Bariatric Care Costs Ballooning

One of the areas of Independent Living that receives plenty of visitors and generates lots of enquiries is the bariatric section. For anyone who isn't au fait with the professional jargon, bariatric is the term used to describe products and services designed for the heaviest of people; those who might be described as morbidly obese.

Any caring procedure that is needed comes with a lot of extra challenges when the person being cared for tips the scales at somewhere over 20 stone, and providing the NHS, social services and other organisations with equipment to meet these needs is definitely a burgeoning industry. As I see safe working loads on hoists, beds, wheelchairs and other essential items heading upwards – 30 stone, 40 stone, even 50, the initial impact of the figures inevitably wears off. From being shocked, initially, asking myself "How can anyone possibly weigh that much?", I fairly quickly graduated onto thinking something along the lines of "Only 25 stone? Should I even be including that in the bariatric section?".

So it was quite instructive to have an insight into the miserable and expensive life of the Londoner who, at 58 stone, is currently Heaviest Man in the World. He is British, as was another recent holder of that title. His existence is miserable because his weight makes him entirely dependent and confines him to his bed. It is expensive because every procedure that has to be carried out to keep him alive and as comfortable as possible (which cannot possibly be very) requires teams of people. Four carers at a time to wash him and monitor his health; an extraordinary eight paramedics required for any trip in an ambulance – specially reinforced, of course. Apart from all that professional input, he relies on his sisters to care for him, and admits to spending all day eating.

Leaving aside the interesting question of why anyone who was caring for someone else with a serious and chronic health problem would provide them with the wherewithal to make themselves ever more ill, it does cause one to think about the allocation of resources, and how to prioritise them. I am very wary of joining the ranks of the "virtue police", advocating denial of treatment to smokers, drinkers, eaters of too many cream cakes or chips, but when you hear that 800,000 of the 2 million people who need care aren't getting any, because of cuts (Age UK research), you really do wonder about the justice of providing so much for someone who is very much the author of his own misfortune.

You might also think about the fact that anything up to 40% of older people are malnourished when admitted to hospital or residential care, and more become so during their stay, and ask yourself whether resources couldn't be better spent on helping those who aren't able to feed themselves properly. Incidentally, for all the expense to the NHS of looking after bariatric patients, it costs the organisation nearly four times as much dealing with the consequences of malnutrition. Some properly joined up social care could be saving us all a lot of money.



 

Health Lottery: What Price a Ticket?

Am I the only one who feels a bit queasy every time I see a poster in a shop window promoting the Health Lottery? Not, until recently, because of any opinions about the rival claims of this organisation and the National Lottery (in fact, I have only just realised that there are different operations going on here).

It just seems to highlight everything that is wrong, and probably going to get worse, about our national health service. If you Google for NHS lottery, you will get a mixed bag of results, some relating to the aforementioned game of chance, others to the variable health service available, depending on where you live.

To save us all the trouble of finding out for ourselves, the government has produced an NHS Atlas of Variation. If you assumed that someone with dementia would have access to the same treatment in Kent as Lancashire, you would be wrong. NHS funding for a care home place for someone who requires continuing care? Much less likely in the West Country than Northumberland. If you need bariatric surgery, the East Midlands is a better bet than East Anglia. These are just a few highlights. The analysis was based on 71 key indicators, including hospital admission rates, treatments that Primary Care Trusts choose to fund, mental health provisions, cancer treatments, etc, and it shows wide differences that cannot be explained by variations in patient illness or patient preferences.

Add to this recent stories in the media highlighting poorer treatment received from the NHS by people with learning disabilities, with dementia, and those with physical disabilities, and "health lottery" really does seem to sum it up.

During the past week, organisations representing nurses and midwives joined doctors in confirming their opposition to the proposed changes to the NHS: people at the sharp end seem unanimous in fearing that however well-intentioned, expecting GPs to take on commissioning of health services will make outcomes even more variable. As funding available for the NHS continues to be squeezed, and the private sector is allowed to take over those areas where they see scope for turning a profit, again, it will be the patients who pay the real price. Expect the recent spat between private cosmetic surgery clinics and the government about responsibility for putting right dodgy breast implants to be repeated multiple times, as entrepreneurial set-ups find the cost of dealing with unforeseen consequences unacceptably high.

