The hardest job I ever had was as a nursing assistant in a psychiatric hospital. On a typical shift, five or six of us would look after 60 patients or more. This was the usual staff:patient ratio throughout the establishment, except in the section for the “criminally insane”. In such conditions, the care philosophy was brutally simple. As a colleague explained on my first day, “If they move, we give them drugs. If they don’t move, we give them electric shocks”.
The hospital had been built as a lunatic asylum in the 19th century, on a moor that was miles from the nearest village. It looked exactly as you’d expect: a grim fortress with bars on the windows and locks on the doors. Our job wasn’t really to look after our patients, we looked at them to make sure there was the same number at the end of the day as at the start.
Except in the geriatric ward where I worked for a few months. Many of the patients were bedridden, and the nurses took great pride in the fact that not one of them ever got a bed sore. We even healed some horrific wounds that had become gangrenous. Some of the people I met there made me realise that in calling their institutions “asylums”, the Victorians were stressing something positive. An asylum is a place of refuge, maybe a last resort, and some of our men (the regular staff always called them “our men”, never our patients, inmates, cases, clients…) had nowhere else to go.
One man had lived on the road for nearly 30 years, making sure he got sent to prison for the winter until finally a magistrate told him he was too feeble to look after himself. The only place that would take him was the psychiatric hospital. Another man was paralysed by Parkinson’s disease and his wife couldn’t cope. A third had spent his whole life locked up after being abandoned as a baby because he had Down syndrome.
The majority of the men had a combination of psychiatric and other conditions – Alzheimer’s, alcoholism, schizophrenia, various degrees of paralysis, and so on. What they had in common was the need for the long-term care the hospital provided. It’s a need that’s going to grow, with the number of people aged over 80 in OECD countries doubling between now and 2050. The share of the over-80s will rise from 3.9% of the population now to 9.1% in 2050, and from 4.7% to 11.3% in the EU-27.
The OECD and the European Commission have just produced a report on monitoring and improving quality in long-term care. If you’re worried about growing old, A Good Life in Old Age? will do nothing to reassure you. “…at least one in two people admitted to hospital from a care home setting are at risk of malnutrition… at least 30% of older people in acute hospitals and 40% of older people in care homes meet the clinical criteria for a diagnosis of depression… There is no sign of a consistent decline in the incidence of physical restraint use… two-thirds of LTC [long-term care] users in institutions were exposed to one or more medication errors… one old person dies due to a fall every five hours… Pressure ulcers are known to affect a large number of LTC recipients in nursing homes…”.
So, what can be done, other than head north to cast yourself adrift on an ice floe before global warming melts them all? A Good Life in Old Age? suggests a combination of regulation; standardization and monitoring; and incentives for providers and choice for consumers. However, most countries do not collect information on quality systematically, and if they do, their efforts are limited to information on aspects such as staffing and the care environment, what the report calls “inputs” rather than the outcomes for the person’s health and well-being.
The OECD and EU are right about the importance of attitudes and behaviours in the quality of care, even if they use the hideous expression “leveraging consumer choice and centeredness” to say so. Apart from depression, I never came across any of the issues listed above, because the people I worked with were “consumer centred” even if the consumers in question had no choice.
That experience convinced me that it’s possible to provide quality care even in a highly unfavourable setting. The OECD-EU report suggests that there are plenty of solutions to help do so now and in the future.