The Scotoma in The 20-20 Vision

Audit Scotland got stuck into the Scottish Government last week because it has thus far failed to realise its “20-20 Vision” of health care delivery.  2020 is a 5 point plan.  In brief, by 2020 we should have:

Integrated health and social care.

A focus on prevention, anticipation, and self-management.

If hospital input is needed, day case treatment will be the norm.

(Virtually meaningless statement about patient centred quality and safety to the highest standard.)

Focus on getting the patient home with minimal risk of readmission.

I wrote to The Herald.  Disgruntled curmudgeon of Breadalbane.  I was particularly exercised about Point 3.  Which particular diagnosis is going to be shoehorned into a day case?  Fractured neck of femur?  Pneumonia?  Sepsis?  Myocardial infarction?  Stroke?  You can’t design a utopian system of health care just by wishing it were so, and by ignoring the slings and arrows of outrageous fortune.  It’s not really the government’s fault; they are in an impossible position.  The medical profession should have told them something of the nature of human pathophysiology.

This agenda is all about the care of the elderly.  It is apparent that the population of over 75s is increasing in Scotland – as elsewhere – and that medical provision for this population must be provided.  You often hear this issue discussed in terms of an intractable problem – the impending crisis of care arising from the aging population.  I don’t care for this notion of the elderly posing intractable problems.  In my experience, the elderly are the least demanding population of all.

I grew up surrounded by old people.  Both my mother and my father were one of seven siblings.  My mum had three brothers and three sisters.  All the girls came down to Glasgow from Skye.  All of my aunts were prematurely widowed.  They all went into business in Glasgow and ran nursing homes for the elderly.  My mum was crucial to this venture because she was a state registered nurse and a midwife (she delivered many of my cousins) and her presence was critical to what would now be described as issues of clinical governance, quality, and safety.

From the earliest age, I became comfortable with people who were decrepit, incontinent, and mentally confused.  It never bothered me.  My mum used to say, it’s not difficult to look after an old person.  All you need is loving kindness, and a bed-pan.

The idea of sustaining sick elderly people at home may sound attractive but if you think about the way in which people now live, it is not always desirable.  Many elderly people live alone.  If not, if they have a surviving spouse, the spouse is likely also to be frail and to have health issues that will impinge on their ability to be the principal carer.  Let’s suppose the elderly patient is living with an offspring and spouse; chances are both will be out working, in order to pay off the enormous mortgage on their property, and support the children in their private education, designed to support them in the ghastly pursuit of advancement to a position of authority in the running of a dark Satanic mill.

There is nobody at home who has the inclination, the time, the skill, and the capacity for a particular kind of intimacy; nobody is willing to remove their outer garments, put a towel round their waist, and get down on their hands and knees to wash a loved one’s feet.


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