Health Lottery indeed. Incidentally, the other Health Lottery is either a clever collaboration between 51 community interest companies (CICs) intended to generate more funds from the public for health-related causes, or an attempt to persuade people away from the National Lottery - which apparently gives a higher percentage of the ticket price to the causes it supports - thus reducing the amount of money available to good causes in general. There is some debate about the ethics of the situation, amongst MPs, third sector organisations, and other interested parties, including the Gambling Commission.

The bottom line, though, is that we all have a choice about which, if either, of the lotteries we choose to support. When it comes to the NHS, there is only one, and when we need its services, we really have very little choice in the matter.

NHS Reform - Maintaining Trust for Doctors

NHS reform – the listening is over, and the amendments to the draft Health and Social Care Bill have been made. 180 of them, apparently, though as the Bill is 360 pages long, and the amendments are distributed throughout its length, the task of finding and assessing them is not inconsiderable.

To be honest, I'm so confused already, I don't really feel up to the challenge!

I know that GPs will have more responsibility for commissioning services for their patients, and also for maintaining controls on budgets, and this is certainly something that concerns Dr Hamish Meldrum, the chairman of the British Medical Association, who is warning that if GPs are rewarded for saving money on commissioning services, as is proposed, it is extremely likely that patients will see a conflict here, and suspect that if a GP won't provide some treatment that they believe they need, it is really on financial rather than clinical grounds.

He made his comments on the eve of the BMA's annual conference, and at a time when 88% of people apparently believe that doctors tell the truth, according to a recent Ipsos Mori poll about trust for various professions. This compares with 68% who believe the same of clergy, 29% for bankers and 14% for politicians. Doctors are clearly the most respected profession, and it would be a tragedy if that high public regard becomes another victim of the reforms.

I wonder, though, whether we are already seeing early signs of GPs as gatekeepers, rationing access to medical resources. For example, a friend who is in her 70s and has chronic knee pain, which has limited her mobility to such an extent that she seldom leaves the house, was recently told by her GP that she personally wouldn't risk knee replacement surgery because it often went wrong. The most casual research on Google will provide you with plentiful evidence that this type of surgery enjoys a success rate of between 85 and 95%, with post-operative infection rates of less than 1%. Here is at least one person who could potentially benefit who has been discouraged from considering the possibility of surgery.

I know the NHS needs to save money, but they waste it in so many foolish ways which could be changed without anyone being the loser. Deterring people from requesting treatment that could enhance their life seems a shabby device, and I hope this GP is sample of one, not representative of a new wave of money-saving zealotry.

Independent Living is collecting stories of NHS waste; we will make sure that they are passed on so that they can do some good - so do please contribute your experiences here!

Can We Teach the NHS to Care for Older Patients?

This week, I was inspired by an interesting blog written by Roy Lilley, high-profile and outspoken commentator on all things NHS.

He wrote a neat piece, suggesting that the changes that might be needed in the NHS could be identified by the simple expedient of asking patients five questions. Their answers would then provide a guide to what matters in a health service, irrespective of the system under which it is run.

His five pillars concerned timeliness of care; trust in the caregivers; whether individual needs were addressed; cleanliness of the environment; and finally – and the place where my enthusiasm for his theme wavered – enjoyment of the NHS experience.

I suspect that a spirit of mischief was at least partly responsible for this last one. Enjoyment is not, after all, the emotion that is likely to be at the top of most people's expectations when they are sufficiently unwell to be hospitalised.

Nevertheless, I would have gone along quite happily with the tongue-in-cheek hypothesis, were it not for the fact that I read it on the same day that the CQC (Care Quality Commission) released their first batch of findings on care for elderly patients in wards up and down the country.

Enjoyment is so far from the widespread experience of older people in NHS establishments that my gorge rises at even including them in the same sentence. People who are continent being forced into nappies; doctors prescribing water because it is apparently the only way to make sure that nurses don't leave their charges to die of dehydration; lack of adequate food.

Anyone who kept a dog in conditions like this would be prosecuted, banned from keeping animals in the future, and probably sent to prison. Apparently when it comes to our mothers and fathers, our grandparents, mentors and teachers, all we can do is wring our hands as yet another report finds precisely the same results as the last one. For some reason, old-age seems to lead ineluctably to a loss of individual human identity once care or medical treatment are required.

