom – I agree its interesting how differently we can all react and respond – its why the debate is crucial! I agree with your views on the wildly mis reported statistics (ie 1 in 5 hospitals when in fact it was 20 hospitals out of a sample of 100). However each of these hospitals isn’t an isolated “case”; these 20 hospitals failed on everything. My points however relate not only to the findings of this one report but the wider, more disturbing trend that this latest report (in a long long line) reflects. The strength of feeling, numerous responses, personal accounts and references back to previous similar reports is really what I’m referring to. This collection of poor practice (with many many reasoned and deliberate explanations of the contributing factors eg resources etc) is a cause for concern. the short national report may not use an example of sitting in urine but individual insepction reports do, and so too do the responses of people contributing their own experiences. I have worked in and around these very services for over 2 decades so yes I can imagine what its like to work with pain, illness, death and dying on a daily basis. I’ve done it, and have witnessed first hand (and continue to work with) staff who are disempowered, demoralised and disengaged. Equally, with good leadership, shared values and a focus on what’s really important to as well as for each individual patient, it is possible to find great care and passionate staff (all staff, this isn’t just about nurses). Its admirable that you are clearly taking a stand for hard pressed staff. But my points are also about how we (all of us) can help to turn around a sytem designed around the needs and priorities of the organisation and professions to one which is designed on the core principles of personalised, high quality, equitable treatment and care. They look different, they feel different, they behave differently, and they are more cost effective. No-one thinks they are in hospital for a good time! Read around the subject beyond this short report and you’ll find a catalogue of repeated, similar concerns that indicate many NHS services including hospitals are indeed failing older people.

  • http://www.mypoliticsdegree.co.uk Tom Brookes

    Helen,

    It’s the language around these sorts of things which aggrevates me as much as the dodgy statistics – I’ve seen many stories about care homes from hell, believe you me I don’t think there’s no such thing as ageism & abuse of the elderly, & you’re evidently far more experienced in this field than I am so I defer to your 2 decades worth of case studies.
    What seems to me to be the danger here is tarring the whole NHS with the same brush – take a look at this awful article which accuses the NHS of ‘torture’ – & this kind of sensationalism informs public opinion, sadly: http://www.dailymail.co.uk/debate/article-2048944/So-Shirl-Pearl-smugly-certain-caring-NHS-does-need-reform.html
    You’re right, I will take a stand for the staff, the vast majority are simply wonderful people. I did medical training for a couple of years but switched to politics because after visiting a hospital as a potential clinician I realised I’d take the emotional baggage home with me – & you can’t do that without going mad or being in constant therapy – hence my point about the need for objectivity & some detachment, whilst still caring.
    It seems you & I want the same things for the NHS, but disagree about the problems. I’d be interested to hear what you think of the governments package of reforms. Reading between the lines of the white paper & it’s soaring rhetoric about choice & competition it really strikes me as being an opportunity for ‘backdoor privatisation’ & a shift towards the American system of commercialised healthcare, under which I doubt the elderly, or anyone, would see the care standard we have now, let alone an improvement. Drug companies already shamelessly profiteer quite enough off of the NHS & by extension the taxpayer. Also I don’t understand how you can introduce competition into healthcare – there aren’t different ways to be cured, just like there aren’t different types of electricity. Do people really want choice, or just for their local hospital to be as consistently excellent as every other hospital? It seems with less managers & more frontline staff – & more of this sort of thing http://www.ted.com/talks/dave_debronkart_meet_e_patient_dave.html (you’ll like the video, it’s all about patient empowerment) the NHS will be perfectly capable of improving itself. Oh and I don’t see the logic in putting GPs in charge of the budget, they’re doctors, not accountants – surely that’s a job for Whitehall given the national coordination it requires.

  • http://uk.linkedin.com/pub/edward-harkins/15/40/635 Edward Harkins FRSA

    Tom, I so wanted to disagree with what your asserted in not accepting the ‘leap into’ a concept of institutional ageism. Another viewpoint has, however, been nagging away in my mind since this morning (Friday). It was expressed by a person whose name I cannot recall, but I think was an academic, being interviewed on the BBC Radio Today programme along with Joan Bakewell.

