You hear this term all the time nowadays, at least, if you work in an NHS hospital, are an inpatient or carer or relative of someone who is occupying a hospital bed.
Most often…
Are they medically fit?
When will they be medically fit?
If they are medically fit, have you done the take-home medicines?
And so on, you get the idea.
It is all to do with the proximity of the patient – person – usually older, but not always, who is occupying a hospital bed and their exit from the ward/unit/department – this in turn will allow for another patient/person to swap places and allow flow.
Flow is another word that has become bastardised by the NHS.
Flow in its original form as described by Mihaly Csikszentmihalyi is a state of mindful occupation where an individual exists almost outside of time and space in a bubble of creativity or doing.
Flow nowadays is how many patients are moving round the micro (hospital) or macro system (entire health and social care network).
Critical to flow is medically fit.
Too many people who are not medically fit, and you have a problem. People keep arriving at the front door and not enough are exiting stage left. Things become crowded.
It is funny. Just a few years ago we used to talk about hospital bed occupancy; there was considered to be an optimum level – somewhere in the mid 80 per-cents, which allowed for flexibility, accurate and appropriate allocation of patients to specialist areas, now, the system only exists at something like 100%.
Like the rush-hour Tube – bursting at the seams, the last person squeezed-in as the doors shut.
An overflowing train may help move people, it might even earn Virgin Trains lots of money, it isn’t however much fun or pleasant for the folk who are knackered, leaning against the toilet door on the six-o-five from Paddington.
We know the reason for the obsession with medical fitness (which I don’t think I have explained, but, you can read more here and here.) – it isn’t that there are not enough hospital beds (although some people would disagree), it is not that the system isn’t slick, effective and efficient (after all, isn’t that the essence of the NHS?), it is that we have lots and lots and lots of older people who have nowhere else to go when they fall or become sick.
And, you ain’t seen nothing yet, as Bachman Turner Overdrive might have said in the 70’s.
The baby-boom generation are still babies. Still young, fit, healthy, vital. Leading independent, productive lives, net contributors to society and the economy.
Take a seventy-year-old, make them 90 add three or more long-term conditions… diabetes, arthritis, dementia, cancer and, you have someone who is potentially frail, existing in a precarious state where the health and social care system has a greater impact.
This is the world of today and will be the UK in 10 or twenty years.
The system is not coping now, how will it manage tomorrow?
Again, there are likely enough hospital beds, it is what is before and after that is inadequate – an older man who falls, bangs their head and can’t get off the floor. This happens all the time, countless times every day across the country. The system often struggles. The standard –
Fall alarm > paramedic > hospital
Breaks-down as the fingers of medicalisation examine and dissect the man, checking his blood pressure and oxygen levels, scanning his brain and testing his urine, the encroachment of a disorganised health and social care system reverts to what is best for the system and risks a flip to ‘not medically fit’ with pyjamas, lost dentures and more investigations.
And, that man who fell, becomes trapped in the flow, moving around a system which is under extreme pressure, and, as with all pressurised systems, the risk is that he will become first systematised, then crushed. Boxed-into a diagnostic formulary and processed.
And the systems that perhaps overzealously brought that man to hospital, despite their usual, although variable efficiency, will break-down when we try to find somewhere for him to go, now that he has acquired a urinary catheter, delirium, hospital acquired infection and increased dependency.
Is he medically fit?
Home? Intermediate Care (Neverland)? Care Home? Rehabilitation?
You see the problem?
He probably can go home, but, the issues that were present before he arrived at hospital, that potentially led to him falling at the outset are still evident – loneliness, social isolation, lack of community.
He sits in his chair, smiling carers, not necessarily focused (or, obsessed as they should be), with his wellbeing popping in an out.
We didn’t evolve to be 90 and sitting alone for 22 hours a day.
We didn’t probably evolve to live to 90, but, that is where we are, we are unlikely to develop a healthy adaptation to a solitary existence which would kill us when we are 40 or 50 years old.
Strip society of community, every person for themselves, Right-Wing dogma and you are left with this fragmentation.
Are they medically fit? They were never medically unfit – they were just socially isolated.
I sometimes think back to my mum’s last months of life, where she was supported in an amazing care home in Glasgow.
My mum, the inveterate talker, the person who thrived on social company and interaction, who found new friends for the first time in years after a slow deterioration from the isolation of living alone.
Were my mum to be within the system nowadays, for all the improvements, all the realisation that person-centre care is the only meaningful care, she would likely have been swept-up in the drives of efficiency to maintain independence (no matter how little was possible or desired), she would have moved or been moved around health and social care, flowing, probably unhappily, becoming more disorientated with each transition, until eventually all options were exhausted and she would be left with care. That is, long-term care, the Holy Land.
You see the disconnection?
Medically fit, pressurised bed occupancy, older people trapped in systems that don’t work and there you are, lonely.
We are social creatures.
Aristotle, quoted by Nietzsche said that to live alone one must be either a beast or a god… well, you probably better add the growing numbers of older people to that list, for that is the picture.
I hope this hasn’t been too gloom and doom, particularly for those of you reading this on Saturday morning, where here in Doncaster the sun is shining.
We are doing great things locally to redress this imbalance, you can go here to check out more!
Dr Rod’s Odd Blog (almondemotion) 