I am sure there are some wonderful examples of compassionate care in hospitals around the country, and equally, it is true that we tend to hear about the cases of neglect and disrespect, if for no other reason than that good news is not really newsworthy. But that mustn't blind us to the fact that unannounced visits found a quarter of the hospitals reported on were flouting legal standards on basic care for their elderly patients.

Every day, two people die of dehydration in a hospital in England and Wales. Starvation kills 300 a year and bedsores – almost entirely avoidable if good nursing care is practised – twice as many. I now have friends who are so terrified that they will be obliged to go into hospital that they won't consult their GP about health problems serious enough to impair their quality-of-life quite severely.

It is a shocking thing that in a "civilised country" to be old and dependent on others means that you have a one in four chance of being denied the basic necessities of life at a time when you are most vulnerable.
 

Dogs Lead the Way!

An item on the Today programme this morning highlighted something that those of us with dogs have probably always known: not only are they our best friends, but they are also rather more effective than humans at using their brains in certain situations.

For example, dogs are much better at really quick decisions. They don't over-analyse once they have made their choice – they know what they know, and have confidence in their decision-making. Another area where they score more highly is in empathetic skills. We are familiar with assistance dogs working to enable people with sensory impairments and physical disabilities to manage their lives independently, sensing their needs as well as responding to commands. Families with a pet dog can attest to the fact that they will often break up an argument, by somehow getting between the opponents and changing the atmosphere by their presence and demands for some friendly attention.

The giant brains currently engaged in reforming the NHS could certainly do with a good dollop of dog sense. It is hard to understand how we have reached a situation where people working within one of the only parts of the economy where funding has not been cut, and where investment over the past decade has been really generous, should be talking about industrial action and claiming that patient services are under threat.

At the same time that the Royal College of Nursing (RCN) is saying that frontline posts are being cut, the Department of Health is pointing out that 2600 extra nurses have been employed in the past 15 months, and that there should be no need for patient care to be affected.

Both cannot be right. The problem may be that emotions and political prejudices are clouding decision-making processes. Some within the NHS might prefer to be able to associate reform with adverse effects on patients, rather than taking the opportunity to identify and eliminate waste and mismanagement.

The NHS is an institution that most of us have great affection for, but that doesn't mean that it can't be improved, and in the future, as medical technology advances and many of us live longer and make more demands on the service, its work will have to be done more efficiently.

The government has said that this is a time for them to pause and reflect on reform, to listen to what people have to say about it. They have shown themselves ready to change their minds in the face of strong opposition – on defence spending, for example. This time, perhaps they should stick to their guns on the need for change, and continue the fight to win support from the people who will be responsible for making a success or otherwise of the NHS project. The status quo is not an option, but driving through reform without engaging the hearts and minds of those whose working lives are at the centre of the change is unlikely to achieve the results we should all be hoping for.

Remploy – Employment Options Narrowing for Workers with Disabilities

Today's blog is all about employment – plenty of budget cuts will translate directly into redundancies, and inevitably, people with disabilities are likely to be affected by this, at least as much if not more than the general working population.

For example, it was announced in the last few days that Remploy, which has more than 50 factories employing 3000 mainly disabled people, will be encouraged to offer voluntary redundancy to staff, in a bid to save money. At first sight, it seems harsh to close off an employment option for a group of people who  often find it more difficult to get a job, and one of my correspondents also pointed out that local government is buying in from China many of the products that are being manufactured by Remploy, and perhaps it would make more sense to support local jobs and local suppliers.

However, if you look at the numbers, they make depressing reading. It is estimated that each Remploy factory job costs £25,000 in government subsidy. Half of the people employed are being paid to do nothing, because the management has failed to win enough contracts to keep them occupied. Despite receiving £555 million of support,  Britain's largest nationalised manufacturer cannot, apparently, operate profitably.

There are plenty of different arguments to be had here. For example, Remploy may not be very good at manufacturing or selling, but they do have an excellent record in supporting people into work with other employers. 24,000 people have found jobs with their help, and they have added 38,000 vacancies during the past financial year. There is a strong case for nurturing this activity, rather than putting more money into the factories.

