Some of you will know that I am a regular dog walker, mostly twice a day, if time and the weather is good, more often.
I am also a little nosey.
Not a peeping-tom or a voyeur. I keep my eyes open.
As with everything in life, I am attracted to the familiar.
The familiar I see is carers coming and going.
Some individually, others in pairs. There is an occasional nurse.
I notice the key-safes. The ramps and hand-rails.
I see through the living room windows the (almost always) old woman, sitting alone in arm-chair, Zimmer frame and the diminished indoor light.
I see the loneliness.
Or, at least, I imagine it.
The carers will come once and up to four times a day, they will come in pairs if there are special concerns, for example, if the person, who is almost always old, needs assistance moving in and out of bed or their chair.
By the time there are two carers, the person is often incontinent.
It is hard to train your bladder or even bowels to operate to the variable regimen of an organisational rota. The calls might be 6, 12, 4 and 8. With every visit there will be latitude. Daisy at no 10 might take a little longer, Francis might be in hospital (no visits that day), carer Rebecca might be sick, and so on.
It is very possible that these old folk are not at all lonely.
They possibly enjoy the solitude.
Solitude is however, at least in my experience, something of a choice. I choose to be alone, I choose to avoid the party or the gathering, and so, I dedicate time to myself. Every day, for regular or intermittent periods, is not a choice, it is an imposition, secondary to the falling apart of society. The move of children and grandchildren to population centres for work or lifestyle, the death of partner or spouse.
This kind of solitude is forced upon us.
And we know the death of a husband or wife has an immediate and medium-term effect on the surviving partners’ wellbeing and life expectancy.
I am unsure whether the moving away of son or daughter has been measured. It is bound to have a similar effect.
And the death of friends, no matter the size of your social circle, if you are buddies for long-enough, there will eventually be only one person left. You might think yourself lucky to be the survivor, the one left behind. Kind of lonely though.
What are the alternatives?
Covid was a death-knell to the alternatives.
This was one of the indirect harms of the pandemic.
There is a trope that Death walks at a certain speed. So long as you walk more quickly you are safe. Covid has slowed-down many people. Some it has brought to a complete stop. Housebound and then bedbound situations make it easy for Death to get you.
There are groups and clubs. Online if you are savvy, switched-on and able, they call it Social Prescribing, when you try to address your loneliness by calling the GP too often. These teams direct you, signpost to places of support and engagement. Useful alternatives to anti-depressants, opiates and alcohol, although frequently ineffective.
And so, the old woman, grey living-room light, the reflection of daytime TV in her specs. I can’t hear and I only glimpse for as long as it takes my dogs to pull me towards their next stop.
In some countries they have built retirement villages, a means to creating a social environment where people can live semi-independently. We have a few areas in Rotherham constructed upon a similar premise, in my experience, the social butterflies engage and connect, many others sit, waiting.
And the final common denominator of living in care. Institutionalisation. Move to the care home. If you are ‘self-funding’ that is, you have money in the bank or property to sell, this is often a straightforward transition.
For those reliant upon social funding there are multiple obstacles to overcome, for the most, the lonely dependent person has to prove that they can no longer cope living alone before this is considered. Often a trip or two to A&E followed by an inpatient stay after falling is enough to tip the balance; certainly if you are confused.
Criteria are determined by checklists – if you tick enough boxes you will be allowed-in, that is for the NHS or the social care departments to pay for your living expenses, if not, you stay in hospital or another temporary facility until you have deteriorated to the extent that you tick more boxes.
Apologies for the cynicism. This is how it appears to me.
For some, moving into care is the worst thing imaginable. Worse than death, worse than a plague. Being allowed to sit for hours alone in their front room with TV and pads for the toilet is considered more desirable than ‘care’.
Some of this bias is I imagine based upon peoples’ own experiences of care in the 50’s and 60’s in the UK when their parents and grandparents were in a similar position. Yes, those environments – NHS long-term care facilities were truly awful. (Have you watched this video yet?).
The world is different and although there are some dodgy care homes, most are good if not great.
In the past year, something like 1000 care homes have closed in the UK, the costs of insurance, inability to recruit or retain staff, the Covid vaccine conditions of employment and the wages (more in Amazon without the emotional baggage, I hear) has led to a decline in the options available.
Yes, it’s Brexit and the Tories and all that.
And, what would I want?
I find it hard to imagine the time or the situation where I would want to move into care.
My current head sees my independence. My ability to move when and where I like (albeit within the constraints of the dogs), I have my family and work and things are fine. My bowels and bladder are fine.
Who knows.
Suddenly in the middle of life is a condition of unexpected catastrophe that changes everything. No one knows when this will be.
We work towards the mantra of ‘home first’ – this being the notion that when an older person falls (most often) or becomes unwell (they often fall, then become unwell because of an unnecessary and prolonged admission to hospital), the ideal outcome is for them to return home.
Home First.
What if home is a broken TV and carers who don’t appear to care or who are unable to engage or relate to you, who don’t speak your language or appreciate your sense of humour (or irony)?
What if home is a prison and even hospital is considered a step-up?
Home, home first, that is the chant you will hear in NHS circles.
Home is best.
