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Notes from Kafka’s care home

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So now we know what the PM is getting the NHS for its 70th – a longer-term funding strategy that steers clear of panicky winter bailouts and instead looks at the bigger picture.

But sometimes you need to look at the smaller picture, too. And if you really want to see the NHS in all its dysfunctional and money-haemorrhaging glory, I’d suggest putting under the electron microscope your local residential home(s).

To give just two examples from recent and painful experience: first, a very elderly and nearly dead care home inmate who had been properly teed up, in every physicopsychosocial respect, to shuffle gracefully off this mortal coil. What could possibly go wrong? Well, at the pre-shuffle stage, she could look a bit ‘flushed’, prompting care home to call end-of-life team, prompting in turn the suggestion she be given some paracetamol, prompting a call from home to 111 because none is available/written up, prompting, unbelievably, a visit from a doctor.

What next? A few days later, she dies, as patients on the end-of-life pathway tend to. Yet the message to 111 is ‘Patient unresponsive’. Cue ambulance, paramedic and unnecessary mayhem. Multiply this by all the care homes in the land and all the days in the year then just imagine the cost to the NHS. Then weep.

GPs don’t have time for the day job, let alone a new role as quasicommunity geriatrician

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Second, a very frail elderly man I initially visit at his own home, who needs admission for falls and dyscopia. Imagine my amusement when, a few weeks later, I am called to see the same man in a ‘re-enablement’ wing of a residential home – this a relatively newly commissioned service set up without our knowledge or involvement as a stop-gap between hospital and home. The issue? Recurrent falls. So the outcome of me deeming a problem unmanageable in the community is for the problem to be put back in the community, for me to manage. When asked by the staff what they should do, I give the only reply possible: ‘Read Kafka’.

As a postscript, I later hear from the re-enablement unit requesting that we routinely send a doctor for half a day a week, unfunded, to provide the care their patients really need. Which, of course, we’d be delighted to do, just not on this particular planet.

The situation is, of course, getting worse as increasingly ill patients are discharged to homes that are decreasingly able to cope. And even if these homes were somehow able to transform their level of function and communication, we GPs don’t have time for the day job, let alone a new role as quasi- community geriatrician. The result is episodic, unplanned care that ticks all the wrong prescribing and admission boxes, and none of the QOF ones.

Solution? Take the responsibility for care homes away from us. Crank up the magnification on that microscope until you reveal local teams of underemployed elderly care consultants and nurses who can take on the role. An initial investment, sure, but think of the returns in terms of improved care and money saved. And imagine the tumbleweed blowing through your visit book.

Dr Tony Copperfield is a GP in Essex



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