Equally, many people feel strongly that mainstream businesses should be employing more people with disabilities; that a great deal of talent and enthusiasm which should be helping Britain out of our financial mess is being lost because, despite many years of equal opportunities legislation, it is still more difficult to find a job if you have a disability. The rider to this argument is that Remploy factories are not providing proper jobs but a sort of day care, which is not only expensive, but rather demeaning to their employees. There isn't much that can beat the satisfaction that comes from doing a job that is worth doing, while turning up for work but not having anything much to do is soul-destroying.

On the other side, at a time when the public sector is cutting jobs, and many are beginning to question the oft-repeated assertion that the private sector will pick up the slack, pulling the rug out from under a significant employer, even if imperfect, is not helpful, and indeed sends out the wrong message when the focus of benefit reform is very much on getting people back into work. If major purchasers (local authorities, housing associations, the NHS) of the products made in their factories, from building products to mobility aids, placed contracts with them, then they would be securing jobs, supporting British industry, reducing environmental impact by buying local, and giving a vote of confidence to an organisation that must be feeling beleaguered. The government is looking increasingly heartless, as deficit reduction is pursued apparently no matter what the cost in human terms: this could be an opportunity to change that perception.

No easy answers, I fear. Should we be maintaining jobs at Remploy at any price? Or is it better to allow this business to succeed or fail by its own efforts, without regard to social implications? Is a Remploy factory an employment ghetto or a valuable source of jobs for people who would otherwise struggle to find one? You can share your opinion by adding a comment here.

The Risks that Carers Run

A number of unrelated events have come together in the last couple of days to get me thinking about the risks that carers run when trying to move the person they care for.

Anybody who works in a job where they are lifting heavy weights receives manual handling training; the risks associated with the lifting are carefully assessed, and equipment is specified to minimise the possibility of injury to the lifter. Even so, musculoskeletal damage is common. Chatting to a friend who supplies stairclimbers (devices to carry a wheelchair user up and down stairs), I heard about the experience of a particular NHS Ambulance Trust who introduced powered stairclimbers and saw the rate of absenteeism due to musculoskeletal injury decline from 48% of the total to 6%, in an 18 month period. And this is amongst people who have had all the training designed to prevent them hurting themselves when lifting.

Another conversation with a long-term correspondent based in the US, who sells a cleverly designed lifting vest which makes manual transfers safer and more dignified for both parties, revolved around the costs of manufacturing in the States and labyrinthine systems of distribution in the UK, both of which tend to push the price of his product to a level where he feared it would be out of reach of potential customers. He said "For the life of me I could not understand why people would not pay to prevent back injuries to themselves and injuries to their loved ones."

To which the answer is probably they would, if they could afford it, or perhaps they would, if they understood both the risks and the alternatives. Which brings me back round to where I started. Organisations that employ people who are at risk of injuring themselves in the course of their work have a real financial incentive and legal requirement to measure and minimise the risks. But when it comes to family carers, who are estimated to save the NHS and social services some £87 billion a year on services that would otherwise have to be provided to the people they care for, who assesses and minimises their risks? Very occasionally, I hear about a manual handling training event aimed at non-professionals, but they are rare and not well-publicised.

Am I right to suspect that nobody wants to "find out" about carers running the risk of injuring themselves because they would then need to do something about it, and that would cost money? Even though keeping those carers fit and healthy is actually cheaper than replacing them when they are unable to carry on.

The final part of my injury/cost jigsaw was the story of former miners taking their former solicitors to court for not getting them full compensation for their inability to do various jobs around the house following damage to their hands caused by vibrating machinery. If a carer could point to some statutory body and demand recognition of damage to their health caused by caring, the risk assessors, equipment providers and manual handling trainers would be on the case in the next five minutes.

Can the NHS Save Money Without Hurting Patients?

I was intrigued a while ago to hear about the success achieved by Essex police in funding an extra 239 jobs largely through cost-saving measures. The force apparently took simple steps like cutting out biscuits with their morning cuppa and stopping the purchase of designer sunglasses, channelling the money instead into front-line posts which make a real difference to the service they can provide to people in the county.

Apart from thinking that's an awful lot of snacks and fancy eyewear, I was cheered by the idea of a large public body taking the sort of homely steps that families all over the country have been pushed to, in our efforts to reduce debts and manage our finances better. My other half being a great advocate of costing things over the year, I have never been in any doubt about just how much can be wasted on a daily cappuccino, Mars bar, packet of fags, (fill in your own favourite treat) - but if you haven't ever tried it, doing the sums can be salutary.