People are less likely to fall or become ill at home, they are in a familiar environment which is particularly important for those who have dementia or cognitive impairment.
What if the reason the person has fallen or has become unwell is because they are at home, alone, lonely day in and day out?
The cost.
Home costs less than 24 hour care, residential or nursing.
And what is the cost of that older person failing?
What is the cost to them?
A current NHS obsession is to create ‘virtual wards.’ These are systems that allow people to be unwell, yet supervised by clinicians when they are in their own homes.
Gadgets attached to arms and legs send continuous transmissions of heart beat, respiratory rate and oxygen levels. Some will monitor temperature and steps taken in a day, others will alert you if the person has fallen.
Teams of staff will soon fan-out across the country to provide this extended care, the intention of which is to allow people to be poorly in their own homes rather than in hospital, something I 100% endorse.
Will it help loneliness?
‘Loneliness is not a medical condition.’
‘It’s not a social problem.’
The managers might say.
‘It is existential.’
Opines the philosopher.
What to do?
If you are lucky someone might buy you a talking doll or purring cat or wriggling puppy to keep you company. A.I. that is meant to bridge the gap between having someone to hold your hand and being alone.
These technologies only seem to work if you have dementia or are adept at fooling the people who have bought them for you that they work.
One patient recently attempted to resuscitate her (toy) baby when the batteries ran-out.
Surely we can do better?
I saw the horror of mechanised flame-throwers en route to Ukraine yesterday.
We have the technology, the sophistication to create these devices but can’t fix loneliness.
What a world.
What a time.
I sometimes joke that we need robots.
I am not sure whether I would get on with a robot in my loneliness. I suppose that would depend upon the algorithms.
Man or woman, Irish or Australian?
Years ago I wrote about the Israeli trend to employ women from the Philippines to look after their pensioners – the idea being that it would cost less to employ such a woman (I didn’t see any men what I was last there) than putting the old person into care.
I don’t know if that system is still operational.
Let’s face it, we have a problem that has no easy solution.
And yet, soldiers march along darkened streets, night and thermal imaging in action.
One of the reasons I moved from working in the hospital to supporting those in the community was the sense of futility I experienced on ward rounds. The daily nods to people who were receiving treatment for conditions that were potentially avoidable, the pressures to discharge to make way for more and more, the conveyor belt of sickness and disease. Chipping away at a mountain that is always growing in size.
When you reflect on the whole system, it is apparent that the hospital is positioned on a tiny hillock, the greater body of human need and suffering is on a massif ten times that size and also growing, moving ever upwards, with increasing frailty and dependence.
I hate to end these blogs on a down note and, I appreciate I have been writing for too many pages – most will likely have lost interest by now.
And so, tenacious reader, if I have managed to maintain your interest, I thank you and move towards some solutions.
Sure, let’s stick with home first, after all, unless it is an option it won’t be considered, yet, let home first be the option only if the person wants to go home. If home is a prison, let’s rethink.
And let us work on preventative care, let us focus on those who are most at risk.
It is ironic, in that every patient in the UK who is 65 or more has a frailty score assigned to them (if you don’t believe me, ask your GP) and, from this it is straightforward to establish who is most at risk of hospital admission, deterioration and decline, you can probably establish who is loneliest too.
Proactively working with the frailest of the frail is a start.
Those living in care homes are frequently at the top of this list of dependencies. Ensuring their wellbeing is fundamental. Helping them to avoid falls and unnecessary hospitalisation can keep them well.
Virtual wards are a fantastic idea and I look forward to supporting our first patients, I can’t wait to peak-in on their physiological parameters and intervene before anything bad happens:
‘Mrs Jones, I can see your heart rate has become a little rapid and your temperature has increased, how are you feeling?…. I’ll be round to see you in 20 minutes.’
Fixing the loneliness epidemic is more difficult than rolling-out Covid vaccines, yet as important.
This is in part a re-fashioning of our society (easy, eh?!) with intergenerational work, supporting older people to realise the value they can bring to others, establishing the social capital of 90 years of life, translating that into engagement, especially the young.
Getting-in early to medical, nursing and schools of therapy and social work.
Explaining that much of the current direction of scientific research, pushing-back the boundaries of smaller and smaller units of knowledge and understanding, whilst essential for growth of technology is not necessarily of benefit to people as individuals.
Establishing an holistic assessment of health and disease, enforcing the complexity of the human condition and staying away from simplistic diagnoses ‘urine infection’ or pathways of care ‘home first’.
Let’s invest some of our sophistication into human interaction rather than iPhones, TVs and missile launchers, I am sure we can do it.
Let’s listen to what our patients tell us they want. Let’s give them the time and the space to communicate, let’s overcome the fear often encountered by people sitting on hospital trolleys, anonymous in tattered gowns. Let’s enable the disabilities, facilitate hearing and seeing to work-out what matters to our patients (and yes, what matters to those staff providing the care and support) – this is person-centred care and teams in tooth and claw.
Stripping away the routines, the should and must do, drilling-down to what it is to be human, to capitalise on the essence of who we are.
At peace, be at peace.
Thank you for reading.
Dr Rod’s Odd Blog (almondemotion) 