    He did not directly argue against the broader ‘philosophical’ notions that society had got less caring or more ageist. His contention was, however, that we had to instead look at the minutiae and the everyday operational detail and ask why it is in that single hospital providing some of the best of excellent care, there was also in specific wards dealing with the elderly, gross and unacceptable practice prevailing.

    I suspect that he was correct in asserting that this was where the causes and the solutions can be found – rather than somewhat grander and detached-from-the-everyday-reality assertions and postulations… and yet… the problem in those very best hospitals was to do specifically with the elderly.

    I’ll have to go away and find the evidence to suit my pre-concluded wish to disagree with you ;-)

  • http://www.mypoliticsdegree.co.uk Tom Brookes

    I’d love to read it Edward!

    The main source of my unwillingness to accept this leap comes from my optimism about humanity – I honestly believe that in their bones people are good, so the whole idea of ageist discrimination in hospitals; places of care, particularly coming off the back of this limited CQC report, really rather rankled me.

    So find your evidence, but try & leave me my optimism won’t you? ;)

    & I’m going out now. I’ve written enough today!

  • Ian Christie

    Thanks to Matthew for a thoughtful post and for the good idea about voice, and the proposal about volunteer friends. I think the issues highlighted in the CQC report also underline the need not to allow any further erosion of hospital chaplaincy, one of the essential services in the NHS that is not amenable to neoliberal targetry and box-ticking.
    The TODAY programme had a wise and calm discussion between Prof. Raymond Tallis, philosopher and geriatric medicine expert, and Dame Joan Bakewell, on the CQC report. Joan noted that it was likely that the social Darwinist neoliberal values of the past 30 years in the UK had influenced nursing and senior medical staff as they have other professions. Ageism probably is affected by gut feelings that old infirm people are a deadweight in the economy and in hard-pressed public services. Ray tended to agree but also made the important point that the report showed not only a minority of wards with some disgraceful abuses and neglect but also many instances of excellent care, sometimes in the same hospital. His solution was to promote empathy and improvement by having peer review within a hospital, so that high performing wards could (constructively and without aggression) challenge the worst performers to do better and also to explain their shortcomings and constraints.

  • http://uk.linkedin.com/pub/edward-harkins/15/40/635 Edward Harkins FRSA

    Ian, further to my earlier reference to that Today programme, I would, respectfully, take issue with you reference to how Professor Tallis ‘tended to agree’ with Joan Bakewell’s opining ‘that it was likely that the social Darwinist neoliberal values of the past 30 years in the UK had influenced nursing and senior medical staff as they have other professions.’

    I seem to recall Professor Tallis beginning his response by saying that he did not accept that notion. I have to say that I was rather dismayed at Joan Bakewell making such as tendentious remark – In my life I have witnessed, for example, religious persons telling people suffering acute pain and illness that the suffering was ‘a gift from God’. Indeed I felt that much of her contribution teetered on populist and faddish notions often expressed along the lines of, ‘I’ll tell you what’s wrong with society today’.

    I much more empathised with Professor Tallin’s urgings that we take a long, dispassionate and evidence-based perspective – crucially, in partnership with the front line nursing staff – to work out why the unacceptable happened in institutions that were otherwise centres of excellence. (You, of course, Ian reiterated his other point about enabling individuals to challenge the unacceptable).

    To that extent I also sympathise with Tom’s resistance to ‘jumping’ to scatter-gun and little-evidenced notions of prevalent ageism in our caring institutions – whether or not those notions are conflated with notions of religiosity.

  • http://www.armslengthstate.blogspot.com Joe Hallgarten

    Cracking idea.. perhaps the easiest first step would be to encourage people already visiting friends and family to spend a bit of time with a lonely patient. I’ve spent hours and days in hospital wards, much of it while my daughter is asleep or seeing physios. I fret, dehydrate and pretend to work. If I got the chance to be distracted from my worries by visiting another patient, I’d jump at it. Just like Speakers for Schools, it would be good for both of us.

    And your final comment on a great school doing great things but going unnoticed by Government resonated with my latest blog entry. http://tinyurl.com/5ud8peo