And now politicians are eyeing up the NHS, and asserting that serious cuts are going to have to be made. We all know that this is the case, but how is it going to be achieved? I would love to think that some of that expensive management time is being dedicated right now to identifying commonsense, waste-cutting measures that would save money without harming patients, but I fear that it's not happening.

I have heard recently a couple of anecdotes about life in the NHS which underscore my scepticism. First, a tale of sterile supplies - gloves in this particular case - supplied to the hospital in question in packs of six, from which the staff were accustomed to take the single pair needed at the time, and throw away the other five, since they were no longer sterile. It did not apparently occur to anybody to question this practice: it was a fact of life that sterile gloves arrived in multipacks, and therefore most had to be discarded. I wonder how many similar rituals are being enacted up and down the country?

And earlier this week, an outpatient attending hospital for an MRI scan took refuge in a changing room, in a clearly distressed condition, because he was obliged to put on one of those humiliating back-opening gowns, and there were no dressing gowns available to preserve his modesty because "we're saving money". This must be a fairly widespread experience; I know people who have been through it over many years and in various hospitals, with differing degrees of upset according to personality and mental state at the time.

So it's probably safe to say that whatever steps are taken to save money, challenging the status quo and respecting the dignity of patients won't be at the top of the list.

It is always tempting when faced with the challenge of cutting costs to go for politically sensitive targets, in the hope that public outrage will be so great that the government will back down from their demands. If you say "cutting X pounds from our budget will mean sacking nurses, or closing intensive care beds", you are far more likely to marshal opinion behind you than if you admit that you could achieve the savings by buying the office supplies from Viking and reducing the proliferation of highly paid managers.

What will probably happen in reality is that cuts will be made in those areas that are least glamorous and most in need of support, such as mental health and geriatric care. But wouldn't it be wonderful to be proved wrong, and see the NHS following the lead of Essex police; saving money in ways that hurt no-one, and actually improving the service they can give to patients?

What do you think? Share your ideas on how money could be saved, or your opinions about the way the NHS uses the funds it has - just click the "comment" link at the top of this piece, and you're away!

Heralding an end to ageism in the NHS

Anyone who has achieved "retirement age" and had cause to visit their GP may well be aware of the rampant ageism within the NHS. One doctor at our own surgery was proposing a range of tests to identify the cause of my husband's sudden bout of exhaustion and weakness when he realised that he was 65, not 60 as he had thought, and changed his recommendations. No tests, just a prescription for a tonic and a suggestion that it was perfectly normal to feel like that at his age.

Although his manner was probably less subtle than the average, the message has been equally clearly received and understood by many older patients: if you are feeling unwell or in pain, it is very likely due to your age, and you needn't expect the over-burdened NHS to do much about it, now that you are no longer a productive member of society. Many of this generation, the last to be brought up with less confidence about their rights, have absorbed the message so well that they don't even bother to consult their GP, but simply live with conditions that limit their activities and enjoyment of life - and which could perhaps be ameliorated, if not cured.

So it was wonderful to hear that as part of its new anti-discrimination legislation, the government will make it illegal to refuse medical treatment on grounds of age. The new law will not, of course, endow the NHS with limitless funds, and hard choices will still have to be made, but hopefully they will be made on a case by case basis, rather than by reference to an arbitrary number.

Since ageism in the workplace became illegal two years ago, the number of people working beyond the official retirement ages of 60 for women and 65 for men has increased quite dramatically, with the number of older women in employment growing faster than any other group - 850,000 now; the highest since records began.

It is scarcely logical to treat individuals in one context as valuable members of a shrinking workforce, and in another as unwarranted burdens on an overstretched health service.

And can a society call itself civilised if it values people purely on their productivity anyway? The confused and frail old woman rendered passive by unnecessary antipsychotic drugs, or left dehydrated and malnourished by carers who have no time to care, could have been you or me yesterday. And unless we all act to change attitudes to the most vulnerable in our society, it may well be you or me tomorrow.

"Shadows in Wonderland"

I have been an avid reader for as long as I can remember, and even my day job, which involves trawling through articles, reports and media releases, many of them rather poorly written, has not killed my enthusiasm.

