Without writing another response that is twice the length of my original column, I will say this
1. We have had an exponential rise in the number of people in society who are living to extreme old age or with extremes of frailty, dementia, age-related disability and multimorbidity. In turn such patients were in the minority in NHS hospitals and indeed primary care and psychiatry when the NHS was founded, when the early pioneers of geriatric medicine and old age psychiatry were developing and describing services which are still seminal today for anyone studying the development of medicine. Try reading Richard Smith's BMJ Blog on how medicine was when he was a house officer in the 1970s compared to now. Or the stark fact that 1 in 4 beds in NHS hospitals has a person with dementia in it, with 40% of acute admissions over 75 being people with Dementia. This was not the picture in the hospitals I trained in as a medical student or as a junior doctor.
2. So given that the NHS in the 1970s and 80s had a considerably larger bed base than it now does and that such older people were in the minority of service users, it was possible to have clinical areas that looked after them "on the NHS" indefinitely.
3. I regret the creation of a health and social care split, between what is means-tested and free at the point based on need, what is local government responsibility and NHS responsibility which is in turn age discriminatory, and arbitrary labels dementia and age-related conditions as "social" not "health" and which puts worried families and carers through terrible distress when they are already on their knees. Sensible recommendations were made in Dilnot and in the Kings Fund Barker Commission and sensible policy decisions made by the Scots when their health system devolved.
4. I also think and have said before that there is a lot of ideological guff and magical thinking about prevention and care closer to home/in the community which is not backed by the level of support (e.g. extra care housing, night sitting, carers that are not on minimum wage/zero hours contracts/able to visit only for 15 minutes, etc) and that if we are serious avout caring for people outside hospital it needs to be staffed and resourced properly.
5. I have said repeatedly that nursing home placement can never be a "never event" - that some people do require and even choose long term care and that we shouldn't label all care homes as bad places to be or places to avoid at all costs.
6. However, I am 100% unapologetic in saying this. We should not aspire to recreate a situation that had existed formerly in which older people with complex care needs, or indeed younger people with chronic mental health problems lived in large numbers for the rest of their lives on hospital wards or entered institutional care such as nursing homes at a threshold where their care needs could and should have been met at home. For me the mistake wasn't aspiring to give people more support and choice and ability to live outside long stay units, it was the blatant attempt to label long term care as "social" thereby liable to means testing - because the public are so supportive of the NHS model that charging people for healthcare would have been beyond contentious. This was one of the worst policy decisions in the history of the NHS.
Anyway, I stand by every word of my original column - that's kind of why I wrote it.
Medicine evolves. At the start of my consultant career, 2 ward rounds a week, no weekend cross cover, 1 Multidisciplinary meeting a week and consultants on call at home in the evening were the norm. I was an A&E SHO in a busy department that had one consultant and one registrar and 6 SHOs. Now it's daily ward rounds, twice daily MDTs, consultants present "on take" never mind "post take" till well into the evening and doing full ward rounds at weekends. We send far more people home from the hospital front door having investigated them far more promptly, there is far more we can do for people with many conditions than we ever could when I started, well beyond TLC.
Does that mean I am attacking or criticizing how things used to be? Not a bit of it. But you don't need to be in an acute hospital bed to have skilled support for your dementia, pressure sores or incontinence and maybe being in that environment worsens the problems.
Rapid Response:
Re: David Oliver: NHS continuing care is a mess
Editor (and commenters)
Without writing another response that is twice the length of my original column, I will say this
1. We have had an exponential rise in the number of people in society who are living to extreme old age or with extremes of frailty, dementia, age-related disability and multimorbidity. In turn such patients were in the minority in NHS hospitals and indeed primary care and psychiatry when the NHS was founded, when the early pioneers of geriatric medicine and old age psychiatry were developing and describing services which are still seminal today for anyone studying the development of medicine. Try reading Richard Smith's BMJ Blog on how medicine was when he was a house officer in the 1970s compared to now. Or the stark fact that 1 in 4 beds in NHS hospitals has a person with dementia in it, with 40% of acute admissions over 75 being people with Dementia. This was not the picture in the hospitals I trained in as a medical student or as a junior doctor.
2. So given that the NHS in the 1970s and 80s had a considerably larger bed base than it now does and that such older people were in the minority of service users, it was possible to have clinical areas that looked after them "on the NHS" indefinitely.
3. I regret the creation of a health and social care split, between what is means-tested and free at the point based on need, what is local government responsibility and NHS responsibility which is in turn age discriminatory, and arbitrary labels dementia and age-related conditions as "social" not "health" and which puts worried families and carers through terrible distress when they are already on their knees. Sensible recommendations were made in Dilnot and in the Kings Fund Barker Commission and sensible policy decisions made by the Scots when their health system devolved.
4. I also think and have said before that there is a lot of ideological guff and magical thinking about prevention and care closer to home/in the community which is not backed by the level of support (e.g. extra care housing, night sitting, carers that are not on minimum wage/zero hours contracts/able to visit only for 15 minutes, etc) and that if we are serious avout caring for people outside hospital it needs to be staffed and resourced properly.
5. I have said repeatedly that nursing home placement can never be a "never event" - that some people do require and even choose long term care and that we shouldn't label all care homes as bad places to be or places to avoid at all costs.
6. However, I am 100% unapologetic in saying this. We should not aspire to recreate a situation that had existed formerly in which older people with complex care needs, or indeed younger people with chronic mental health problems lived in large numbers for the rest of their lives on hospital wards or entered institutional care such as nursing homes at a threshold where their care needs could and should have been met at home. For me the mistake wasn't aspiring to give people more support and choice and ability to live outside long stay units, it was the blatant attempt to label long term care as "social" thereby liable to means testing - because the public are so supportive of the NHS model that charging people for healthcare would have been beyond contentious. This was one of the worst policy decisions in the history of the NHS.
Anyway, I stand by every word of my original column - that's kind of why I wrote it.
Medicine evolves. At the start of my consultant career, 2 ward rounds a week, no weekend cross cover, 1 Multidisciplinary meeting a week and consultants on call at home in the evening were the norm. I was an A&E SHO in a busy department that had one consultant and one registrar and 6 SHOs. Now it's daily ward rounds, twice daily MDTs, consultants present "on take" never mind "post take" till well into the evening and doing full ward rounds at weekends. We send far more people home from the hospital front door having investigated them far more promptly, there is far more we can do for people with many conditions than we ever could when I started, well beyond TLC.
Does that mean I am attacking or criticizing how things used to be? Not a bit of it. But you don't need to be in an acute hospital bed to have skilled support for your dementia, pressure sores or incontinence and maybe being in that environment worsens the problems.
David Oliver
Competing interests: No competing interests