On the other hand, I probably wouldn't pick up a book about serious illness and hospitals if it hadn't come my way for review - but having started reading it, I found that I couldn't stop.

"Shadows in Wonderland" is written by Colin Ludlow and published by Hammersmith Press. It is his account of how he was found to be suffering from bowel cancer, his treatment at London's Royal Free Hospital, and how it all went terribly wrong. At the same time, it is a thoughtful analysis of the state of the health service in this country, how far apart are our expectations and the reality.

Colin Ludlow was a television producer before his illness, and his acute visual sense brings the hospital environment alive, in all its grimness. He makes the point, which had not occurred to me before, that our expectations of hospital are largely shaped by TV dramas, which condition us to expect a lot more action - and definite answers - than real-life medical treatment generally delivers.

His own experience, which he relates honestly and without self pity, is that medical interventions bring consequences, which may well be much worse than the patient imagines when starting their treatment. If we understood completely ahead of time, perhaps we would be much more reluctant collaborators in the process. So his initial surgery to remove a tumour in the bowel - a routine, albeit fairly major intervention - is followed by severe internal haemorrhaging, a dose of MRSA, and months of drip feeding, which sets off an unsurprising series of problems with his digestive system.

In reading this book, I learned that there is a word for illnesses caused by medics - iatrogenic - and also why it is necessary. The hospital environment itself, dreary, confusing and inadequately provided with simple facilities, such as comfortable waiting areas and natural light, is shown to be an obstacle to recovery. It is telling that the first time the writer finds himself in a hospital building which is bright, welcoming and restful, he realises that he is in a hospice wing for the terminally ill: you have to be dying before the NHS treats you like a human being.

"Shadows in Wonderland" is a compelling read, whether you are a healthcare professional or a "consumer" of the increasingly business-oriented NHS services. It clearly illustrates the fact that patients are more then just a set of medical conditions, and hospitals should be more than just a collection of facilities. Until we recognise this at the deepest level, treating the whole person in an environment that makes a positive contribution to wellness, the NHS is not likely to deliver the sort of results that we should aspire to as an affluent society in the 21st century.

Carers and Caring

September is rushing by at even more than its customary speed - after the more languid months of summer, everything seems to move up a gear at this time of year. One of the customary markers on the calendar for those of us with an interest in independent living is conspicuous by its absence this time round. I'm talking of course about the annual exhibition which shares our name, and has been held regularly at various London venues until the last event staged in 2006.

Whether this absence represents a hole in your diary or a welcome reprieve from what seems to be an ever increasing roster of exhibitions will depend on many factors. Personally, I have definitely been suffering from exhibition overload in the last few years, and this seems to be a feeling shared by many businesses in our industry, who find themselves trying to stretch their marketing budget around an increasing number of shows, which may or may not deliver the audience they are seeking.

Visitors also are expressing their interest in less stressful forms of research, with a growing enthusiasm for online, virtual events, where they can catch up with the latest news in the comfort of their own home or office, and at a time that suits them.

For Age Concern, last week was "silver surfer week" - a time to highlight increasing internet use by older people. The driver for this rush into new technology is, apparently, the desire to stay in touch with grandchildren who probably don't live nearby as they did in earlier generations. Internet, email and mobile phones are therefore essential tools. Whatever the reasons, the over-65s now spend more time on the web than the 18 - 24s, making products and services of interest to this group a real growth area.

Carers have been very much in the news recently - and there are perhaps a few small signs that they are moving up the political agenda as well. Such a large group of people, who are estimated to save the country as much money as the entire NHS budget - £87 billion - every year, certainly should be receiving rather more attention. Already, ten percent of the population is caring on an informal basis for a friend or family member who can't manage alone: as increasing numbers of us develop diseases such us Alzheimer's, this percentage is bound to grow.

Caring for each other, gladly and without expecting recompense, is an important part of the glue that holds society together: as we see it become increasingly fragmented and dysfunctional, it seems ever more vital to cherish those elements that still work. Even if it was affordable, can you imagine anything more soulless than a world where all care was delivered professionally and in an institutional setting?

Don't forget that we have an extensive area on the site dedicated to resources for carers

Please let us know if you come across any useful products or services that aren't yet included. And of course we always want to hear about your personal experiences, good or bad.

Please feel free to add your comments here.